Childress Regional Medical Center Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 43999 Based on observation and interview the facility failed to provide and monitor a sanitary environment to minimize the spread of infectious agents. Findings: During observation on the treatment floor on 2/28/24, a total of 2 staff did not have proper PPE on when providing direct patient care. Staff # 3 and #4 did not have a gown on when providing direct patient care. Staff # 4 did not wear gloves when handling blood tubes. Above discrepancies were confirmed on 2/28/24 by the staff during the observation.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 43999 Based on observation and interview, the facility failed to ensure all staff wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. This practice placed all patients at risk for cross-contamination and/or infection. Findings : During a tour of the facility on 2/28/24, the surveyor observed staff #4 & #5 provide direct patient care with only one glove on one hand. Staff # 4 & #5 wore disposable gloves when touching a dialysis machine and provided direct patient care without disinfecting hands and changing gloves. On 2/28/24, staff #4 & #5 acknowledged the above discrepancies.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 43999 Based on observation, interview and record review the facility staff failed to wear personal protective equipment to prevent and control cross-contamination and the spread of infectious agents. Findings: During observation on the treatment floor on 2/28/24, a total of 2 staff did not have proper PPE on when providing direct patient care. Staff # 3 and #4 did not have a gown on when providing direct patient care. Staff # 4 did not wear gloves when handling blood tubes. Above discrepancies were confirmed on 2/28/24 by the staff during the observation.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 28421 Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff. Findings were: “OSHA/Bloodborne Pathogen Regulations Policy #138-030-060” stated in part “The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner.” * Floor tiles throughout the facility were cracked and water damaged. * Upon entry into the facility, the automatic door did not function for the survey team. These findings were confirmed by the Charge Nurse on 2/28/24.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 43999 Based on observation, record review, and staff interview, the staff failed to notify the nurse and physician to assess the patient when significant changes occurred during treatment and report significant blood pressure changes for intervention. This deficient practice had the likelihood to cause harm to the patients at the facility. Findings: Facility standing orders stated, “Hypertension: Notify MD if BP> 210/120 “ A review of patient #5 treatment sheets for the following dates revealed facility staff did not report abnormal vital signs to the Charge Nurse and the Charge Nurse did not report abnormal findings to the physician for further evaluation and instruction. 2/7/24 treatment sheet: “ Start B/P (blood pressure 232/58 ; End B/P 235/102 “ 2/9/24 treatment sheet: “Start B/P 244/123” 2/14/24 treatment sheet: Start B/P 219/80” 2/21/24 treatment sheet: “Start B/P 220/88; End B/P 213/71 An interview conducted with Staff #2 on 02/28/24 confirmed the flow sheet findings did not provide documentation the nurse or the physician had been notified.”