Watson Wise Dialysis Center

“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: 48653 Based on observation and staff interviews, the facility staff failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center’s in-center treatment area. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed the following infection control issues: In-Center Treatment Area * There was a beige-colored patient chair sitting inside a supply area on the in-center treatment floor. The chair was directly next to the dirty sink where dirty supplies had been placed. The chair was used for patients who may need additional time to sit and hold pressure on their access site due to prolonged bleeding. Therefore, patients could be exposed to dirty supplies used on other patients. * At the supply counter located in front of Station # 12, there were two bins with pick-up wands stored inside of them. The wands on top were dirty and sitting on top of the wands designated as clean. The supply counter was considered clean and had dirty supplies stored on it. * There was a brown and red colored splatter on the wall at Station # 13. The station was considered clean and ready for the next patient. Patient Isolation Room *A large crack was found at the base of the wall molding inside the in-center treatment area’s isolation room. The large crack was located under wall box # 18. There was a hole in the molding which could allow for insects and other pests to enter the in-center treatment area. Also, the crack left areas of building material exposed which could not be properly disinfected. * The lab supplies located inside the isolation room had a black and brown substance on them. The supplies had not been properly disinfected or cleaned. The isolation room was considered clean and ready for a patient. During an interview with Staff # 1 on 05/28/2024 at 10:45 AM, Staff # 1 acknowledged the infection control issues and findings present inside the in-center treatment area.”

“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: 48653 Based on observation and staff interview, the facility’s direct care staff failed to change gloves and perform hand hygiene between touching the patient’s access and the dialysis machines and equipment. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed Staff # 7 don a pair of gloves and touch the patient’s access and dialysis tubing. Staff # 7 then touched the dialysis machine and the computer without performing hand hygiene or changing gloves. This deficient practice had the likelihood to result in the transmission of bodily fluids and infectious organisms between dialysis staff and patients. An interview with Staff # 1 on 05/28/2024 at 10:50 AM confirmed Staff # 7 was observed performing direct patient care without performing hand hygiene or donning new gloves.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation and staff interview, the facility staff failed to ensure medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed two cabinet drawers in the medication area unsecured and accessible to unauthorized persons. The drawers contained prescription medications including, Calcitriol. The drawers were unsecured and there were no authorized and qualified personnel at the medication station to safeguard the open drawers. During an interview with Staff # 1 on 05/28/2024 at 10:40 AM, Staff # 1 acknowledged the drawers were unlocked and not properly safeguarded from unauthorized persons. Staff # 1 attempted to close one of the drawers but was unable to due to the lock being broken.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure proper cleaning and disinfection of the dialysis station was performed before the next patient’s treatment. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed Staff # 10 performing cleaning and disinfection of dialysis Station # 14 following a patient’s hemodialysis treatment. The surveyor observed Staff # 10 open the wings of the dialysis chair, clean them, and promptly close them. The staff member did not allow for adequate drying time of the disinfectant before closing the wings on the chair. A review of the facility’s policy, “Cleaning and Disinfection of the Dialysis Station” revealed, “PURPOSE: The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors .... PROCEDURE: 4. Clean all surfaces. Make the surfaces glistening wet and allow to air dry unless otherwise specified by the manufacturer ...” During an interview with Staff # 1 on 05/28/2024 at 10:40 AM, Staff # 1 acknowledged Staff # 10 did not allow the chair to air dry prior to closing the wings and promptly addressed the staff member.”

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 48653 Based on observation and staff interview, the facility’s biomedical staff failed to identify and promptly correct an acid leak present in the facility’s water room. During a tour of the facility’s water room with Staff # 1 and # 13 on 05/28/2024 at 2:00 PM, the surveyor observed a large acid leak under the acid mixer. There was a large puddle of acid concentrate on the floor under the acid mixer. The puddle of concentrate extended to the acid concentrate storage tank. Also, there was a large amount of dried white crystals around the piping of the acid mixer. During an interview with Staff # 1 and Staff # 13 on 05/28/2024 at 2:05 PM, Staff # 1 and # 10 acknowledged the acid leak present and Staff # 13 stated, “I will have to disconnect all of this to fix it”.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure the emergency code cart (also called crash cart) had a full tank of oxygen stored on it at all times available for use in the event a patient required a high dose of oxygen administration due to respiratory distress or respiratory arrest. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed the emergency code cart had a tank of oxygen stored on it. When the surveyor attempted to turn on the oxygen tank, it was empty, and no oxygen came out of the tank. When asked, Staff # 1 stated there were no other backup oxygen tanks in the facility. Also, the surveyor observed the emergency suction device on top of the emergency code cart was not plugged in to an electrical outlet. A review of the facility’s policy “Emergency Medications, Equipment, and Supplies” with a published date of 05/01/2023 revealed, “PURPOSE: The purpose of this policy is to provide guidelines for staff when determining and maintaining emergency equipment and supplies. POLICY: The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible, and immediately available: *Oxygen, tubing, and masks/cannulas ... All equipment that requires an electrical charge must be plugged in at all times ...” During an interview with Staff # 1 on 05/28/2024 at 11:00 AM, Staff # 1 confirmed the oxygen tank was empty and there were no other tanks available in the facility that could provide greater than 5 liters of oxygen per minute and confirmed the suction device was not plugged in.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure the arteriovenous fistula access was visible at all times during treatment on 1 (Patient # 2) of 10 patient observations. Ensuring proper visualization of the arteriovenous fistula access is important for the early recognition and prevention of bleeding from the patient’s access site. During a tour of the facility’s in-center treatment area on 05/28/2024 at 10:30 AM with Staff # 1, the surveyor observed Patient # 2 receiving hemodialysis treatment at Station # 15. The patient’s access was covered with a blanket and was not visible to the direct care staff. The surveyor observed the patient’s access covered for more than 10 minutes without any intervention from the direct care staff. A review of the facility’s policy, “Monitoring During Patient Treatment” revealed, “PURPOSE: The purpose of this policy is to provide direction for monitoring dialysis patients during treatment. POLICY: Monitor the patient at the initiation of treatment and every 30 minutes, or more frequently as necessary ... Access: Observe and document at the initiation of dialysis and at every safety check that all connections are secure and visible ...Ensure access remains uncovered throughout the treatment ...” During an interview with Staff # 1 and # 10 on 05/28/2024 at 10:30 AM, Staff # 1 and # 10 acknowledged the patient’s site was covered. Staff # 10 stated, “The patient keeps covering his access. I have educated him about the importance of always keeping the access visible during treatment”.”

“PR-PTS INFORMED OF RIGHTS WHEN BEGIN TX CFR(s): 494.70 The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to ensure a properly executed informed consent for hemodialysis treatment was completed for 3 (# 1, # 3, and # 4) of 3 patient medical records reviewed. Patient # 1 A review of medical records for Patient # 1 revealed the patient was admitted to the facility on January 20, 2015. A review of the patient’s “Informed Consent for Hemodialysis Treatment” revealed there was no witness signature, physician signature, or date and time on the consent form. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no date and time on the consent form. There was no documentation in the medical record by the physician confirming risks and benefits had been explained to the patient before the initiation of hemodialysis treatment as required by the facility’s informed consent policy. Patient # 3 A review of medical records for Patient # 3 revealed the patient was admitted to the facility on 05/02/2023. A review of the patient’s “Informed Consent for Hemodialysis Treatment” revealed there was no physician’s signature or time on the consent form. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. There was no documentation in the medical record by the physician confirming risks and benefits had been explained to the patient before the initiation of hemodialysis treatment as required by the facility’s informed consent policy. Patient # 4 A review of medical records for Patient # 4 revealed the patient was admitted to the facility on 10/15/2021. A review of the patient’s “Informed Consent for Hemodialysis Treatment” revealed there was no physician’s signature or time on the consent form. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. There was no documentation in the medical record by the physician confirming risks and benefits had been explained to the patient before the initiation of hemodialysis treatment as required by the facility’s informed consent policy. A review of the facility’s policy, “Informed Consent” with a publish date of 04/05/2021 revealed, “PURPOSE: The purpose of this policy is to ensure that each patient, or authorized decision maker, has provided consent for the patient to receive designated dialysis care and procedures. RESPONSIBILITY: Nephrologist, physician extended or licensed nurse (as defined by job description, license, certification, State and Federal Regulations). The patient’s physician(s) or, (if permitted in the patient’s state) a physician extender will explain dialysis therapy, alternatives, and associated risks, benefits, and consequences to the patient prior to the patient starting dialysis. The nurse may reinforce this information while obtaining a signature on the consent and answer any questions raised by the patient. It is inappropriate to have the consent reviewed with the patient by other non-medical personnel such as a social worker or facility clerical staff. Although these persons may explain various aspects of treatment and have expertise in their area of work, the person reviewing the consent requires a broader scope of knowledge ...” During an interview with Staff # 1 and # 3 on 05/28/2024 at 1:30 PM, Staff # 3 acknowledged there was no physician signature, date, time, or witness signature on some of the patient consents and acknowledged the facility staff were not following the facility’s informed consent policy.”

“PR-RECEIVE UNDERSTANDABLE INFORMATION CFR(s): 494.70(a)(2) The patient has the right to- (2) Receive all information in a way that he or she can understand; This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to ensure the patient was properly consented for hemodialysis treatment and provided information in a way the patient understood in 1 (Patient # 1) of 3 patient medical records reviewed. Patient # 1 A review of medical records for Patient # 1 revealed the patient was admitted to the facility on January 20, 2015. The patient was documented as speaking and reading in Spanish only. A review of the patient’s “Informed Consent for Hemodialysis Treatment” revealed the patient was given and signed an Informed Consent for Hemodialysis Treatment in English. There was no Spanish version signed by the patient. There was no documentation to support the patient was consented for hemodialysis treatment in a way the patient understood. There was no witness signature on the informed consent. During an interview with Staff # 1 on 05/28/2024 at 1:30 PM, Staff # 1 acknowledged Patient # 1 read and spoke in Spanish only. Staff # 1 acknowledged the Informed Consent for Hemodialysis Treatment signed by the patient was in English only and there was no Spanish version in the medical record.”

“PA-ASSESS LAB PROFILE CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: (3) Laboratory profile, This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility’s direct care staff failed to notify the physician when the patient’s laboratory values were outside of the facility’s set parameters and considered critical. A review of Patient # 1’s medical records revealed the patient had hyperkalemia (elevated potassium) for three consecutive weeks without the physician being made aware. Hyperkalemia can cause dangerous, life threatening cardiac arrythmias, paralysis and death due to cardiac arrest. The patient’s potassium results were: “1/16/2024: 5.4 milliequivalents per liter (mEq/L) 1/20/2024: 6.8 (mEq/L) 2/06/2024: 6.7 (mEq/L)” A review of medical records revealed there was no documentation to support the physician being made aware of the elevated potassium on 1/6/2024, 1/20/2024, and 2/06/2024. A review of the facility’s “2024 Outpatient Hemodialysis Physician Orders” revealed, “Potassium: Less than 3.0 or greater than 6.0: Staff repeat Spectra and call physician. Above 7.0: local lab and call physician”. Patient # 1’s last hemodialysis treatment at the facility was on 02/08/2024. The patient was transported to the hospital by family members on 02/13/2024 due to unresponsiveness. The patient was pronounced dead on 02/13/2024 at the hospital due to cardiac arrest. The patient’s potassium on 02/13/2024 was 8.8 (mEq/L). According to the National Kidney Foundation (NKF), a normal blood potassium level for adults is 3.5-5.2(mEq/L). During an interview with Staff # 1 on 05/28/2024 at 1:00 PM, Staff # 1 acknowledged there was no documentation from the facility’s staff that confirmed the physician was made aware of the patient’s elevated potassium.”