Irc - San Antonio - Castroville

“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: 22676 Based on observation, interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure that the 30 wall boxes (dispensing outlets) 30 of 30 dialysis (Station 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) stations had a build-up of a dark yellow substance with some dark green areas. This deficient practice had the potential to cause bacteria to grow in the wall boxes and could potentially affect the 37 patients receiving in-center hemodialysis at the facility. Findings include: During observation of all wall boxes on 10/23/24 at 9:45 AM, Stations 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30 had a build-up of a dark yellow substance. During an interview on 10/23/24 at 9:45 AM, the Facility Technician Lead (FTL)Technician confirmed the above findings. He/she stated that he/she had been trying to get new wall boxes for the treatment unit. Review of the facility’s policy titled, “Cleaning and Disinfection of the Dialysis of Equipment, Supplies, and Treatment Area” dated 06/20/24 indicated, “All routine touched reusable equipment and surfaces in each patient’s treatment area must be disinfected after each patient’s treatment. Caregivers will ensure that cracks/crevices come in contact with the bleach solution. This includes, but not limited to the counters and wall boxes...” Review of the “CDC Dialysis Safety” located on the CDC website at www.cdc.gov titled, “Wall boxes and Drains” last reviewed: October 25, 2019, indicated, “All box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). Cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during patient care activities ... ... More than one disinfectant wipe or application may be needed to ensure all wall box surfaces are visibly wet with disinfectant to achieve contact time specified by the manufacturer.””

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 22676 Based on interview, document review, policy review, manufacturer’s instructions review, the facility failed to ensure the “GEM FR-4” Water System Reverse Osmosis (RO) was disinfected for six of six months of logs reviewed. This had the potential to cause harm to all 37 in-center hemodialysis patients receiving care at the facility by failure to disinfect the “GEM” reverse osmosis system (RO). Findings include: Review of the “RO waterlogs” from 04/01/24 through 09/30/24, revealed the facility failed to disinfect the RO. Interview with the Facility Technical Lead (FTL) on 10/21/24 at 3:14 PM, he/she stated that he/she was told on hire they do not disinfect the 30-year-old RO. He/she stated they did not have the manufacturers’ instruction for the GEM RO, but that Mar Cor Purification Company had acquired the GEM FR-4 RO manufacturing company several years ago. He/she stated the cultures and endotoxin reports from the GEM FR-4 RO have all been normal since he/she has been working at the facility. Review of the “GEM FR-4 RO cultures and endotoxins reports” from 01/24 through 09/24 revealed they were all within normal limits. Review of the facility policy titled, “RO Machine Disinfection “dated 10/27/20 indicated, “The RO machine must be cleaned and disinfected per manufacture’s recommendation, and minimally once every three months.” Review of “Mar Cor Purification System” manufactures instruction for the GEM FR-4 indicated, “The RO machine ... should be disinfected monthly. As the system is operated for a period of time, it may be possible to extend the period between disinfections (under NO conditions should the period between disinfections exceed 3 months).””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 22676 Based on observation, interview, and facility policy review, , the facility failed to ensure that the wall bases at one of 30 stations (station 10)_was not exposing the porous sheetrock. This deficient practice had the potential to cause bacteria to grow in the wall behind the station and could potentially affect the 37 patients receiving in-center hemodialysis at the facility. Findings include: Observations on the treatment floor on 10/22/24 at 9:45 AM, about eight inches of the wall base behind station 10, was loose at the floor, the sheet rock had deteriorated, and the inside chalk portion of the sheet rock was exposed. During an interview on 10/23/24 at 9:45 AM, the Facility Technician Lead (FTL)Technician confirmed the above findings. Review of facility’s policy titled, “Physical Environment Innovative Renal Care IRC Policy Texas Specific Appendix.” Dated 07/1/22 indicated, “Wall bases in patient treatment and other areas which are frequently subject to wet cleaning methods shall be tightly sealed to the floor and the wall, impervious to water ...””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 22676 Based on record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for three of nine sample in-center dialysis patients (Patient (P)2, P3, and P4). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 37 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P2’s electronic medical record (EMR) revealed a prescribed Blood Flow Rate (BFR) of 450 milliliters per minute (ml/min). Review of six of six “Post Treatment” flowsheets from 10/07/24 through 10/21/24 in the EMR indicated the following: a. On 10/07/24, the BFR was documented at 400 ml/min from 7:11 AM until 10:16 AM. b. On 10/09/24, the BFR was documented at 400 ml/min from 6:32 AM until 10:31 AM. c. On 10/14/24, the BFR was documented at 400 ml/min from 6:15 AM until 10:00 AM. d. On 10/16/24, the BFR was documented at 400 ml/min from 7:30 AM until 9:49 AM. e. On 10/18/24, the BFR was documented at 400 ml/min from 8:06 AM until 10:31 AM. f. On 10/21/24, the BFR was documented at 400 ml/min from 7:16 AM until 10:01 AM. There was no documentation of the rationale for the change to the prescribed BFR. 2. Review of P3’s EMR revealed a prescribed Dialysis Flow Rate (DFR) of 500 ml/min. Review of one of six “Post Treatment flow sheets from the EMR from 10/09/24 through 10/21/24 in the EMR indicated the following. a. On 10/09/24 the DFR ran at 800 ml/min from 10:06 AM until 2:13 PM. There was no documentation of the rationale for the change to the prescribed DFR. 3. Review of P4’s EMR revealed a prescribed BFR of 450 ml/min and a DFR at 700 ml/min. A review of two of six “Post Treatment” flowsheets from 10/09/24 through 10/21/24 in the EMR indicated the following: a. On 10/09/24 the BFR ran at 400 ml/min and the DFR at 500 ml/min from 5:44 AM until 9:30 AM. b. On 10/11/24 the BFR ran at 400 ml/min from 5:54 AM until 9:59 AM. There was no documentation of the rationale for the change to the prescribed BFR and DFR. During an interview on 10/22/24 at 3:15 PM AM, Registered Nurse Clinic Manager RN-CM confirmed the above findings and confirmed that the staff did not follow the physician’s order for dialysis treatment and that there was no progress note explaining why it wasn’t followed. Review of the facility’s policy titled, “Monitoring and Documentation of Patient Care During Treatment”,” dated 11/29/22, revealed, “ If the patient’s prescription was not met for any reason A detailed progress note must be entered explaining why the prescription was not met and actions taken to address the situation.””