Swiss Avenue 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: 30377 Based on observation and interview, the facility failed to monitor and maintain a sanitary environment to minimize the transmission of infectious agents within the dialysis center. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the dialysis facility. Findings Include: BIOMED WORK AREA: *Disorganized and cluttered. *Stored alongside the BioMed’s machine parts were open cardboard boxes of supplies for in-center use. (Medication cups used for dispensing medications to the patient, Alcohol prep and drinking cups) WAREHOUSE: *Observed large areas in the warehouse floor were the epoxy was damaged or worn away. *Shelving for in-center supplies had a white panel tapped to the base of the shelfs. The panel was chipped with dust buildup. The clear tape holding the panel to the shelf was discolored and peeling up in multiple areas. *Grim build up along the base boards and doorways. IN-CENTER TREATMENT AREA: *The metal door frame to the isolation room had a build-up of discolored white substance on the metal frame. *Observed windowsill bases and walls throughout the treatment area with exposed drywall second to paint cracked, damaged or peeling away. *Observed laminate countertops throughout the treatment area with missing and chipped laminate. These areas were used to store clean supplies for patient care. *Patient’s wheelchairs/walkers were stored alongside used biohazard containers in the treatment area. *There were 2 of 2 dialysis chairs inspected that had grim build-up on the metal aspect of the chair. Observed a dried brown stain that appeared to be dry blood splatter on the inside cushion of the left arm of one of the two chairs. These dialysis chairs had been designated as “clean.” *Observed re-usable blood pressure cuffs with unknown substances and materials stuck to the Velcro section. An interview with Staff #2 on 02/27/2023 at 10:00 AM confirmed the infection control and safety issues found in the BioMed area, warehouse and in-center treatment area”

“PR-RECEIVE WRITTEN NOTICE 30 DAYS PRE IVD CFR(s): 494.70(b)(2) The patient has the right to- (2) Receive written notice 30 days in advance of an involuntary discharge, after the facility follows the involuntary discharge procedures described in §494.180(f)(4). In the case of immediate threats to the health and safety of others, an abbreviated discharge procedure may be allowed. This Standard is not met as evidenced by: 50181 Based on a review of the medical records, policy and procedure review and staff interviews the facility failed to enforce policies and procedures regarding the involuntary discharge of a patient. These findings have the likelihood to place all patients and staff within the facility at risk for harm or injury. In review of the facility-based policy entitled, “Routine and Involuntary Patient Discharge” stated in part, “The Medical Director shall ensure that no patient is involuntarily discharged or transferred from the facility unless: 4. the patient’s behavior is deemed disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired 5. The patient’s behavior is an immediate and severe threat that is deemed dangerous to the health and safety of others.” Findings included: Documentation in patient #1 medical records indicates the event of disruptive behavior with verbalized threats occurred on the treatment floor prior to initiation of treatment on 12/26/2023. The patient (Patient #1) was dialyzed on this day. There is no evidence that the police were notified to remove patient #1 from the premises to secure the safety of the other patients and staff. Patient #1 was allowed to return to the facility and dialyze on 12/28/2023 after the above occurrence. Timeline of events from the record review: 12/26/23: Event of disruptive behavior and verbal threats by patient #1; patient #1 dialyzed in the facility 12/28/23: Patient #1 dialyzed at the facility 12/29/23:MD order written ordering immediate patient discharge from the facility due to disruptive and threatening behavior Patient #1 was notified on 12/29/2023, via phone and certified letter, of the facility’s decision to immediately discharge from the facility in regard to his behavior and threats. ESRD Network was notified of the immediate involuntary discharge 12/30/23: TDH Report submitted The above findings were confirmed during an interview with Staff #1 and Staff #23 on 2/27/2024.”