Usrc Mid Valley Weslaco Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 34839 Based on observation, interviews and documentation reviewed, the facility is not in compliance with applicable State regulatory licensing requirements and other relevant health and safety requirements. Specifically, The facility failed to provide adequate staffing to meet the patient needs when the Charge Nurse(CN) was observed providing direct patient care duties contrary to Texas ESRD Rules and Regulations. Findings included: Adequate staffing: Review of the staff/patient daily assignments for 8/5/24 , documentation revealed the RN who was also the CN was assigned all nursing responsibilities for all patients that included initiation and termination of patients that have a central venous catheter (CVC) as well as administration of all patient ordered medications, assessments, and other CN duties. Review of patient/staff assignments identified 2 CN, 1 LVN and 5PCTs (patient care technicians) assigned to provide direct patient care to the facility’s patient census of 149, on the following date: February 7th, 8th, 15th and 26th. Direct patient care includes initiation, termination of all patients with a CVC, administration of medications and charge nurse duties. Documentation of patient treatments have the CN signatures for patient care and medication administration. In an interview on 2/26/24 at 2:30 PM with the Director of Operations confirmed CN/RN (staff #10) does provide direct patient care. Review of the Governing Body Policy published 07/03/2023 version 1 indicated, in part under “ General Responsibilities” Governing Body duties ( generally in conjunction with the Medical Director) include but not limited to: Ensuring adequate staff coverage. Maintaining compliance and adherence to federal healthcare program requirements/state regulations including staffing.”

“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: 34839 Based on observation, policy and procedure review and staff interview, the facility staff failed to ensure a clean and sanitary environment was monitored and maintained to minimize the transmission of infectious agents in the patient lobby, in-center treatment area, supply room; and in accordance with the facility’s policy titled, “General Cleanliness and Infection Control Guidelines”. This deficient practice had the likelihood to result in the transmission of infectious agents within the unit and between patients, staff members, and members of the public. Findings included: During a tour of the facility on 08/05/24 the following infection control issues were observed: Treatment Area: Bleach water containers dated but no concentration labeled. blue clamps in 2 of the buckets were closed not allowing for proper disinfection, the 3rd bucket was full of disposable white clothes. Clean supply carts ( 2 ) were observed in the treatment area approximately 3 feet away from the patients and staff preparing supplies for patients. 10 biohazard bins placed in between the machines, touching the Hanson lines. Supply cart at the back wall storing piles of saline bags, had a 4x4 depression with a yellow substance, debris and bugs. The laminate Paper towel holder at the clean sink is cracked and exposed wood not allowing for proper disinfection. Supply room: Missing and stained ceiling tiles above the electronic equipment. Acid mixer has heavy build up of dust dirt and white crystals. Rust noted on the metal pieces of the device. A beaker and a meter observed on top of the mixer. Interview with Biomed stated he mixed acid 8/1/24 “ I mix my acid and I leave it there until the next batch is made. I will dump it rinse it and check the conductivity on the new batch”. Double doors in the supply room had light shining trough the bottom allowing varmints to enter the clean supply room. Interview with S#1 at 1530 confirmed above findings and stated she had identified the issues as well.”

“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: 34839 Based on observation and interview, the facility failed to maintain the building free from defects and hazards in the water treatment area. Findings included: On 08/05/24, the following was observed: Water Treatment area 1. At 14:15 PM, it was observed that the floors surrounding the brine, multimedia, softener, water holding, and 2-Carbon tanks were dirty and had not been maintained. The floor around the brine tank and the drain is deteriorating, and the surveyor was able to move the concrete with shoes. Review of the governing body dated February through May stated “ water room floor quote has not been approved, pending additional quote”. On 08/05/24 at 14:25 AM, the Clinical Service specialist said a quotes have been submitted to the facility’s corporate office, but no further action was taken. Based on observation and interview, the facility failed to maintain the building free from defects and hazards in two of two areas (water treatment area and hemodialysis treatment area). Findings included: On 05/23/23, the following was observed: Water Treatment area 1. At 11:15 AM, it was observed that the floors surrounding the brine, multimedia, softener, water holding, and 2-Carbon tanks were dirty and had not been maintained. Hemodialysis Treatment area 2. At 11:25 AM, it was observed that the countertops at the “Clean” and “Dirty” areas near hemodialysis station #6 were faded and porous and did not allow for effective cleaned and disinfection. 3. At 11:50 AM, it was observed that the “Clean” and “Dirty” areas between hemodialysis stations #21 #22 had countertops that were faded and porous and did not allow for effective cleaning and disinfection. The “Dirty” sink in the same area was rusted throughout the sink. On 05/23/23 at 11:25 AM, the Facility Administrator (Personnel #1) said a work order was submitted to the facility’s corporate office, but no further action was taken.”