Scott & White Artificial Kidney Unit

“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: 28421 Based on observation, it was determined that the facility staff did not practice appropriate infection control. 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.” In an article published by Spectrum Health in July 2014 it was stated “The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests.” Tour of the water room on January 9, 2024 revealed the following: * Clean dialysis supplies were stored on the same shelves as shipping boxes, which could lead to cross contamination. This infection control issue was confirmed by the interum Administrator on the same day.”

“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: 30250 Based on observation and staff interview the facility staff failed to ensure that clean areas were clearly separated from contaminated areas where used supplies and equipment are handled. Findings included: During a tour of the facility on 01/09/24 the following observations were made: * 2 patient personal wheelchairs were observed stored beside the biohazard and trash cans in the middle of the treatment area and not in the designated wheelchair storage area, presenting a risk of cross contamination. * The phoenix meter was identified by the facility as “clean” equipment. A cart labeled “clean” where the Phoenix meter was stored, it was observed multiple stethoscope and face shields were being stored directly above the clean cart, presenting a risk of contamination. The above findings were confirmed in an interview with staff member #2 on 01/09/24.”

“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: 30250 Based on observation and staff interview the facility staff failed to clean and disinfect contaminated surfaces of equipment, per facility procedures. The findings included: Facility based policy entitled, “Disinfection of Surface and Equipment” stated in part, “Machines... 4. Use disinfectant cloth/wipe to visibly wet all machine top, front, back, side of surfaces, dialysate hoses, Hansen connectors and doors, outside surfaces of concentrate jugs, and clip board. Disinfect hand sanitizer, critline, interface cords or anything hanging on the dialysis machine... Other... 1. Apply disinfectant to all non-disposable items: BP cuff and tubing...” During observation in the patient treatment area on 01/09/24 between 9:30 AM and 11:30 AM, the following observations were made regarding cleaning the dialysis machine and surrounding areas after treatment: * Staff did not remove and clean blood pressure cuffs attached to and stored on the dialysis machines during 6 out of 7 observations. * Staff did not clean the critline monitor that was attached to the dialysis machined during 7 of 7 observations. The above findings were confirmed in an interview with staff member #2 on 01/09/24.”