Usrc East Fort Worth

“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: 50181 Based on observation and interview, the facility staff failed to ensure that clean areas are 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 or store medications or clean supplies in the same or adjacent area to that where used equipment or blood samples are handled. During a tour of the facility’s in-center treatment area with the Facility Administrator (Staff #1) on the morning of 05/16/2024, the surveyor observed patient wheelchairs and roller walkers stored with IV poles, privacy screens and oxygen concentrators. During a tour of the facility’s in-center treatment area with the Facility Administrator (Staff #1) on the morning of 05/16/2024, the surveyor observed a face shield used by staff members as personal protective equipment (PPE) hanging on the clean supply cart. During the tour of the facility on 05/16/2024, the above findings were confirmed and acknowledged by the Facility Administrator (Staff #1).”

“BICARB CONC DIST-COLOR CODED BLUE & SEALED CFR(s): 494.40(a) 5.5.4 Bicarbonate concentrate distribution systems: color coded blue & sealed Bicarbonate concentrate delivery piping should be color-coded blue at the point of use (at the jug filling station or dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility failed to ensure that the wall boxes (dispensing outlets) at the dialysis stations were properly disinfected between each patient treatment. This deficient practice had the likelihood to cause bacterial growth in the wall boxes. Findings included: During a tour of the facility treatment floor on the morning of 05/16/2024 the wall boxes were noted to have a crusted, white sediment and build-up around the connectors of the wall box. The Facility Administrator (Staff #1) confirmed the findings noted on the wall boxes on the treatment floor during the tour on 05/16/2024.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility staff failed to ensure the dialysis facility was maintained in a safe, functional, and comfortable treatment environment. During a tour of the facility on the morning of 05/16/2024 the following were noted: *Wheelchairs and roller walkers not stored in designated area*Dirt and buildup noted on a red biohazard container located near the scale*Two masks on the ground entering the facility*Stained ceiling tiles noted in the exam room and the treatment floor*Multiple dialysis machines noted with paint peeling and discoloration on the base The Facility Administrator (Staff #1) accompanied the surveyor on the tour of the facility and all findings were acknowledged and confirmed.”

“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: 50181 Based on observation the facility staff failed to ensure the emergency pull cord (a call light strategically placed throughout the facility to provide a user with a convenient means of summoning help in an emergency) was accessible for patients in the event of an emergency. The emergency pull cord should be within 6 inches of the floor, hanging freely, and accessible to patients and visitors. Upon entering the facility’s lobby on the morning of 05/16/2024 the surveyor observed the emergency pull cord was blocked by a table and inaccessible to patients and visitors in the event of an emergency requiring assistance.”