Ara - Mechanicsville Dialysis

“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: 42042 Based on observations and interviews, it was determined the facility staff failed to maintain a sanitary environment by not properly disposing of trash and failing to empty waste receptacles. The findings include: The surveyor conducted observations on the treatment floor to include infection control practices and overall cleanliness. On 12/18/23 at 2:24 pm, the surveyor observed the trash can located by the medication storage refrigerator to be over-filling with trash. Additionally, the surveyor observed various small pieces of trash and other waste scattered throughout the treatment floor with emphasis around the door leading to the lobby and around the nurse’s station. The surveyor also observed unknown white stains that were apparent throughout the treatment floor. In the evening of 12/18/23, the surveyor met with Staff Member #1 regarding the observations. The staff member was unable to provide an explanation except stating they believed the unknown white substance seen throughout the treatment floor during treatments was related to the retrieval of the prescribed bicarbonate jugs. Staff Member #1 added during interview that staff were required to manually carry the jugs to and from the water room during the ongoing facility renovations. On 12/18/23 at 2:35 pm, the surveyor conducted interview with Patient #3, who speculated that staff might not have time for trash maintenance as they were usually busy performing ongoing treatment interventions. On 12/19/23 at 12:38 pm, the surveyor returned to the treatment floor for additional observations of dialysis treatment of second shift patients. The surveyor observed a trash bin located by the “clean sink area”, and adjacent to the conductivity meters, to be overflowing with waste. On 12/19/23 at 5:10 pm, the surveyor conducted a group interview with Staff Member #2, Staff Member #11, Staff Member #12, and Staff Member #13. The surveyor informed the staff members regarding the filled trash cans, white substance on floor, and the miscellaneous scattered trash debris that were observed on the treatment floor on 12/18/23 and 12/19/23. The surveyor asked the staff about the expectation for prompt trash removal and general cleanliness. Staff Member #2 stated the primary responsibility lies within the contracted cleaning company that comes to clean at the end of every treatment day. The surveyor received additional clarification from Staff Member #11 that the maintenance of general, non-biohazard and sharps related trash disposal is primarily the responsibility of the cleaning company. Staff Member #2 added that the treatment floor is cleaned and scrubbed by the cleaning company in the evenings following all patient treatments, and the treatment floor presents as clean prior to the start of first shift patients every morning. The surveyor requested a copy of the agreement with the contracted cleaning crew and a policy related to trash disposal/service. Staff Member #2 stated no other policies or procedures were available. As of time of exit conference, Staff Member #2 was not able to provide a copy of the requested aforementioned contract, procedures, or policies.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 42042 Based on document review and interview, it was determined that the facility staff failed to monitor intradialytic vital signs appropriately for one (1) of eighteen (18) patients reviewed. The findings include: On 12/19/23 at 11:07 am, the surveyor met with Staff Member #6 for interview. During interview, Staff Member #6 referenced an incident in November 2023 in which Patient #8 had reported a concern of not having vital signs taken for approximately a two (2) hour period during treatment. On 12/19/23 at 3:41 pm, the surveyor initiated review of eighteen (18) patient flowsheet documentation with the assistance of Staff Member #2. The flowsheet documentation for Patient #8’s dialysis treatment on 11/02/23 revealed that treatment was initiated at 6:40 am. At 7:04 am, the surveyor observed a set of vital signs taken with blood pressure of “76/15”. Another set of vital signs--to include heart rate and blood pressure--were not taken until 8:57 am which had a blood pressure recorded as “61/18”. The corresponding note by the PCT read, in part, “patient constantly moves around so BP cuff doesn’t inflate ...” Staff Member #2 supplied the surveyor with the facility policy titled, “IC08 Monitoring & Documentation of Patient Care During Treatment” (with last revision date of 11/29/22). On page two (2), the document reads, in part, “10. Data that must be documented (by direct entry and/or by data feed from the dialysis machine) at least every 30 minutes and PRN depending on the patient’s condition includes but is not limited to: Patient blood pressure and heart rate (BP & HR)”.”