HospitalInspections.org

Based on observation, interview and record review, the hospital and its Governing Body:

- failed to establish a contract or agreement with a separate, Federally certified end stage renal disease (ESRD) facility that provides renal dialysis services to hospital patients and outpatients that would provide oversight by hospital staff of the hospital patients treated at the ESRD to ensure safe and appropriate care;
- failed to develop, monitor, and sustain systems ensuring nursing education, appropriate chlorine testing and disinfecting processes related to dialysis, and overall safety of the patients during dialysis treatments;
- failed to follow professional standards of care and facility/contract policy regarding patient care and assessment for dialsys patients with known risks druing treatment; and
- failed to devleop systems, then identify, report, investigate, or control conditions regarding infections and communicable diseases of patients and personnel in the Dialysis Unit.

These failures effected all 25 dialysis patients in the Dialysis Unit. The hospital census was 219.

The severity and cumulative effect of the systemic practices resulted in the facility being out of compliance with 42 CFR 482.12 - Condition of Participation: Governing Body.

See the deficiencies at:

- A-083 Contracted Services
- A-397 Patient Care Assignments
- A-749 Infection Control Officer Responsibiities

Based on observations and interviews, the hospital failed to have a contract with a separately certified entity that provides renal dialysis services to patients who had been admitted to the hospital. Lack of a contract does not allow for oversight by hospital staff of the hospital patients treated at the separately certified dialysis facility to ensure safe and appropriate care. This failure effects 25 (patients #4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28) of 25 hospital patients treated for renal dialysis in the separately certified end stage renal disease (ESRD) facility (called the Dialysis Unit). The hospital census was 219.

Renal dialysis is a process used to treat patients whose kidneys are not working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body.

Findings include:

1. During an interview on 01/29/10 at approximately 9:30 AM with Staff A, RN (Registered Nurse), Associate Chief Nursing Officer; Staff N, Chief Nursing Officer; and Staff O, Vice President of Quality Improvement, they stated that the dialysis unit is dually certified to provide dialysis services to both hospital inpatients and patients treated only by the ESRD/Dialysis Unit using the same nursing staff, supplies, equipment and beds. No contract or agreement exists delineating the responsibiities of each party regarding dialysis care and services to hospital inpatients.

Observations during the survey at various times from 6:00 AM to 6:30 PM on 01/25/10, 01/26/10, 01/27/10, 01/28/10, and 01/29/10 found nursing staff caring for hospital inpatients and patients who only received care at the separately certified ESRD facility concurrently, using the same dialysis machines, medications and medical supplies. Hospital inpatients treated in this separately certified ESRD entity as well as the ESRD's patients were put in one of twelve beds based on availability of the bed. There was no distinct time when only hospital patients received dialysis within the Dialysis Unit.

2. Interview with staff at the Kansas City Office of the Centers for Medicare and Medicaid Services' (CMS) Regional Office (RO), Staff RO1 on 1/27/10 about 9:00 a.m., revealed that the the dialysis unit is certified with CMS Certification number 262304 as a supplier of ESRD services.

A separately certified entity, such as the dialysis unit, cannot also be certified as part of the hospital's certification unless there is a clear distinction between what is the ESRD and what is the hospital. For example, a clear distinction would be that the hospital's certification was for the ESRD location during specific hours on specific days when patients and staff of the ESRD were not present, or hospital staff came from the hospital and only treated patients brought from the hospital in specific dialysis units/positions/chairs/beds designated only for hospital patients.

Therefore, although both the separately certified hospital and separately certified ESRD may be under the same corporate structure, administrative control, and Governing Body, each is separately certified to meet different Federal regulations and the hospital must, therefore, have a contract or agreement for the care of hospital inpatients who are transported to the separately certified ESRD and receive renal dialysis services within that separately certified entity.

3. A survey of the separately certified ESRD, also known as the Dialysis Unit, that ended 1/29/10 revealed the following:

- The survey, using Federal ESRD regulations at 42 CFR 494 found that patients were in immediate jeopardy to their health and safety when the ESRD did not meet the following ESRD Conditions of Participation: Infection control, water and dialysate quality, physical environment, responsibilities of the Medical Director, and Governance. The Social Security Act directs that no Federally-certified facility can continue to be certified when it is not in compliance with a Condition of Participation. Action was then initiated by the State that began decertification of the separately-certified ESRD.
- Deficient practices included at least the following:

- The facility failed to provide a clean and sanitary environment when it was cluttered, untidy, the floor dirty, steel clean supply carts covered with dust, debris and stains with the clean supplies in dirty and dusty containers, etc.
- The facility failed to perform and/or document the routine serological testing for Hepatitis B virus patients, vaccination of susceptible patients against Hepatis B, and to provide infection control training and education.
- The facility failed to handle items taken into the dialysis station according to the guildeinges from the Centers for Disease Control and Prevention (CDC) when the bins with individual patient supplies were not cleaned and disinfected before taken to a common clean area. In addition, the facility failed to designate tape for each patient, separate clean from dirty areas and to remove linens from the station after use to minimize the transmission of infectious organisms.
- The facility failed to restrict the unauthorized access to the water room and biocarbonate room to other than the individuals responsible for the monitoring and maintenance of the system.
- The facility failed to perform the Chlorine Testing every four hours, perform the test according to the hospital's Policy and Procedure, provide a timer, have an extablished procedure for reporting or correcting results that were outside of the acceptable range, provide training regarding the importance of the test and the consequences of improper testing, or provide on-going trianing and evaluations of personnel performing the Chlorine Testing. Chlorine is a substance that at certain levels will make patients receiving dialysis ill and at a certain level can be lethal.
- The faiclity failed to monitor daily the pH/conductivity of the dialysate before starting the treatment of the next patient with an independent testing device to ensure the proper dialysate concentraiont and to have set limits for the allowable variability of the hand-held values from the machine's readings for the year 2009.
- The facility failed to monthly collect and document the results of bacterial cultures from water collected from different parts of the water distribution system.
- The facility failed to collect the cultures prior to the disinfection of the water treatment system and dialysis machines.
- The facility failed to ensure a safe environment; provide an acceptable training program; inform staff of the importance of the testing of the water system; inform staff of notification of the dialysis staff of the results; update staff and perform annual audits and observations of the staff performing the testing for Chlorine, cultures, endotoxins and for the disinfection of the system; and to have a back-up test for Chlorine as stated in their competency testing.
- The facility failed to provide a safe environment for the patients when the facility was cluttered and dirty, hallways were obstructed with beds, carts, and other articles.
- The facility failed to ensure the safety of the patients when the staff failed to view the patients as well as his/her face/vascular access site and bloodline connections throughout the dialysis treatment.
- The facility failed to ensure nursing staff was properly trained in the use of emergency equipment and emergency drugs.
- The facility failed to protect each patient's hard copy medical records in a secure location when not in use and when they displayed patient names on a white board in the treatment room.
- The facility failed to provide the patients with the contact infromation for the ESRD Network and the State for the grievance procedure.
- The facility failed to fulfill the operational responsibility for the quality assurance performance improvement program for the oversight and discussion of issues regarding patient care, water and dialysate cultures, Chlorine testing, infection control, physical environment, and the education and training of facility and medical staff.
- The facility and its Medical Director failed to complete the required 90-day assessment on each patient, complete the discharge summaries within 30-days, and failed to update the policies and procedures to reflect all ESRD regulations.

Because patients receiving dialysis already have a comprimised medical status and are at increased risk for infections as well as declines in their medical condition if the conditions within the facility are not clean, staff do not accurately test equipment and dialysis components and report discrepencies from normal, and staff are not adequately trained and can demonstrate competence of the training.

The failures contributed to an adverse incident in the ESRD treatment room on 1/16/10 at 2:00 PM when a hospital inpatient (Patient #26), who was being dialyzed in the separately certified ESRD, bled copiously from an unwitnessed removal of a dialysis catheter needle during hemodialysis treatment. A Code Blue (an emergency call for staff to come to the patient's location because the patient is at high risk of dying) was initiated and the patient was transferred to the Intensive Care Unit at the hospital. Although the patient recovered, observation, interview, and review of documents in the Dialysis Unit revealed that conditions still present in the unit found ESRD Conditions of Participation not met as of 1/29/10.

Based on observation, the hospital failed to ensure confidentiality for 13 patient's privacy of treatment. The facility census was 219.

Findings include:

Observation in the Dialysis Unit found a large white board, approximately 3-feet by 4-feet in size, with each patient's first initial, full last name, patient's location on the unit, and the name of patient's physician. The board was visible for anyone who came into the unit and would not keep the names of patients treated confidential.

27029

Based on observation, interview and personnel record review, the facility failed to follow professional standards of care and facility/contract policy regarding patient care and assessment for 11 of 11 dialysis patients with known risks during treatment. The facility census was 219.

Findings included:

1. Observation during all days of the survey, from 01/25/10 through 01/29/10, revealed hospital staff had taken inpatients to the separately certified end stage renal disease entity for renal dialysis. Observations in the Dialysis Unit revealed the dialysis unit is located on the fifth floor of the hospital on 5 East. The arrangement is a square shape with the nurses' station at one end. Patient beds 1,2,3,4, and 5 are located on the left of the nurses' station; patient beds 6,7, and 8 are in front of the nurses' station; and patient beds 8-12 on the right of the nurses' station - bed 12 being the isolation room for patients with Hepatitis B. Observation found the only patients visible to a nurse sitting at the nurses' station would be patients in beds 4 and 9. If the nurse stood up she could see patients in beds 4, 6, 7, 8, and 9, leaving patients in beds 1-3, 5 and 10-12 unattended and unobserved.

However, observation on 01/25/10 at 6:50 AM revealed 11 patients, two Registered Nurses (RN), one technician, and the Director 5 East and Dialysis, Staff E, in the unit. All patients could not be visualized by staff from the nurses' station throughout their dialysis treatment, a period usually of more than two hours.

Observation on 01/25/10 at 4:45 PM in the Dialysis Unit revealed four RNs sitting at the nurses' station. At that time Staff E verified that only 2 of 11 patients receiving dialysis were visible to the nurses responsible for their care.

Dialysis is a specialized treatment that requires visual contact with the patient and the patient's access site at all times throughout dialysis treatment as a standard of practice. Dialysis access is an entranceway into the patient's bloodstream that lies completely beneath the patient's skin. The access is usually in the arm, but sometimes in the leg, and allows blood to be removed from the patient, circulated through tubing into a machine where unwanted blood components are removed, then returned through tubing back into the patient. This can be done quickly, efficiently, and safely. However, venous pressure alarms that are part of this system are not consistently reliable in detecting venous disconnections before a significant amount of blood is lost. Therefore, the patient should not be placed alone where the access site cannot be seen by staff trained to watch for problems, such as rooms which do not permit ongoing observation of the blood lines. In the majority of these cases, the venous pressure alarm on the dialysis machine fails to detect the event until significant blood loss had occurred. Episodes of blood loss can occur that if not detected or stopped can result in hospital admission or death of the patient.

2. Observation on 01/26/2010 at 7:00 AM requested Staff D, RN, run a test strip from the defibrillator off of the crash cart. Staff D stated, "I'm agency." Staff E, RN, Director 5 East & Dialysis stated, "I can't run one either."

At 8:30 AM on 1/26/10, Staff K, RN, surveyors requested to run a defibrillator test strip she stated she did not know how. Through observation and interview it is confirmed that the dialysis director lacks competency how to operate a defibrillator.

During an interview on 01/26/10 at 1:07 p.m. Staff E, RN, Director, 5 East & Dialysis, stated that all nurses working in the dialysis unit are employees and must pass a return demonstration of skills before working in the unit. She also stated that during a shortage of nursing staff she would fill in and work directly with the patients.

Patients are at great risk if the Registered Nurses on duty are unable to run a test strip on a defibrillator as dialysis patients. Patients receiving renal dialysis are among the patient at high risk in a hospital where cardiac problems are a common factor during dialysis treatments. Therefore, knowledge of a nurse to run a test strip on a defibrillator, a machine used to try to restart a patient's heart if it stops, is an indicator for lack of knowledge to efficiently operate the machine during a patient's cardiac arrest.

Review of the agency contract, received by administration as a fax from the nursing agency, All About Staffing, Inc. revealed the contract is titled "Professional Staffing Services Agreement", HCA Facility: Research Medical Center, All About Staffing, Inc., Agreement Date: January 1, 2010 to December 31, 2011, Agreement No.: 142. It stated on page A-1 under 2.0 AAS Responsibilities:

e. Skills Checklist-Completed Annually (if applicable)

However, at 1: 05 PM on 1/26/10, interview with the dialysis director Staff K revealed that staff is determined to be competent related to the provision of dialysis care at the time of orientation when the staff demonstrates dialysis competency. When asked if competencies are re-evaluated at any time after orientation, she answered, "No."

Record review on 01/26/10 at 1:22 p.m. of Staff D, RN, revealed this agency nurse had completed 'no return demonstrations' at time of hire or since date of hire on 03/09. The nurse's skills and competency's expired 11/30/09 with no current information in the employee personnel file reflecting inservice training, specialized education, or skills and competency requirements. There was no documentation regarding infection control training.

Record review of seven additional employees (Staff G, RN; Staff H, RN; Staff I, RN; Staff J, RN; Staff K, RN; Staff L, RN; Staff M, RN) revealed that competency testing was complete upon hire dates but had not been repeated since that time for any of the seven employees reviewed. Some hire dates were as far back as 06/1987. Documents included no information regarding training regarding infection control. See the deficiency at A-0749 regarding infection control practices observed in the dialysis unit.

Record review on 01/26/10 at 1:22 p.m. of Staff D, RN, revealed this agency nurse had completed 'no return demonstrations' at time of hire or since date of hire on 03/09. The skills and competency's expired 11/30/09 with no current information in the employee personnel file reflecting inservices, specialized education, or skills and competency requirements. The file included no documentation regarding infection control training. The agency contract was not available in the personnel file of Staff D, RN, but was produced approximately two hours later by administration as a fax from the nursing agency, All About Staffing, Inc..

Review of agency contract for Staff D, RN, titled "Professional Staffing Services Agreement", HCA Facility: Research Medical Center, All About Staffing, Inc., Agreement Date: January 1, 2010 to December 31, 2011, Agreement No.: 142, stated on pages A-1 under 2.0 AAS Responsibilities:

Skills Checklist-Completed Annually (if applicable)

Reviews of competency record on 01/27/10 in 7 of 7 records reviewed revealed:
Review of competency record for dialysis nurse " H " revealed: The competency dated 2/12/02 for " Changing out Clotted Blood Lines " is incomplete when area " MEETS CRITERIA " " DOES NOT MEET CRITERIA " is blank and no other documented evidence produced shows completion of this competency. The competency dated 3/6/02 for " Dry Ultrafiltration " is incomplete when area " MEETS CRITERIA " " DOES NOT MEET CRITERIA " is blank and no other documented evidence produced shows completion of this competency. The competency dated 3/16/02 for " Testing for Dialyzer Blood Leak " is incomplete when area " MEETS CRITERIA " " DOES NOT MEET CRITERIA " is blank and no other documented evidence produced shows completion of this competency. The competency dated 2/17/02 for " Chemical Disinfection of Dialysis Machine " is blank other than a comment " Unable to Evaluate " and it is signed by the preceptor and head nurse. There is no documented evidence produced showing the competency of " Chemical Disinfection of Dialysis Machine " has been completed. The competency dated 2/17/02 for " Heat Disinfection of Dialysis Machine " is blank other than a comment " Unable to Evaluate " and it is signed by the preceptor and head nurse. There is no documented evidence produced showing the competency of " Heat Disinfection of Dialysis Machine " has been completed.
Review of competency record for dialysis nurse " I " revealed: The competency for " Bacteriologic Surveillance " is not completed. The competency document states the " nurse/technician " will correctly complete this competency, but there is no documented evidence of completion.
Review of competency record for dialysis nurse " M " revealed: The competency for " Hemodialysis Machine Line Placement " on 7/15/08 is not complete when the area " MEETS CRITERIA " or " DOES NOT MEET CRITERIA " is blank and no other documented evidence produced shows completion of this competency. The competency for " Priming Blood Lines and Dialyzer " on 7/15/08 is without a name and there is no other documentation produced for this competency. The competency " Disconnecting Blood Lines " on 7/15/09 is without a name and there is no other documentation produced for this competency. The competency for " Heat Disinfection of Dialysis Machine " on 7/15/08 is without a name and there is no other documentation produced for this competency. The competency for " Chemical Disinfection of Dialysis Machine " on 7/29/08 is without a name and there is no other documentation produced for this competency. The competency for " Mixing Dialysate " on 7/31/08 is without a name and there is no other documentation produced for this competency. The competency for " Accessing AV Fistula " on 7/23/08 is without a name and there is no other documentation produced for this competency. The competency for " Accessing Dual Lumen Catheters " on 7/23/08 is without a name and there is no other documentation produced for this competency. The competency for " Discontinuing Hemodialysis with AV Graft of Fistula " on 7/23/08 is without a name and there is no other documentation produced for this competency, also the area " MEETS CRITERIA " or " DOES NOT MEET CRITERIA " is blank. The competency for " Drawing Lab from Vascular Access " on 8/7/08 is without a name and there is no other documentation produced for this competency. The competency for " Initiating Dialysis " on 7/23/08 is without a name and the area " MEETS CRITERIA " or " DOES NOT MEET CRITERIA " is blank, also there is no other documentation produced for this competency. The competency for " Intradialysis Monitoring " on 8/1/08 is without a name and there is no other documentation produced for this competency. The competency for " Changing Out Clotted Blood Lines " on 8/1/08 is without a name and there is no other documentation produced for this competency. The competency for " Removing Air from Blood Lines " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " Heparin Free Dialysis (NS Flushes) " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " Dry Ultrafiltration " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " Blood Product Administration " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " IVPB Administration " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " IVP Administration " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " Removal of Temporary Dual Lumen Catheter " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " IDPN Administration during Hemodialysis " on 8/4/08 is without a name and there is no other documentation produced for this competency. The competency for " Testing for Dialyzer Blood Leak " on 8/4/08 is without a name and no other documentation was produced for this competency, also the area " MEETS CRITERIA " or " DOES NOT MEET CRITERIA " is blank and there is no other documentation produced for this competency.

4. During an observation on 01/25/10 at approximately 4:50 p.m. in front of patient bed #6 a dialysis machine alarm kept going off. The nurse would reset the alarm and the alarm would go off and then go back on. The conductivity button and the temperature button turned red. This activity continued for several minutes. When asked what the parameters were for the temperature and the conductivity, the nurse stated, "I don't know." During this encounter she called another RN over to help her quiet the alarm.

The standard of nursing practice in a dialysis unit is that a patient will feel the effects of a medical episode long before the episode is detected by nursing or the dialysis machine and its alarms. However, neither nurse talked with the patient or asked the patient questions to determine if he/she perceived a change in their condition.

27029

Based on observation and interview, the facility failed to ensure medications are kept in a secure area and locked when needed to prevent access by unauthorized persons in 3 of 3 medication areas observed (the dialysis area medication refrigerator, the dialysis code cart, and the Short Stay Unit). The facility census was 219.

Findings include:

1. Observation on 01/25/10 at approximately 4:35 PM revealed a refrigerator on a countertop in the dialysis unit across from the isolation room with a large gold padlock hanging on the door. However, the padlock was not engaged. Inside the refrigerator were several vials of Procrit (medication intended to increase red blood cell production) that were accessible to patients, non-licensed staff, or visitors to the unit. Staff present stated at 4:40 PM that, "It should be locked."

During interview on 01/25/10 at 4:45 PM, the dialysis nursing director Staff K confirmed the dialysis refrigerator should be locked.

2. Observation of the crash/code cart in the dialysis area on 01/26/2010 at 7:30 AM revealed 3 unused yellow plastic tamper resistant locks on top of the code cart making it possible for the code cart and the emergency medication box to be entered and then locked by unauthorized persons.

The medications in the code cart include:
- Adenosine 6 mg (milligrams) (slows electrical conduction in the heart) syringe x 3;
- Amiodarone 150 mg/3 ml (milliliters)(an antiarrhythmic medication) ampule (Ampule a small sealed glass container that holds a measured amount of a medicinal substance) x 5;
- Atropine 1 mg/10 ml syringe (Atropine is used to decrease the production of saliva and secretions of the airway) x 3;
- Calcium Chloride 1 gm/10 (Calcium is necessary for normal cardiac function) ml syringe x 2;
- Dextrose 50% 50 ml syringe x 1 (Dextrose (provides sugars to your body);
- Dopamine 400 mg/250 ml (Dopamine treats low blood pressure due to heart attack) x 1;
- Epinephrine 1:1000 ml (Epinephrine treats shortness of breath and chest tightness) ampule x 2;
- Epinephrine 1:10,000 10 ml syringe x 6;
- Flumazenil (Romazicon) 5 ml (Flumazenil reverses the effects of certain types of sedatives) vial x 1;
- Lidocaine 100 ml/ 5 ml (Lidocaine is used to manage irregular heart beats) syringe x 3;
- Lidocaine 2 gm/250 ml x 1;
- Magnesium Sulfate 1 gm/ 2 ml (Magnesium is a mineral used by muscles and nerves) vial x 2;
- Metoprolol 5 mg (Metoprolol is used to treat angina chest pain, high blood pressure and prevent heart attack) syringe x 3;
- Naloxone (Narcan) 0.4 mg/1ml (Narcan used for reversing the effects of narcotics) vial x 1;
- Nitroglycerin 50 mg/250 ml (Nitroglycerin used for preventing or relieving a sudden attack of chest pain) x 1;
- Norepinephrine 4 mg (Norepinephrine is used to treat life-threatening low blood pressure) vial x 2;
- Procainamide 1 gm (Procainamide is used for treating certain abnormal heart rhythms) vial x 2;
- Sodium Bicarbonate 50 meq (Sodium bicarbonate is used to make the blood less acidic) syringe x 2;
- Vasporessin 20 unit (Vasopressin helps prevent the loss of water from the body vial x 2;
- D5W (5% glucose in water) 100 ml bag x 1; D5W 250 ml bag x 2;
- D5W 250 ml bottle x 1; and
- NS (Normal Saline is 0.9% solution of Sodium Chloride) 30 ml vial x 4.

4. Observation on 01/26/10 at 10:55 AM in the short stay nursing unit next to the conference room on the 3rd floor that the cabinet by the ice machine is labeled, "Make sure drawer is locked," and a built-in combination lock is available for that purpose. However, the drawer was unlocked and opened freely. It contained three vials of Zosyn 3.375 grams of antibiotic medication, available to anyone on the unit.

27029

Based on observation, interview and record review, the facility failed to develop systems, then identify, report, investigate, or control conditions regarding infections and communicable diseases of patients and personnel in the Dialysis Unit. This failure effected all 25 of 25 hospital patients receiving dialysis treatments in the Dialysis Unit. The hospital census was 219.

Findings include:

1. Observation on 01/25/10 at approximately 4:30 PM in the dialysis unit where hospital inpatients received renal dialysis revealed the following:

-Dirty floor with spots of unidentifiable debris or residue, rolls of tape;
-Tubing from the front of the dialysis machines X 11;
-No toilet paper in the patient bathroom for patients to use to minimize the transmission of urine and feces onto clothing which could be spread further in the environment;
-Nurses wearing their infection control gowns open in the front that did not protect their clothing from the spread of potential microorganisms that could, then, be transmitted to others;
-Nurses station countertop with visible residue of unknown substances so objects or people touching the surface could spread potential bacteria onto other objects;
-The three "clean" carts containing three shelves of clean patient supplies were visibly dusty with dirt spots and a dark substance that appeared to be dried blood;
- Chipped corners on the nurses station countertop that did not provide a sanitizable surface;
- Chipped floor tiles in front of all 12 dialysis stations which can hold debris, a non-cleanable area; and
- Plastic bins used to store patients' medical items and are removed by staff from the bin in the cabinet when needed. However, when staff remove the bins and place the bin on the bedside tables, then carry them back to the storage cabinets, all of the items including the bins are potentially contaminated. This was the normal practice in the dialysis unit.

2. Observation of the crash/code cart (a cart that contains medications and equipment needed to treat a patient in cardiac arrest or another like emergency) in the dialysis area on 1/25/2010 at 4:45 PM revealed areas with dried residue of an unknown subtance and a collection of dust and debris that looks like wood splinters.

3. Observed the following on a dirty counter top of the dialysis nursing station on 01/25/2010 at 5:02 PM: a blood box bin; an open box of gloves and dialysis tubing.

4. Observation of two medical supply carts for clean medical supplies in the dialysis area on 01/26/2010 at 7 AM revealed metal carts with 3 shelves and the carts are on 4 wheels. Each cart height is approximately 2.5 feet tall, approximately 2 feet wide and approximately 1.5 feet in depth. All shelves have dirty spots and a collection of dust. Clean medical supplies are placed on each of the dirty shelves.

5. Observation of the crash/code cart in the dialysis area on 01/26/2010 at 7:30 AM revealed: the top of the code cart has dried residue of an unknown substance and a collection of dust and debris that looks like wood splinters (observed at 4:45 PM the day before). A defibrillator is on top of the code cart with the defibrillator supplies scattered on top of the dirty code cart (scattered defibrillator supplies included: 2 rolls of defibrillator paper, a defibrillator pad package, a defibrillator adult pre-connected electrode package and an adult mouth-to-mouth resuscitation mask). In addition to the defibrillator supplies observation found defibrillator test strips from previous dates present on top the code cart, and a clip board with documentation of a daily code cart check-off list.

6. During interview with the dialysis nursing director staff K on 01/26/2010 at 8:30 AM, staff K acknowledged the dirty top of the code cart with clean defibrillator supplies on top of the dirty cart. She/he states the top of the code cart is cleaned daily when the daily code cart check is done. However, there is no documentation of cleaning.

7. Interview with dialysis nurse staff F on 01/26/2010 at approximately 8:35 AM revealed he/she thought central supply cleaned the top of the code cart after a code, but could not confirm if the top of the code cart gets cleaned.

8. Observation of dialsys nurse staff F on 01/26/2010 at approximately 8:40 AM run a defibrillator test strip and do the daily code cart check-off, but he/she did not clean the top of the code cart.

9. Observation of the top of code cart on 01/27/2010 at approximately 9 AM revealed the top of the code cart remains unchanged over the last 3 days (1/25/10, 1/26/10 and 1/27/10) with dirty areas and a collection of dust with debris that appears to be wood splinters. Clean defibrillator supplies remain scattered on top of the dirt code cart.

10. During interview on 01/27/10 at 11:30 AM, Staff R, RN, Infection Control Clinical Director, stated he/she had been in that position for three years and was still learning the job.

11. Observation on 01/27/10 at approximately 6:00 a.m. of the water room and the process of disinfecting revealed that staff did not perform the chlorine checks every four hours following the manufacturer's recommendations. Staff write down the results of the tests, but there is no process to report poor results or improve processes. It was discovered during this observation that bacteriological cultures are being taken after disinfectant is used rather than before. The engineer performing the test, Staff Q, Director of Plant Operations, stated that this has been the practice for over one year.

This practice is the opposite as intended to be performed following standards of practice for renal dialysis as the cultures provide no accurate data for surveillance or infection control purposes. Although Staff C, Medical Director of the Kidney Center, has signed the forms for the past year, the data collected and reported has not identified what contaminants or pathogens all dialysis patients have been exposed to in the last year.

12. Observation on 01/25/2010 and on 01/26/2010 showed:

- Rolls of tape (used and unused) on top of the unlocked medication refrigerator, the bed side tables at each station, window ledges, the tops of the machines at twelve (12) of twelve (12) stations, the floor at Station #11, the cooling and heat register at Station #9, and on the counters at the Nurses Station and the Medication Area with charts, papers and gloves
Counters and cabinets with laminate missing and exposed porous material, unable to disinfect
- No "clean" and "dirty" areas observed or designated by the staff
- The unit had debris on the floor consisting of rolls of tape, alcohol wipes, needle caps and scraps of paper;
- Staff break room with papers, binders in the sink, and staff PPE coats on the same rack as staff coats worn out of the hospital.
- The crash cart with dust and dirt present;
- Tubing on the floor from 3K (water containing Potassium) bath jugs at eleven (11) of twelve (12) dialysis stations with the straws just placed into the jugs;
- Dirty laundry consisting of blankets and sheets on the floor at Stations #2, 3, and 9;
- A face mask on the heating and cooling register at Station #9;
- Black mats, approximately 9 feet by 6 feet, dirty and with white precipitate in Stations # 9,10,11, and in the Isolation Room;
- Three blue dialysis treatment chairs in the back hallway adjacent to the Isolation Room with dust and streaks on the entire chair and with unidentified particles on the material between the chair and the footrest;
- No toilet paper on the toilet paper holder in the patient's restroom directly across from the Nurses Station;
- Dead insects in the light fixtures throughout the unit
- Black floor trim approximately two inches in width surrounding the perimeter in front of each dialysis station with approximately 120 feet long with approximately twelve feet missing with the dirty floor exposed;
- The bedside tables at each station with accumulated dirt and dust on the tops and the stand base area;
- Three steel carts with clean supplies with dust, debris, stains and dirty containers for the clean supplies;
- Patient bins with individual patient supplies placed at each station and not cleaned before placing back into the storage cabinet, when supplies were only to be taken to the station and the bin left in the cabinet;
- Twelve (12) of twelve (12) blood pressure stands dust covered;
- Twelve (12) of twelve (12) televisions in patients' stations dust covered;
- Blood Pressure cuff lying on the floor is Station #7;
- Leak in the wall at Station #7
- Bicarbonate Room with everything, including all pipe connections, coated with dust and white precipitate;
- The floor drain from the bicarbonate tank is directly into the fluid in the bottom of the drain for approximately six (6) inches (this does not protect the contents of the bicarbonate tank from backflow of contaminated liquid or debris from the drain; and
- The water room floor drain with debris of paper, strips and unidentified items partially obstructing the drain.

13. Observation on 01/26/2010 showed Staff A, MSN, RN, Associate Chief Nursing Officer, and Staff S, Chief Operating Officer, in their business suits cleaning three dialysis treatment chairs in the hallway by the isolation room.