The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on document review, observation and interview, the facility did not ensure: a) adherence to their Policy and Procedure regarding isolation, b) staff followed Standard Infection Control Practices regarding the cleaning of surfaces, maintained environmental isolation and proper use of PPE (Personnel Protective Equipment.) and, c) medications were stored and prepared in a clean environment.

This places patients at risk for cross contamination and potential hospital acquired infection.

Findings pertinent to a) above include:

Observations of the facility's Acute Dialysis Unit (ADU) during a tour between 9:30AM-10:00AM on 04/02/19 identified the following:

Three (3) Patient Stations with curtains hanging at each station. The curtain between Stations #2 and #3 were noted to be in contact with both Patient #7's (Station #2) and Patient #6's (Station #3) Hemodialysis and Reverse Osmosis (RO) machines during their dialysis.

Observation of Patient #6, admitted to the facility on [DATE], noted the patient was on contact precautions for Carbapenem-Resistant Enterobacteriaceae (CRE) of the blood.

Review of the "Department Appointment Reports" [Patient Schedule] revealed that Patient #6 had received dialysis on the Dialysis Unit twenty-three (23) times since 02/01/19.

The facility Policy and Procedure titled "Cubicle Curtain Cleaning" last dated 01/21/19, instructs "All cubical curtains in isolation rooms will be cleaned as soon as the patient in the room is discharged ."

Review of the facility "Monthly Cubicle Curtain Cleaning Log" revealed that the ADU curtains were last changed in January 2019. There was no documented evidence that the curtains in the Dialysis Unit were changed after the hemodialysis treatment of an Isolation Patient as per facility Policy.

During interview with Staff E, Director of Environmental Services, on 04/02/19 at 2:00PM, the staff member confirmed these findings.

Per interview with Staff I, Director of Infection Control, on 04/02/19 at 1:10PM, the Unit should be changing the ADU curtains after each isolation patient.

Findings pertinent to b) above include:

Observations in the facility's Acute Hemodialysis Unit on 04/02/19 between 1:00PM and 3:00PM identified the following:

Staff J (RN) at Station #3 and Staff H (RN) at Station #2, were observed providing patient care and cleaning and disinfecting the Dialysis Station between patients.

At Station #3 Patient #6 was on Contact Isolation for CRE of the blood. As Staff J (RN) was providing patient care, her gown had contact with the bed linen, hemodialysis machine, and curtain. She exited the station without doffing her "dirty" gown to obtain clean supplies. Then she returned to Station #3 to provide patient care.

In order to move CRE Contact Isolation Patient #6 from the hemodialysis chair to the stretcher via a Hoyer lift, two (2) staff members stood against Patient #7's bed in Station #2 who was not on isolation. They brought the "dirty" chair into Station #2 and when the task was completed Patient #6's "dirty" chair was placed against Patient #7's bed.

Staff H (RN) removed the needles from Patient #7's access. Because the sharps container was not accessible, the staff member carrying the needles exited the station. He walked past a patient, staff member and surveyor, approximately twelve (12) feet, to discard the needles.

The same problem of disposing of needles in the sharps container outside the patient's station was observed with Staff J (RN).

The outside surfaces of the dialysate concentrate containers, the internal and external surfaces of the prime waste container, call buttons, Oxygen gauges, suction gauges, suction container and tubing, RO tubes, hoses and connections on the wall, the RO machine and carbon tanks, books on the RO and hemodialysis machines were not disinfected.

Wall mounted baskets behind the RO machines containing medical equipment (Oxygen tubing and suction tubes) were not discarded between patients.

A blood pressure cuff was disinfected and placed in the basket, on the side of the hemodialysis machine, containing "dirty" blood pressure cuffs and tubing.

Two (2) pillows and a cushion from Station #3 (Contact Isolation) were placed on top of the linen hamper outside Station #3. The top of the hamper was not disinfected after the "dirty" pillows and cushion had contact with it.

Per interview with Staff Members H and J, at the time of the observations, the stations were ready for the next patient.

During interview with Staff I (Director of Infection Prevention) and Staff A (Vice President) on 04/03/19 at 12:55PM they acknowledged the findings. Staff I agreed the gown needed to be removed before the Nurse left the Patient Station, that the needles need to be discarded in sharps containers at the station and that the isolation patient's "dirty" equipment should never have been placed in the non-isolation patient's station.

The facility Policy and Procedure titled "Disinfection of Dialysis Related Equipment" last revised 07/2004, stated the following: "Dialysis related equipment will be disinfected after each patient use. Give special attention to cleaning ... other surfaces that are frequently touched and potentially contaminated with patient's blood - this includes call bell and any other items that are touched by the patient or healthcare personnel."

The facility Policy and Procedure titled "Isolation Precautions/Standard Precautions" last revised 12/15, stated the following: "Contact Precautions: Patient Care Equipment: When possible dedicate the use of noncritical patient care equipment to a single patient to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patients. Gown: Remove the gown before leaving the patient's environment."

Findings pertinent to c) above include:

Observations of the facility's Acute Dialysis Unit (ADU) during a tour between 9:30AM-10:00AM on 04/02/19 identified the following:

A cabinet containing patient medications was being stored inside of Patient Station #1 Treatment Area. The cabinet was less than 1-2 (one to two) feet from where dialysis patients' chairs or beds would be while receiving hemodialysis treatment.

The facility Policy and Procedure titled "Medication - Administration", last revised 01/16/19, instructs "when medications are delivered to the Nursing Unit, they will be in the appropriate place. (Pyxis, Med cart, med room)"

The Unit did not contain a Med Room or any clean area for the preparation of medication.

Also, it was observed that several jugs containing the dialysate components (Bicarbonate and Acid) were noted to be stored in an Equipment Storage Room. The room was not locked and access to the room was not controlled.