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Based on record reviews and interviews, the Governing Body failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients. The facility failed to:


1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments; and


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments, and;


3.) Ensure dialysis patients were tested for Hepatitis B prior to receiving dialysis treatments.


4.) Ensure dialysis patients were properly weighed prior to and after dialysis treatments according to established dialysis procedures and facility policy


This deficient practice placed all 41 patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


An Immediate Jeopardy situation was identified and reported to the facility on 10/14/15, at 11:05 a.m., and lifted on 10/14/15, at 6:00 p.m. prior to exiting the facility.


Findings included:


1a) Observations conducted on 10/13/15, at 10:30 a.m. on the Intensive Care Unit (ICU) revealed Patient #1 was on isolation for C-Difficile (C-Diff) Toxin, Vancomycin Resistant Enterococci (VRE) of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, had a tracheostomy, was on a ventilator, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:


· Dialysis nursing staffs RN-A and LVN-A were at the bedside. Neither staffs were wearing face shields while performing the dialysis treatment. In addition, their protective respiratory face masks were down around their necks.


· RN-A had her long braided hair down, which was coming into contact with the front of her protective gown. RN-A manipulated the patient ' s dialysis blood lines, then without changing her gloves, moved her hair with her gloved hands. The front of the gown was gaped open at the neck, exposing the neck and upper chest area of her clothing.

· The only sink available for handwashing was located in the patient bathroom, and was being used to provide water to the portable RO unit. The sink faucet was hooked up via a hose to the RO water inlet. Staffs were not able to wash their hands before exiting the isolation room. In addition, cannulation supplies (blood lines, needles), test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.


1b) Observations conducted on 10/14/15, at 9:15 a.m., on the medical surgical floor, with the facility Quality Assurance (QA) nurse, revealed Patient #2 was on isolation for blood borne Methicillin-resistant Staphylococcus aureus (MRSA) infection, was using a c-pap machine to assist with respiration, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:


· Dialysis nursing staffs RN-B and LVN-B were at the bedside. The dialysis blood lines were observed running across the patient ' s face and C-pap mask to his Central Venous Catheter (CVC) in his right upper chest. LVN-B was observed to remove her protective gown, gloves, and face shield in the patient ' s bathroom. She proceeded to walk the entire length of the patient ' s isolation room, with her clothing exposed, coming into contact with the dialysis machine and the foot of patient #2 ' s bed. She then exited the isolation room to obtain supplies.


· RN-B was observed to disconnect the dialysis blood lines. He then, without changing/ removing his gloves, placed his gloved hand underneath his protective gown touching his clothing, trying to obtain a pen from the upper pocket of his scrub top.


1c) Observations conducted on 10/14/15, at 10:30 a.m., on the medical surgical floor, with the facility QA nurse, revealed patient #3 was on isolation for Multi drug resistant (MDR) E. Coli and MDR Enterococcus Faecalis, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:


· Dialysis nursing staffs RN-B and LVN-B were at the bedside. Both staffs were still wearing the same contaminated clothing. RN-B was observed with blood on his gloves after accessing patient #3's arteriovenous graft (AVG) used for dialysis treatment. Without removing/ changing his gloves, RN-B proceeded to open the room door with his soiled gloves, seemingly trying to exit the room while still wearing his protective equipment. The surveyor asked him not to exit the isolation room while wearing his PPE. RN-B was then observed to be holding the same pen he had used in Patient #2 ' s isolation room. He then used his blood soiled gloves to open his protective gown, and attempt to place the pen in the upper pocket of his scrub top.

· RN-B and LVN-B did not weigh the dialysis patient prior to and after the dialysis treatment according to established dialysis policy and procedures. RN-B and LVN-B acknowledged they guessed at the pre and post weights because they were not certain of what equipment to use to weigh bed-bound dialysis patients.


Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:


2.) Droplet precautions

-Wear a surgical mask when entering the room.

- Maintain strict adherence to universal/ standard precautions concerning protection from splash exposures.


3.) Contact Precautions (C-Diff, MRSA, VRE, ect ...)

-Maintain strict adherence to universal/ standard precautions.

-Change gloves during the course of providing patient care after having contact with infective material (feces, wound drainage, blood)

- Remove gloves before leaving the patient care environment.

- Wash hands immediately with an antimicrobial agent or waterless antiseptic.

- Ensure hands do not touch contaminated surfaces after handwashing upon exit.

-Wear a clean, non-sterile gown when entering the room ...

- Remove gown before leaving the patient environment.

- Ensure that clothing does not come into contact with potentially contaminated surfaces upon exit. In the event that a staff member's clothing is contaminated; a hospital gown must be worn over the staff members clothing for the remainder of the shift to prevent further possible cross contamination.


2a) Observations conducted on 10/13/15, at 1:30 p.m., of the facility dialysis treatment area, with the facility Chief Nursing Officer (CNO) and the Contracted Dialysis Facility Administrator (FA) revealed the following:


· RN-A and LVN-A placed the dialysis machine used in patient #1's isolation room on the dialysis treatment floor. A face shield which was visibly soiled with biological material and a blue nylon blood pressure cuff (non- disposable and non- wipeable) were hanging from an Intravenous (I.V.) pole attached to the machine. The dialysis machine had a white substance observed on the programming screen.

· The portable RO unit which was also used in patient #1's isolation room was sitting in the area used to store clean supplies. The unit was in direct contact with the clean supply shelves. Cannulation supplies, test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.


In an interview conducted on 10/13/15, at 1:40 p.m., both the CNO and dialysis FA confirmed the above findings, stating that the dialysis machine, face shield, blood pressure cuff and RO unit, including the cannulation supplies, test strips, phoenix meter, and wrench, were the same equipment used to treat patient #1. The FA stated that staffs only wipe down the front exterior of the dialysis machine with antimicrobial wipes. He further revealed that packaged supplies and non-disposable equipment (blood pressure cuffs, pipe wrenches, ect..) are routinely used in isolation rooms. These supplies are not disinfected or discarded, and are placed back into circulation for use with other patients. The FA acknowledged that he did not have clinical director or designated clinician to assist in monitoring the dialysis nursing staff with regulatory requirements and quality related issues. During further interview, the CNO stated that facility policy requires all durable medical equipment to be terminally cleaned before removal from isolation rooms, with only disposable blood pressure cuffs, stethoscopes and supplies used and disposed of at the conclusion of patient care; the dialysis staff were required to weigh all patients pre and post dialysis treatments according to established dialysis procedure and facility policy. The CNO indicated that the facility had devices including hoyer lifts to assist in determining patient weights.


2b) Observations conducted on 10/14/15, at 9:15 a.m., on the medical surgical floor, with the facility Quality Assurance (QA) nurse revealed Patient #2 was on isolation for blood borne MRSA infection, and was actively receiving hemodialysis treatment at the bedside.


In an interview conducted on 10/14/15, at 9:30 a.m., the surveyor asked RN-B how dialysis machines were internally disinfected after use on isolation patients with blood borne pathogens (hepatitis, MRSA, ect ...). RN-B stated that the dialysis nursing staffs are responsible for doing the bleach disinfection of dialysis machines, and that hemodialysis machines are only internally disinfected with bleach once a week (Wednesdays) regardless of the circumstances.


2c) Observation conducted on 10/14/15, at 3:30 p.m., in the facility revealed RN-B wheeled the portable RO cart out of Patient #3 ' s isolation room and left it sitting in the hall outside the dialysis treatment area. A bottle of water test strips, phoenix meter, and a rust corroded pipe wrench were noted on top of the cart.


In an interview conducted on 10/14/15, at 3:30 p.m., RN-B confirmed the water test strips, phoenix meter, and pipe wrench were used in patient #3's isolation room and had not been disinfected. He further stated that he was not aware that supplies had to be disinfected and/or disposed of prior to leaving the isolation area.


Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

3f.) Patient Care Equipment:

-When possible, dedicate the use of non- critical patient care
Equipment to a single patient.

- If use of common equipment or items is unavoidable, adequately Clean and disinfect them before use for another patient.


Record review of the facility policy entitled: Environmental Services Cleaning Procedures- Terminal Isolation Cleaning, dated 3/1999, revealed the following:

C.) Assemble all supplies- germicidal solution.

8.) All central supply equipment should be wiped down with a germicidal Solution and returned to the central supply for disinfection.

10.) Clean all equipment.


3) Record review of patient #1's medical record revealed she was a 72 year old, female, admitted on 9/11/15, with diagnosis of: Recurrent C-diff, VRE of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, hear failure, End Stage Renal Disease (ESRD) anemia, and tracheostomy. Further review revealed Patient #1 had been receiving hemodialysis treatments at the facility since admission on 9/11/15. A Hepatitis B panel had not been obtained until 10/07/15 (26 days) after admission.


Record review of patient #2's medical record revealed he was a 64 year old, male, with diagnosis of: MRSA of the blood, chronic respiratory failure, cellulitis, obstructive sleep apnea, congestive heart failure, hypertension, Diabetes Mellitus Type 2 (DM II), and ESRD. Further review revealed Patient #2 had been receiving dialysis treatments at the facility since admission on 8/26/15, with no evidence that a Hepatitis B panel had been obtained.

Record review of patient #3's medical record revealed she was a 69 year old, female, with diagnosis of: MDR E. Coli, MDR Enterococcus Faecalis, Hypertension, DM II, and ESRD. Further review revealed Patient #3 had been receiving hemodialysis treatments at the facility since admission 10/06/15, with no evidence that a Hepatitis B panel had been obtained.



In an interview conducted on 10/13/15, at 2:35 p.m., the facility CNO and QA nurse confirmed the above findings, and stated that the facility does not obtain Hepatitis B panels on dialysis patients unless they are seeking community placement for them after discharge.


In an interview conducted on 10/13/15, at 2:50 p.m., the dialysis FA stated, "We (facility) do not have to draw Hepatitis B labs on our patients here because we are in acute care. You only have to do that (draw Hepatitis B panel) in the chronic (long term) dialysis setting." During further interview, the dialysis FA revealed the facility does not have a designated dialysis machine for the treatment of Hepatitis B positive patients.


In an interview conducted on 10/14/15, at 4:00 p.m., the CNO stated the facility had been aware of some of the deficient practices identified by the Surveyors for over a month prior and acknowledged the facility should have made more significant changes and improvements.


Review of the facility's last quarter Governing Board Minutes did not document the deficient practices identified by the Surveyors.

Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:


1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments, and;


3.) Ensure dialysis patients were tested for Hepatitis B prior to receiving dialysis treatments.


This deficient practice placed all 41 patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


An Immediate Jeopardy was identified on 10/14/15, at 11:05 a.m., and removed on 10/14/15 at 6:00 p.m.


Refer to tag: A-0749






29363

Based on record reviews and interviews, the Governing Body failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients. The facility failed to:

1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments; and

2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments, and;

3.) Ensure dialysis patients were tested for Hepatitis B prior to receiving dialysis treatments.

4.) Ensure dialysis patients were properly weighed prior to and after dialysis treatments according to established dialysis procedures and facility policy

This deficient practice placed all 41 patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


Findings included:

1a) Observations conducted on 10/13/15 at 10:30 a.m. on the Intensive Care Unit (ICU) revealed Patient #1 was on isolation for C-Difficile (C-Diff) Toxin, Vancomycin Resistant Enterococci (VRE) of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, had a tracheostomy, was on a ventilator, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-A and LVN-A were at the bedside. Neither staffs were wearing face shields while performing the dialysis treatment. In addition, their protective respiratory face masks were down around their necks.

· RN-A had her long braided hair down, which was coming into contact with the front of her protective gown. RN-A manipulated the patient ' s dialysis blood lines, then without changing her gloves, moved her hair with her gloved hands. The front of the gown was gaped open at the neck, exposing the neck and upper chest area of her clothing.

· The only sink available for handwashing was located in the patient bathroom, and was being used to provide water to the portable RO unit. The sink faucet was hooked up via a hose to the RO water inlet. Staffs were not able to wash their hands before exiting the isolation room. In addition, cannulation supplies (blood lines, needles), test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.

1b) Observations conducted on 10/14/15 at 9:15 a.m. on the medical surgical floor, with the facility Quality Assurance (QA) nurse, revealed Patient #2 was on isolation for blood borne Methicillin-resistant Staphylococcus aureus (MRSA) infection, was using a c-pap machine to assist with respiration, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-B and LVN-B were at the bedside. The dialysis blood lines were observed running across the patient ' s face and C-pap mask to his Central Venous Catheter (CVC) in his right upper chest. LVN-B was observed to remove her protective gown, gloves, and face shield in the patient ' s bathroom. She proceeded to walk the entire length of the patient ' s isolation room, with her clothing exposed, coming into contact with the dialysis machine and the foot of patient #2 ' s bed. She then exited the isolation room to obtain supplies.

· RN-B was observed to disconnect the dialysis blood lines. He then, without changing/ removing his gloves, placed his gloved hand underneath his protective gown touching his clothing, trying to obtain a pen from the upper pocket of his scrub top.


1c) Observations conducted on 10/14/15 at 10:30 a.m. on the medical surgical floor, with the facility QA nurse, revealed patient #3 was on isolation for Multi drug resistant (MDR) E. Coli and MDR Enterococcus Faecalis, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-B and LVN-B were at the bedside. Both staffs were still wearing the same contaminated clothing. RN-B was observed with blood on his gloves after accessing patient #3 ' s arteriovenous graft (AVG) used for dialysis treatment. Without removing/ changing his gloves, RN-B proceeded to open the room door with his soiled gloves, seemingly trying to exit the room while still wearing his protective equipment. The surveyor asked him not to exit the isolation room while wearing his PPE. RN-B was then observed to be holding the same pen he had used in Patient #2 ' s isolation room. He then used his blood soiled gloves to open his protective gown, and attempt to place the pen in the upper pocket of his scrub top.
· RN-B and LVN-B did not weigh the dialysis patient prior to and after the dialysis treatment according to established dialysis policy and procedures. RN-B and LVN-B acknowledged they guessed at the pre and post weights because they were not certain of what equipment to use to weigh bed-bound dialysis patients.

Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

2.) Droplet precautions
-Wear a surgical mask when entering the room.
- Maintain strict adherence to universal/ standard precautions concerning protection from splash exposures.

3.) Contact Precautions (C-Diff, MRSA, VRE, ect ...)
-Maintain strict adherence to universal/ standard precautions.
-Change gloves during the course of providing patient care after
having contact with infective material (feces, wound drainage, blood)
- Remove gloves before leaving the patient care environment.
- Wash hands immediately with an antimicrobial agent or waterless
antiseptic.
- Ensure hands do not touch contaminated surfaces after handwashing
upon exit.
-Wear a clean, non-sterile gown when entering the room ...
- Remove gown before leaving the patient environment.
- Ensure that clothing does not come into contact with potentially
Contaminated surfaces upon exit. In the event that a staff member ' s
clothing is contaminated; a hospital gown must be worn over the staff
members clothing for the remainder of the shift to prevent further
possible cross contamination.

2a) Observations conducted on 10/13/15 at 1:30 p.m. of the facility dialysis treatment area, with the facility Chief Nursing Officer (CNO) and the Contracted Dialysis Facility Administrator (FA) revealed the following:

· RN-A and LVN-A placed the dialysis machine used in patient #1 ' s isolation room on the dialysis treatment floor. A face shield which was visibly soiled with biological material and a blue nylon blood pressure cuff (non- disposable and non- wipeable) were hanging from an Intravenous (I.V.) pole attached to the machine. The dialysis machine had a white substance observed on the programming screen.

· The portable RO unit which was also used in patient #1 ' s isolation room was sitting in the area used to store clean supplies. The unit was in direct contact with the clean supply shelves. Cannulation supplies, test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.

In an interview conducted on 10/13/15 at 1:40 p.m. both the CNO and dialysis FA confirmed the above findings, stating that the dialysis machine, face shield, blood pressure cuff and RO unit, including the cannulation supplies, test strips, phoenix meter, and wrench, were the same equipment used to treat patient #1. The FA stated that staffs only wipe down the front exterior of the dialysis machine with antimicrobial wipes. He further revealed that packaged supplies and non-disposable equipment (blood pressure cuffs, pipe wrenches, ect..) are routinely used in isolation rooms. These supplies are not disinfected or discarded, and are placed back into circulation for use with other patients. The FA acknowledged that he did not have clinical director or designated clinician to assist in monitoring the dialysis nursing staff with regulatory requirements and quality related issues. During further interview, the CNO stated that facility policy requires all durable medical equipment to be terminally cleaned before removal from isolation rooms, with only disposable blood pressure cuffs, stethoscopes and supplies used and disposed of at the conclusion of patient care; the dialysis staff were required to weigh all patients pre and post dialysis treatments according to established dialysis procedure and facility policy. The CNO indicated that the facility had devices including hoyer lifts to assist in determining patient weights.

2b) Observations conducted on 10/14/15 at 9:15 a.m. on the medical surgical floor, with the facility Quality Assurance (QA) nurse revealed Patient #2 was on isolation for blood borne MRSA infection, and was actively receiving hemodialysis treatment at the bedside.

In an interview conducted on 10/14/15 at 9:30 a.m., the surveyor asked RN-B how dialysis machines were internally disinfected after use on isolation patients with blood borne pathogens (hepatitis, MRSA, ect ...). RN-B stated that the dialysis nursing staffs are responsible for doing the bleach disinfection of dialysis machines, and that hemodialysis machines are only internally disinfected with bleach once a week (Wednesdays) regardless of the circumstances.

2c) Observation conducted on 10/14/15 at 3:30 p.m. in the facility revealed RN-B wheeled the portable RO cart out of Patient #3 ' s isolation room and left it sitting in the hall outside the dialysis treatment area. A bottle of water test strips, phoenix meter, and a rust corroded pipe wrench were noted on top of the cart.

In an interview conducted on 10/14/15 at 3:30 p.m., RN-B confirmed the water test strips, phoenix meter, and pipe wrench were used in patient #3 ' s isolation room and had not been disinfected. He further stated that he was not aware that supplies had to be disinfected and/or disposed of prior to leaving the isolation area.

Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:
3f.) Patient Care Equipment:
-When possible, dedicate the use of non- critical patient care
Equipment to a single patient.
- If use of common equipment or items is unavoidable, adequately
Clean and disinfect them before use for another patient.

Record review of the facility policy entitled: Environmental Services Cleaning Procedures- Terminal Isolation Cleaning, dated 3/1999, revealed the following:
C.) Assemble all supplies- germicidal solution.
8.) All central supply equipment should be wiped down with a germicidal Solution and returned to the central supply for disinfection.
10.) Clean all equipment.

3) Record review of patient #1 ' s medical record revealed she was a 72 year old female, admitted on 9/11/15 with diagnosis of: Recurrent C-diff, VRE of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, hear failure, End Stage Renal Disease (ESRD) anemia, and tracheostomy. Further review revealed Patient #1 had been receiving hemodialysis treatments at the facility since admission on 9/11/15. A Hepatitis B panel had not been obtained until 10/07/15 (26 days) after admission.

Record review of patient #2 ' s medical record revealed he was a 64 year old male with diagnosis of: MRSA of the blood, chronic respiratory failure, cellulitis, obstructive sleep apnea, congestive heart failure, hypertension, Diabetes Mellitus Type 2 (DM II), and ESRD. Further review revealed Patient #2 had been receiving dialysis treatments at the facility since admission on 8/26/15, with no evidence that a Hepatitis B panel had been obtained.


Record review of patient #3 ' s medical record revealed she was a 69 year old female with diagnosis of: MDR E. Coli, MDR Enterococcus Faecalis, Hypertension, DM II, and ESRD. Further review revealed Patient #3 had been receiving hemodialysis treatments at the facility since admission 10/06/15, with no evidence that a Hepatitis B panel had been obtained.


In an interview conducted on 10/13/15 at 2:35 p.m. the facility CNO and QA nurse confirmed the above findings, and stated that the facility does not obtain Hepatitis B panels on dialysis patients unless they are seeking community placement for them after discharge.

In an interview conducted on 10/13/15 at 2:50 p.m., the dialysis FA stated, " We (facility) do not have to draw Hepatitis B labs on our patients here because we are in acute care. You only have to do that (draw Hepatitis B panel) in the chronic (long term) dialysis setting. " During further interview, the dialysis FA revealed the facility does not have a designated dialysis machine for the treatment of Hepatitis B positive patients.



29363

Based on record reviews and interviews, the hospital's administration failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients. The facility failed to:

1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments; and

2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments, and;

3.) Ensure dialysis patients were tested for Hepatitis B prior to receiving dialysis treatments.

4.) Ensure dialysis patients were properly weighed prior to and after dialysis treatments according to established dialysis procedures and facility policy


This deficient practice placed all 41 patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


Findings included:

1a) Observations conducted on 10/13/15 at 10:30 a.m. on the Intensive Care Unit (ICU) revealed Patient #1 was on isolation for C-Difficile (C-Diff) Toxin, Vancomycin Resistant Enterococci (VRE) of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, had a tracheostomy, was on a ventilator, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-A and LVN-A were at the bedside. Neither staffs were wearing face shields while performing the dialysis treatment. In addition, their protective respiratory face masks were down around their necks.

· RN-A had her long braided hair down, which was coming into contact with the front of her protective gown. RN-A manipulated the patient ' S dialysis blood lines, then without changing her gloves, moved her hair with her gloved hands. The front of the gown was gaped open at the neck, exposing the neck and upper chest area of her clothing.

· The only sink available for handwashing was located in the patient bathroom, and was being used to provide water to the portable RO unit. The sink faucet was hooked up via a hose to the RO water inlet. Staffs were not able to wash their hands before exiting the isolation room. In addition, cannulation supplies (blood lines, needles), test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.

1b) Observations conducted on 10/14/15 at 9:15 a.m. on the medical surgical floor, with the facility Quality Assurance (QA) nurse, revealed Patient #2 was on isolation for blood borne Methicillin-resistant Staphylococcus aureus (MRSA) infection, was using a c-pap machine to assist with respiration, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-B and LVN-B were at the bedside. The dialysis blood lines were observed running across the patient ' S face and C-pap mask to his Central Venous Catheter (CVC) in his right upper chest. LVN-B was observed to remove her protective gown, gloves, and face shield in the patient ' S bathroom. She proceeded to walk the entire length of the patient ' s isolation room, with her clothing exposed, coming into contact with the dialysis machine and the foot of patient #2 ' s bed. She then exited the isolation room to obtain supplies.

· RN-B was observed to disconnect the dialysis blood lines. He then, without changing/ removing his gloves, placed his gloved hand underneath his protective gown touching his clothing, trying to obtain a pen from the upper pocket of his scrub top.

1c) Observations conducted on 10/14/15 at 10:30 a.m. on the medical surgical floor, with the facility QA nurse, revealed patient #3 was on isolation for Multi drug resistant (MDR) E. Coli and MDR Enterococcus Faecalis, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-B and LVN-B were at the bedside. Both staffs were still wearing the same contaminated clothing. RN-B was observed with blood on his gloves after accessing patient #3 ' s arteriovenous graft (AVG) used for dialysis treatment. Without removing/ changing his gloves, RN-B proceeded to open the room door with his soiled gloves, seemingly trying to exit the room while still wearing his protective equipment. The surveyor asked him not to exit the isolation room while wearing his PPE. RN-B was then observed to be holding the same pen he had used in Patient #2 ' s isolation room. He then used his blood soiled gloves to open his protective gown, and attempt to place the pen in the upper pocket of his scrub top.

· RN-B and LVN-B did not weigh the dialysis patient prior to and after the dialysis treatment according to established dialysis policy and procedures. RN-B and LVN-B acknowledged they guessed at the pre and post weights because they were not certain of what equipment to use to weigh bed-bound dialysis patients.

Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

2.) Droplet precautions
-Wear a surgical mask when entering the room.
- Maintain strict adherence to universal/ standard precautions concerning protection from splash exposures.

3.) Contact Precautions (C-Diff, MRSA, VRE, ect ...)
-Maintain strict adherence to universal/ standard precautions.
-Change gloves during the course of providing patient care after
having contact with infective material (feces, wound drainage, blood)
- Remove gloves before leaving the patient care environment.
- Wash hands immediately with an antimicrobial agent or waterless
antiseptic.
- Ensure hands do not touch contaminated surfaces after handwashing
upon exit.
-Wear a clean, non-sterile gown when entering the room ...
- Remove gown before leaving the patient environment.
- Ensure that clothing does not come into contact with potentially
Contaminated surfaces upon exit. In the event that a staff member ' s
clothing is contaminated; a hospital gown must be worn over the staff
members clothing for the remainder of the shift to prevent further
possible cross contamination.

2a) Observations conducted on 10/13/15 at 1:30 p.m. of the facility dialysis treatment area, with the facility Chief Nursing Officer (CNO) and the Contracted Dialysis Facility Administrator (FA) revealed the following:

· RN-A and LVN-A placed the dialysis machine used in patient #1 ' s isolation room on the dialysis treatment floor. A face shield which was visibly soiled with biological material and a blue nylon blood pressure cuff (non- disposable and non- wipeable) were hanging from an Intravenous (I.V.) pole attached to the machine. The dialysis machine had a white substance observed on the programming screen.

· The portable RO unit which was also used in patient #1 ' s isolation room was sitting in the area used to store clean supplies. The unit was in direct contact with the clean supply shelves. Cannulation supplies, test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.

In an interview conducted on 10/13/15 at 1:40 p.m. both the CNO and dialysis FA confirmed the above findings, stating that the dialysis machine, face shield, blood pressure cuff and RO unit, including the cannulation supplies, test strips, phoenix meter, and wrench, were the same equipment used to treat patient #1. The FA stated that staffs only wipe down the front exterior of the dialysis machine with antimicrobial wipes. He further revealed that packaged supplies and non-disposable equipment (blood pressure cuffs, pipe wrenches, ect..) are routinely used in isolation rooms. These supplies are not disinfected or discarded, and are placed back into circulation for use with other patients. The FA acknowledged that he did not have clinical director or designated clinician to assist in monitoring the dialysis nursing staff with regulatory requirements and quality related issues. During further interview, the CNO stated that facility policy requires all durable medical equipment to be terminally cleaned before removal from isolation rooms, with only disposable blood pressure cuffs, stethoscopes and supplies used and disposed of at the conclusion of patient care; the dialysis staff were required to weigh all patients pre and post dialysis treatments according to established dialysis procedure and facility policy. The CNO indicated that the facility had devices including hoyer lifts to assist with determining patient weights.

2b) Observations conducted on 10/14/15 at 9:15 a.m. on the medical surgical floor, with the facility Quality Assurance (QA) nurse revealed Patient #2 was on isolation for blood borne MRSA infection, and was actively receiving hemodialysis treatment at the bedside.

In an interview conducted on 10/14/15 at 9:30 a.m., the surveyor asked RN-B how dialysis machines were internally disinfected after use on isolation patients with blood borne pathogens (hepatitis, MRSA, ect ...). RN-B stated that the dialysis nursing staffs are responsible for doing the bleach disinfection of dialysis machines, and that hemodialysis machines are only internally disinfected with bleach once a week (Wednesdays) regardless of the circumstances.

2c) Observation conducted on 10/14/15 at 3:30 p.m. in the facility revealed RN-B wheeled the portable RO cart out of Patient #3 ' s isolation room and left it sitting in the hall outside the dialysis treatment area. A bottle of water test strips, phoenix meter, and a rust corroded pipe wrench were noted on top of the cart.

In an interview conducted on 10/14/15 at 3:30 p.m., RN-B confirmed the water test strips, phoenix meter, and pipe wrench were used in patient #3 ' s isolation room and had not been disinfected. He further stated that he was not aware that supplies had to be disinfected and/or disposed of prior to leaving the isolation area.

Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:
3f.) Patient Care Equipment:
-When possible, dedicate the use of non- critical patient care
Equipment to a single patient.
- If use of common equipment or items is unavoidable, adequately
Clean and disinfect them before use for another patient.

Record review of the facility policy entitled: Environmental Services Cleaning Procedures- Terminal Isolation Cleaning, dated 3/1999, revealed the following:
C.) Assemble all supplies- germicidal solution.
8.) All central supply equipment should be wiped down with a germicidal Solution and returned to the central supply for disinfection.
10.) Clean all equipment.

3) Record review of patient #1 ' s medical record revealed she was a 72 year old female, admitted on 9/11/15 with diagnosis of: Recurrent C-diff, VRE of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, hear failure, End Stage Renal Disease (ESRD) anemia, and tracheostomy. Further review revealed Patient #1 had been receiving hemodialysis treatments at the facility since admission on 9/11/15. A Hepatitis B panel had not been obtained until 10/07/15 (26 days) after admission.

Record review of patient #2 ' s medical record revealed he was a 64 year old male with diagnosis of: MRSA of the blood, chronic respiratory failure, cellulitis, obstructive sleep apnea, congestive heart failure, hypertension, Diabetes Mellitus Type 2 (DM II), and ESRD. Further review revealed Patient #2 had been receiving dialysis treatments at the facility since admission on 8/26/15, with no evidence that a Hepatitis B panel had been obtained.


Record review of patient #3 ' s medical record revealed she was a 69 year old female with diagnosis of: MDR E. Coli, MDR Enterococcus Faecalis, Hypertension, DM II, and ESRD. Further review revealed Patient #3 had been receiving hemodialysis treatments at the facility since admission 10/06/15, with no evidence that a Hepatitis B panel had been obtained.


In an interview conducted on 10/13/15 at 2:35 p.m. the facility CNO and QA nurse confirmed the above findings, and stated that the facility does not obtain Hepatitis B panels on dialysis patients unless they are seeking community placement for them after discharge.

In an interview conducted on 10/13/15 at 2:50 p.m., the dialysis FA stated, "We (facility) do not have to draw Hepatitis B labs on our patients here because we are in acute care. You only have to do that (draw Hepatitis B panel) in the chronic (long term) dialysis setting." During further interview, the dialysis FA revealed the facility does not have a designated dialysis machine for the treatment of Hepatitis B positive patients.

Based on observation, interview and record review the facility failed to maintain a safe environment for the well-being of patients.

1) An approximate 2 inch diameter water drain pipe used to collect drain water from four hemodialysis stations was secured to a back wall of a hemodialysis treatment room and secured across an existing exit door. The door separated the hemodialysis treatment room and the rehabilitation department. The door was labeled "Not an Exit"

The facility's failure to install and secure a hemodialysis water drain pipe away from an existing exit door put the dialysis patients at risk for potential safety concerns.

The findings included:

During an observation of on 10/14/15 at approximately 11:00 a.m., a water drain pipe used to collect drain water from four hemodialysis stations was secured to a back wall of a hemodialysis treatment room and secured across an existing exit door. The door separated the hemodialysis treatment room and the rehabilitation department. The door was labeled "Not an Exit."

During an interview with the Director of Plant Operations on 10/14/15 at approximately 11:30 a.m. confirmed the hemodialysis water drain pipe was installed across an existing exit door without notification and or approval from the State Agency Life Safety Code and was potentially a safety concern for hemodialysis patients and or staff. The director acknowledged the water drain pipe could be structurally fractured and or broken if any personnel attempted to open the existing door from either side of the door causing process water to instantly drain to the floor in and around hemodialysis equipment and patients. The director also acknowledged the drain water pipe also blocked an exit/entrance door and limited exit routes in case of emergencies.

Review of the facility's First Floor Life Safety Plan undated did not clearly identify the water drain pipe installation in the hemodialysis treatment room.

During the Exit Conference on 10/14/15, the facility was given an opportunity to provide additional information regarding the water draining pipe in the hemodialysis treatment room and to ask questions. No additional information was provided.

Based on observations, interviews and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:


1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 3 of 3 isolation patients (#1, #2 and # 3) who received dialysis treatments, and;


3.) Ensure dialysis patients were tested for Hepatitis B prior to receiving dialysis treatments.


This deficient practice placed all 41 patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


An Immediate Jeopardy was identified on 10/14/15, at 11:05 a.m., and removed on 10/14/15 at 6:00 p.m.


Findings included:


1a) Observations conducted on 10/13/15, at 10:30 a.m., on the Intensive Care Unit (ICU) revealed Patient #1 was on isolation for C-Difficile (C-Diff) Toxin, Vancomycin Resistant Enterococci (VRE) of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, had a tracheostomy, was on a ventilator, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:


· Dialysis nursing staffs RN-A and LVN-A were at the bedside. Neither staffs were wearing face shields while performing the dialysis treatment. In addition, their protective respiratory face masks were down around their necks.


· RN-A had her long braided hair down, which was coming into contact with the front of her protective gown. RN-A manipulated the patient's dialysis blood lines, then without changing her gloves, moved her hair with her gloved hands. The front of the gown was gaped open at the neck, exposing the neck and upper chest area of her clothing.

· The only sink available for handwashing was located in the patient bathroom, and was being used to provide water to the portable RO unit. The sink faucet was hooked up via a hose to the RO water inlet. Staffs were not able to wash their hands before exiting the isolation room. In addition, cannulation supplies (blood lines, needles), test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.


1b) Observations conducted on 10/14/15, at 9:15 a.m., on the medical surgical floor, with the facility Quality Assurance (QA) nurse, revealed Patient #2 was on isolation for blood borne Methicillin-resistant Staphylococcus aureus (MRSA) infection, was using a c-pap machine to assist with respiration, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:


· Dialysis nursing staffs RN-B and LVN-B were at the bedside. The dialysis blood lines were observed running across the patient's face and C-pap mask to his Central Venous Catheter (CVC) in his right upper chest. LVN-B was observed to remove her protective gown, gloves, and face shield in the patient's bathroom. She proceeded to walk the entire length of the patient's isolation room, with her clothing exposed, coming into contact with the dialysis machine and the foot of patient #2's bed. She then exited the isolation room to obtain supplies.

· RN-B was observed to disconnect the dialysis blood lines. He then, without changing/ removing his gloves, placed his gloved hand underneath his protective gown touching his clothing, trying to obtain a pen from the upper pocket of his scrub top.


1c) Observations conducted on 10/14/15, at 10:30 a.m., on the medical surgical floor, with the facility QA nurse, revealed patient #3 was on isolation for Multi drug resistant (MDR) E. Coli and MDR Enterococcus Faecalis, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

· Dialysis nursing staffs RN-B and LVN-B were at the bedside. Both staffs were still wearing the same contaminated clothing. RN-B was observed with blood on his gloves after accessing patient #3's arteriovenous graft (AVG) used for dialysis treatment. Without removing/ changing his gloves, RN-B proceeded to open the room door with his soiled gloves, seemingly trying to exit the room while still wearing his protective equipment. The surveyor asked him not to exit the isolation room while wearing his PPE. RN-B was then observed to be holding the same pen he had used in Patient #2's isolation room. He then used his blood soiled gloves to open his protective gown, and attempt to place the pen in the upper pocket of his scrub top.


Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

2.) Droplet precautions

-Wear a surgical mask when entering the room.

- Maintain strict adherence to universal/ standard precautions concerning protection from splash exposures.


3.) Contact Precautions (C-Diff, MRSA, VRE, ect ...)
-Maintain strict adherence to universal/ standard precautions.

-Change gloves during the course of providing patient care after having contact with infective material (feces, wound drainage, blood)

- Remove gloves before leaving the patient care environment.

- Wash hands immediately with an antimicrobial agent or waterless antiseptic.

- Ensure hands do not touch contaminated surfaces after handwashing upon exit.

-Wear a clean, non-sterile gown when entering the room ...

- Remove gown before leaving the patient environment.

- Ensure that clothing does not come into contact with potentially contaminated surfaces upon exit. In the event that a staff member's clothing is contaminated; a hospital gown must be worn over the staff members clothing for the remainder of the shift to prevent further possible cross contamination.


2a) Observations conducted on 10/13/15, at 1:30 p.m., of the facility dialysis treatment area, with the facility Chief Nursing Officer (CNO) and the Contracted Dialysis Facility Administrator (FA) revealed the following:


· RN-A and LVN-A placed the dialysis machine used in patient #1's isolation room on the dialysis treatment floor. A face shield which was visibly soiled with biological material and a blue nylon blood pressure cuff (non- disposable and non- wipeable) were hanging from an Intravenous (I.V.) pole attached to the machine. The dialysis machine had a white substance observed on the programming screen.

· The portable RO unit which was also used in patient #1's isolation room was sitting in the area used to store clean supplies. The unit was in direct contact with the clean supply shelves. Cannulation supplies, test strips, phoenix meter, and a rust corroded pipe wrench were observed to be sitting on top of the RO cart.


In an interview conducted on 10/13/15, at 1:40 p.m., both the CNO and dialysis FA confirmed the above findings, stating that the dialysis machine, face shield, blood pressure cuff and RO unit, including the cannulation supplies, test strips, phoenix meter, and wrench, were the same equipment used to treat patient #1. The FA stated that staff only wipe down the front exterior of the dialysis machine with antimicrobial wipes. He further revealed that packaged supplies and non-disposable equipment (blood pressure cuffs, pipe wrenches, ect..) are routinely used in isolation rooms. These supplies are not disinfected or discarded, and are placed back into circulation for use with other patients. The FA acknowledged that he did not have clinical director or designated clinician to assist in monitoring the dialysis nursing staff with regulatory requirements and quality related issues. During further interview, the CNO stated that facility policy required all durable medical equipment to be terminally cleaned before removal from isolation rooms, with only disposable blood pressure cuffs, stethoscopes and supplies used and disposed of at the conclusion of patient care.


2b) Observations conducted on 10/14/15, at 9:15 a.m., on the medical surgical floor, with the facility Quality Assurance (QA) nurse revealed Patient #2 was on isolation for blood borne MRSA infection, and was actively receiving hemodialysis treatment at the bedside.


In an interview conducted on 10/14/15, at 9:30 a.m., the surveyor asked RN-B how dialysis machines were internally disinfected after use on isolation patients with blood borne pathogens (hepatitis, MRSA, ect ...). RN-B stated that the dialysis nursing staffs are responsible for doing the bleach disinfection of dialysis machines, and that hemodialysis machines are only internally disinfected with bleach once a week (Wednesdays) regardless of the circumstances.


In an interview conducted on 10/14/15, at 9:40 a.m., the facility QA nurse confirmed the above findings and the facility's deficient practice.


Record review of the dialysis machine microbiological testing for the months of August 2015- September 2015 revealed that 3 of 4 dialysis machines currently in use had microbiological cultures which exceeded action level, which is above 200 Colony Forming Units (CFU).


The facility CNO and QA nurse were notified of the immediate jeopardy in Infection Control on 10/14/15, at 11: 30 a.m.


The Facility's Plan of Removal was accepted by the survey team on 10/14/15, at 1:40 p.m. and included the following:


Infection Control/PPE:

· RN will remain in the room/dialysis unit while dialysis is being performed to assure adherence to PPE and isolation measures. Nurse to report any violations immediately to one or all of the following: ICC; Nurse Manager; Quality Director; CNO. Immediate action and in place. 10/14/15; 1:00p.m. Will be monitored for 2 weeks. Ongoing routine surveillance rounds.

· Dialysis hours will be performed between 8:00a.m.-5:00p.m. until further notice.

· Effective immediately.

· Immediate re-education on Infection Control measures during dialysis, to include, use of appropriate PPE, with return demonstration. Effective Immediately 10/14/15.

· Education on external disinfection of dialysis equipment with return demonstration. Scheduled for 10/14/15, at 3:30p.m. Ongoing prior to any dialysis treatments.

· Internal disinfection education to be performed by the Biomed personnel available through the dialysis contract service. Scheduled for 10/14/15, at 3:30p.m.

· Must perform return demonstration on Infection Control practices and be deemed competent by the Hospital Educator and Infection Control Coordinator. Scheduled for 10/14/15, at 3:30p.m.

· Failure to comply with utilization of appropriate PPE and Infection Control policies and procedures will result in nurse being removed from the facility with a 'DO NOT RETURN.' Immediate action and in place, 10/14/15, 1:00p.m.

· Annual skills fair will be mandatory for dialysis staff. Effective October 20-22 2015.



Care of the Patient

Hepatitis B Panel-

· Hepatitis B screening of Patient: Corporate is in process of revising the IRIS (Transferring documents from Hospitals) to include a gate for Hepatitis B panel that must be completed and documented, before the IRIS can be transmitted to the organization. Currently in process.

· The Clinical Liaisons will ensure that Hepatitis B panel is part of the admission packet.

· Patients that present without Hepatitis B documentation in the medical record will result in a call being placed to the transferring facility to obtain a copy of the most current Hepatitis B panel. Effective Immediately.

· If Hepatitis B panel cannot be obtained immediately from the transferring facility, or if it ' s greater than 30 days; an order will be obtained from the admitting physician to perform the Hepatitis B panel, in house. Effective immediately 10-14-15. Monitoring by Infection Control Coordinator; Case Management; Charge Nurses during weekends and after hours.

· If panel results are not available prior to the first dialysis treatment, the patient will be dialyzed and treated as an Isolation Patient. All isolation precautions will be adhered to. Effective immediately.

· On Friday October 16, 2015, at the APIC (Association for Practitioners Infection Control) meeting, the Hepatitis B panel topic will be placed on the agenda for coordination of care.

· On Friday October 30, 2015, at the STONE (South Texas Organization of Nurse Executives) meeting, the Hepatitis B panel topic will be placed on the agenda for coordination of care. Effective immediately.


Weights-
· Effective immediately, pre and post dialysis weights will be obtained and documented in the Medical Record. Effective Immediately and ongoing.

· Isolation patients on low beds will utilize the hoyer lift to obtain weights with appropriate disinfection. Effective Immediately and ongoing.


Hand off communication-

· The dialysis nurse will obtain report from the primary nurse prior to dialysis therapy. Dialysis nurse will report to the primary nurse at the end of treatment. Effective Immediately and ongoing.


Supervising RN-

· Hire qualified dialysis supervising RN by dialysis company.



Dialysis Contract Company

· RN with ongoing issues is a 'DO NOT RETURN.' Effective immediately.

· Renal Support Services contract will be terminated.


2c) Observation conducted on 10/14/15, at 3:30 p.m., in the facility revealed RN-B wheeled the portable RO cart out of Patient #3's isolation room and left it sitting in the hall outside the dialysis treatment area. A bottle of water test strips, phoenix meter, and a rust corroded pipe wrench were noted on top of the cart.


In an interview conducted on 10/14/15, at 3:30 p.m., RN-B confirmed the water test strips, phoenix meter, and pipe wrench were used in patient #3's isolation room and had not been disinfected. He further stated that he was not aware that supplies had to be disinfected and/or disposed of prior to leaving the isolation area.


Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

3f.) Patient Care Equipment:

-When possible, dedicate the use of non- critical patient care
equipment to a single patient.

- If use of common equipment or items is unavoidable, adequately clean and disinfect them before use for another patient.


Record review of the facility policy entitled: Environmental Services Cleaning Procedures- Terminal Isolation Cleaning, dated 3/1999, revealed the following:

C.) Assemble all supplies- germicidal solution.

8.) All central supply equipment should be wiped down with a germicidal Solution and returned to the central supply for disinfection.

10.) Clean all equipment.


3) Record review of patient #1's medical record revealed she was a 72 year old, female, admitted on 9/11/15 with diagnosis of: Recurrent C-diff, VRE of the urine, Gram Negative Stenotrophomonas Maltophilia pneumonia, heart failure, End Stage Renal Disease (ESRD) anemia, and tracheostomy. Further review revealed Patient #1 had been receiving hemodialysis treatments at the facility since admission on 9/11/15. A Hepatitis B panel had not been obtained until 10/07/15 (26 days) after admission.


Record review of patient #2's medical record revealed he was a 64 year old, male, with diagnosis of: MRSA of the blood, chronic respiratory failure, cellulitis, obstructive sleep apnea, congestive heart failure, hypertension, Diabetes Mellitus Type 2 (DM II), and ESRD. Further review revealed Patient #2 had been receiving dialysis treatments at the facility since admission on 8/26/15, with no evidence that a Hepatitis B panel had been obtained.



Record review of patient #3's medical record revealed she was a 69 year old, female, with diagnosis of: MDR E. Coli, MDR Enterococcus Faecalis, Hypertension, DM II, and ESRD. Further review revealed Patient #3 had been receiving hemodialysis treatments at the facility since admission 10/06/15, with no evidence that a Hepatitis B panel had been obtained.



In an interview conducted on 10/13/15, at 2:35 p.m., the facility CNO and QA nurse confirmed the above findings, and stated that the facility does not obtain Hepatitis B panels on dialysis patients unless they are seeking community placement for them after discharge.


In an interview conducted on 10/13/15, at 2:50 p.m., the dialysis FA stated, "We (facility) do not have to draw Hepatitis B labs on our patients here because we are in acute care. You only have to do that (draw Hepatitis B panel) in the chronic (long term) dialysis setting." During further interview, the dialysis FA revealed the facility does not have a designated dialysis machine for the treatment of Hepatitis B positive patients.


The survey team continued the complaint investigation visit and monitoring of the plan of removal until the time of exit on 10/14/15, at 6:00 p.m., at which time the Immediate Jeopardy was removed.








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