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Based on review of documentation and interview, it was determined that the facility dialysis nurses did not have annual training and supervision as per standard of care regulated by the Texas Administrative Code Title 25, Chapter 117.

Findings were:

Dialysis nurses # 10, 13 and 14 had an initial check off in dialysis dated 2016. There were no documented annual assessments in the employee files. Per interview with the Director of Nurses on 11/02/22, the nurses have had no direct supervision since the death of their supervisor.

The deficient annual assessments were acknowledged by administrative staff on 11/2/22.

Based on observation and interview, it was determined that the facility was not maintained to assure the safety of staff and patients.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Tour of the facility on 11/01/22 and 11/02/22 revealed copious amounts of bird feces on the sidewalk leading into the building and on every observable window in the building. Each window had a ledge atop which allowed congregation of birds.

Various administrative officials including the Director of Nurses acknowledged the excessive fecal matter on and around the building on 11/2/22.

Based on a tour of the facility, the hospital does not provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings were:

During a tour of the facility on 11-1-2022 the following was observed:
In the clean supply room , there were three blood pressure machines placed with no indication of clean versus dirty status.
Two clean linen carts with clean linen were open to access, with the drape pulled up on top.

On the patient floor, a layer of dust was discovered on the top of the ice machine used for patients.

In the Dialysis equipment room, a hole in the ceiling around a vent was not sealed, exposing the area below to contamination.

The above observations were confirmed in interviews with the facility staff # 16 doing the tour.

Based on observation, a review of facility documentation and staff interviews, the facility failed to ensure an effective infection control program which addressed the prevention and control of infections and communicable diseases, as they failed to provide a sanitary environment, and failed to effectively implement infection control policies.

Findings were:

1. During an interview on the morning of 11/1/22, revealed Staff # 2 demonstrating a glucometer glucose check. Following the test Staff # 25 stated that she wiped the glucose meter down with a bleach wipe. When asked by this surveyor what the minimum contact time was for the wipes, she replied one minute. Review of the label "Clorox Healthcare Bleach Germicidal Wipes reflected a minimum contact time of three minutes.
During an interview with Staff # 25 she stated that she "wipes the meter off with an alcohol wipe after each use."

During an interview with Staff #18, Infection Preventionist, on the afternoon of 11/1/2022 he stated, "The meter should remain wet for the contact time of three minutes."

2. Observation on the morning of 11/2/2022, revealed Staff # 19, enter a patient room for wound care. Staff # 19 brought the wound care cart into the patient room, placed supplies on the cart and performed wound care. Following the procedure she wheeled the cart to the hallway, wiped the adhesive remover spray bottle and scissors off with Clorox Healthcare® Hydrogen Peroxide Cleaner Disinfectant wipes and placed the supplies back inside the wound care cart. Staff # 19 did not wait the required one-minute contact time or ensure that the scissors were in the open position when disinfecting.

During an interview with Staff #19, Wound Care Nurse, she stated that she always takes the cart into the patient room when she does wound care. She continued that she wipes her supplies off, returns them to the cart, and then wipes the cart down.

During an interview with Staff # 18, Infection Preventionist, on the morning of 11/2/22, he stated that staff should not take the wound care cart into a patient room. He verified that the contact time on the disinfecting wipes was one minute and that that should have been followed.

Staff # 18 stated there is no specific policy related to the cart.