HospitalInspections.org

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 contracted dialysis nursing staff utilized disposable and/ or supplies capable of being disinfected for 1 of 3 isolation patients (#1 ) who received dialysis treatments and

2.) Ensure that the building floors, walls, sinks and countertops were maintained and free of accumulations of dust, dirt, and debris.

This deficient practice placed all 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:


1.) Observations conducted on 6/20/156, at 12:30 p.m., within the patient care area revealed Patient #1 was on isolation for Vancomycin Resistant Enterococci (VRE), and was actively receiving hemodialysis treatment at the bedside. Further observations revealed that contracted dialysis nursing staffs were using blue blood pressure cuffs made from a porous, non- wipable nylon weave material. At termination of dialysis treatment, staff removed the blood pressure cuff with the dialysis machine from the isolation room for use on other patients.

In an interview conducted on 6/20/16 at 1:25 pm, Dialysis Registered Nurse (RN)- staff #12 confirmed that the blue nylon blood pressure cuffs were removed from the isolation rooms and reused on other patients. She further revealed that the reason the blue non- disposable cuffs were used was because the white disposable cuffs the facility utilized in isolation rooms did not fit the connectors on the dialysis machines.


In an interview conducted on 6/20/16 at 2:30 pm. Dialysis RN- Staff #13 also confirmed that she used the blue nylon non-disposable blood pressure cuffs in isolation rooms as well due to the facility ' s disposable blood pressure cuffs not fitting the connectors on the dialysis machines.

In an interview conducted on 6/21/16 at 11:00 am the staff #1 facility's Chief Executive Officer/ Regional Director of Operations confirmed the above findings.

Record review of the facility policy entitled: Standard Precautions Policy # IC 5, revised 9/ 2015 revealed the following:

- Reusable equipment is not to be used for the care of another patient until it has been appropriately cleaned with appropriate disinfectant. Single use items are properly discarded after single use.

Record review of the facility Contract Agreement for dialysis services, dated 9/25/13, section entitled: Hospital Obligations- Section 9-Supplies, revealed the following:

- (ii) The hospital shall provide all equipment and supplies necessary for the (dialysis) company to comply with all hospital policies and procedures with respect to the treatment of patients with communicable diseases and/ or infections in conjunction with the provision of services.


2.) Observations on 6/20/16 during a tour of the facility revealed the following:

- In the nourishment room, the counter top had a build up of caulk around the sink basin and backsplash. The countertop was very worn and dirty.

- The floors and base boards through out the facility were dirty and dusty.

-The walls throughout the facility had worn/chipped paint.

-The counters at the nurses station had missing laminate, were cracked and very worn. The wall to the nurses station had missing "chunks" of wood veneers. The cabinets behind the nurses station was very worn and dirty.

-The sink in the therapy room had green build up around the faucet. A large stain was in the basin of te sink. The countertop was worn and cracked. The wall above the counter top was cracked.


3.) Interview on 6/20/16 at 2:40 p.m. with staff #5, Host facility Environmental Manager who is
the environmental manager for the whole Detar Hospital facility revealed that stripping and
waxing of the floor is determined on an as needed case and he is the one that makes the
determination on when the floors are stripped and waxed. The Environmental Manager revealed
he did not know when the floors were last done. When asked for a policy and schedule on floors
to be waxed and stripped, the Environmental Manager revealed he does not have a policy and
did not have a schedule.

4.) Interview on 6/20/16 at 3:20 p.m. with staff #1 Chief Executive Officer/ Regional Director
of Operations confirmed the above findings. Staff #1 Chief Executive Officer/ Regional
Director of Operations also revealed she has been getting after housekeeping to get the floors
done. When the floors are scheduled to get done, it is always cancelled. She is always getting
after them to stay on top it.

















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