Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on October 1, 2021, Albert Einstein Medical Center ESRD, was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.
Plan of Correction:
Initial Comments:
0000-Based on the findings of an onsite unannounced Medicare recertification survey conducted September 28, 2021, through October 1, 2021, Albert Einstein Medical Center ESRD was identified to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.30(b)(1) STANDARD
IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P
Name - Component - 00
The facility must-
(1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit;
Observations:
Based on review, observation, and interview with the facility Administrator, the facility failed to monitor infection control activities within the dialysis unit for two (2) of two (2) observations conducted. (Observation #1, and #2 with PF #1).
Findings include:
On October 1, 2021 at approximately 10:30 a.m., a review of PF #1, a Patient Care Assistant, (PCT), revealed a date of hire on December 22, 2015. Competencies were up to date.
On September 29, 2021, from approximately 11:00 a.m., to 11:10 a.m., while conducting observation #3, Discontinuation of Dialysis with Central Venous Catheter, (CVC), with PF #1, at station #10, the procedure was completed in the following order:
1. Hand hygiene and gloves donned.
2. Extracorporeal circuit reinfused.
3. No glove change.
4. CVC disinfected.
5. Touched the keys on the dialysis machine.
6. Without changing gloves or hand hygiene, PF #1, returned to the Patient, disconnected blood lines, and completed the discontinuation process on the Patient.
On September 29, 2021, from approximately 11:10 a.m., to 11:20 a.m., while conducting observation #2, Discontinuation of Dialysis with a Central Venous Catheter, (CVC), at station #2, with PF #1, the observation continued as previously described:
1. Hand hygiene and gloves donned.
2. Extracorporeal circuit reinfused.
3. No glove change.
4. CVC disinfected.
5. Touched the keys on the dialysis machine.
6. Without changing gloves or hand hygiene, PF #1, returned to the Patient, disconnected blood lines, and completed the discontinuation process on the Patient.
In an exit interview with the facility Administrator on October 1, 2021 at approximately 11:45 a.m. it was confirmed that the facility failed to monitor and supervise infection control activities within the dialysis unit for all employees.
Plan of Correction:All nursing and patient care techs will be re-educated on the importance of following infection control protocols for hand hygiene. This education will be completed on or before 11/1/2021.
Beginning 11/2/2021 for a period of four weeks the Unit Manage will be responsible for conducting 10 observations per week for compliance with appropriate infection control practices. The results will be shared weekly with the Director of Nursing who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Directors of Nursing will determine the need for continued audits, based on performance. The Director of Nursing has ultimate accountability for this corrective action.
494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT
Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.
Observations:
Based on an observational tour of the dialysis unit, and interview with the facility Administrator, the facility failed to maintain a safe, functional, treatment environment for Dialysis Patients.
Findings include:
On September 29, 2021, from approximately 8:45 a.m., to 10:45 a.m., while conducting an observational tour that included the Patient Bathroom, it was revealed that the bathroom emergency call bell would not activate when pulled. The bell did not light, or make a sound in the patient's bathroom, and there was no light or audible sound outside of the bathroom. Further observation revealed no light or audible sound in the treatment area to alert staff that a patient was experiencing an emergency.
On October 1, 2021, at approximately 11:45 a.m. during an exit interview with the Administrator, the above findings were confirmed.
Plan of Correction:Call bell repaired on 9/30/2021. The Director of Nursing will be responsible for monitoring the continued implementation of the plan of correction. The Director of Nursing will also be responsible for ensuring the call bell continues to operate as intended and address any concerns. In addition, the monitoring of the call bell system will be completed through normal ongoing rounding by the environment of care team and through the self inspections completed bi-annually by the local manager. Findings are reported on regular basis to the Environment of Care Committee.
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