Poorly kept dialysis unit is cleaned up

Poorly kept dialysis unit is cleaned up

by Yvonne Wingett and Amanda J. Crawford
Apr. 11, 2008 12:00 AM
The Arizona Republic

Inside a small, quiet room of the Maricopa Integrated Health Systems' Phoenix kidney dialysis unit, patients are hooked up to machines that drain blood from their bodies, cleansing it of poisons and toxins.

Because kidney-dialysis centers deal so extensively with bodily fluids, health officials emphasize the importance of maintaining sanitary conditions to prevent blood contamination and other health threats.

But nine months ago, conditions in the center were not as safe and sanitary as they are today. State health surveyors found dried blood on chairs, walls and the floor. Dialysis machines, parts still wet with blood, were not appropriately checked for contamination after treatments. Ants infested the treatment area and crawled on patients.

State health officials were so concerned about the conditions in the dialysis unit in July, the most recent inspection by state surveyors, that they considered it an "immediate threat" to patients' safety. Inspectors refused to leave the facility until the most serious deficiencies were addressed.

The problems at the Phoenix unit, identified in a report by the Arizona Department of Health Services, were so severe that the center was at risk of losing its Medicare funding within 90 days. MIHS immediately began to correct the problems and developed a plan to avert similar problems in the future. The facility now is in full compliance. No Medicare funding was affected, and MIHS staff continues to monitor the unit closely.

"Many of these things were corrected before the first day (of the survey) ended," said Karen Ford, chief nursing officer for MIHS.

Still, the report provides a glimpse into operations of one unit of the taxpayer-funded county health system. Over the past three years, only one other dialysis center out of about 100 inspected throughout Arizona warranted the same "immediate jeopardy" rating by state health officials, they said.

Overall review

The problems at the center were not the only ones MIHS needed to address.

The system received a preliminary denial of accreditation in a review of its overall operation by a private accrediting organization, the Joint Commission.

That inspection has not been released to the public. After MIHS appealed the rating, the commission dropped several of its initial findings and upgraded the rating to conditional accreditation. MIHS officials continue working to correct problems and hope to earn full accreditation.

The kidney-dialysis center is one of two MIHS units inspected by the state health department on behalf of the federal Centers for Medicare and Medicaid Services.

In July 2005, less than a year after a newly elected board took over operations of MIHS, state officials also found deficiencies at the Phoenix center. Those findings were far less significant than last year's review, according to state health officials and survey documents.

Growing industry

Kidney dialysis is a growing health industry in Arizona. There are approximately 100 Medicare-accredited dialysis centers in the state, which are inspected by state health surveyors about every three years.

Over the past three years, 21 of those centers were under threat of losing Medicare funding within 90 days because of problems found by state surveyors, said Kathryn McCanna, licensing-program manager for the DHS. None of the centers lost Medicare funding.

Only one other dialysis center, the Chinle Dialysis Facility on the Navajo Reservation, was also found to pose immediate jeopardy to patients, like the MIHS unit.

McCanna said the dried blood on the dialysis chairs and equipment and ant infestation at the MIHS unit in Phoenix triggered the immediate-jeopardy finding, but the poor contamination controls on the dialysis machines posed the potential for serious harm to patients. The controls ensure that blood from patients is not transmitted to others.

"Infection control in dialysis is an area focused on because of the potential transmission of blood-borne diseases," McCanna said. "It is extremely important that good infection-control practices be done: wearing the gloves, cleaning between patients."

McCanna praised MIHS administrators for working to address problems immediately.

"I believe the organization took this issue very seriously," she said.

In response to the survey, MIHS officials immediately cleaned up the facility, called in exterminators and bought new chairs.

They made personnel changes, assigned additional leadership to help oversee the facility and implemented a self-monitoring system. They also hired an outside consultant, which continues to do unannounced surveys of the unit to make sure it remains in compliance with federal and state regulations.

"We have a new administrator," Ford said. "We have new chairs. We went through extensive retraining of staff. We put in different types of monitoring and checks and balances."

The findings

Among the findings by state surveyors in July:

• There were no stethoscopes in the unit, yet staff members recorded that heart and lung functions were checked. Patients told inspectors such checks were rare.

• Employees did not wear personal protective equipment, such as gowns, aprons, gloves, masks or face shields, while caring for patients.

• Equipment was not disinfected as required.

• An inspector found a 2.5-foot-wide stain of what appeared to be dried blood on the floor behind one of the hemodialysis chairs. Spots that appeared to be dried blood were also noted on a wall, a container for used syringes, two over-bed tables and a patient scale.

• Staff members did not immediately replace bloody transducers on the dialysis machines and did not inspect the machines, as required, to make sure they were free of blood contamination before preparing the machine for the next patient.

• Dialysis chairs used by patients were dirty and had stains resembling blood. Condiment packets, plastic eating utensils, scissors and a used syringe were found in the metal framework of the chairs.

• Nurses altered medication for patients without consulting physicians as required.

• Inspectors noted a large number of ants feeding on food particles and found dead insects on the floor of the treatment area as well as behind and under the patient chairs and hemodialysis machines.

The survey was conducted July 16-20. MIHS staff members said some construction was going on at the unit during that time. Surveyors returned on Sept. 7 to make sure the deficiencies were corrected and found no problems.

Thousands of treatments

The Phoenix dialysis unit is inside the Comprehensive Healthcare Center near 24th and Roosevelt streets. It serves almost 70 patients and performs 18,600 treatments yearly, according to MIHS. The health system operates another outpatient kidney-dialysis center in Glendale, which serves about 36 people and performs 4,800 treatments yearly.

A routine inspection of the Phoenix unit in 2005 found "standard level" deficiencies, a less serious rating than the "condition level" problems found in the 2007 visit by state officials. The Glendale clinic's last Medicare survey, in 2005, also found standard-level problems, which were corrected. A less detailed inspection of the Glendale facility in May found no problems.

Kidney disease mostly affects adults who may also have other conditions, such as diabetes, hypertension and obesity, said Jamie Dove, development director for the Arizona Kidney Foundation, which provides financial aid and education to people with kidney disease.

Depending on the patient, dialysis treatment can be life-altering.

"It's a cycle of feeling better, feeling worse, going through dialysis, getting better, feeling worse," Dove said. "That has a big impact on what people are able to do and how they're able to live."

Unsanitary conditions at dialysis centers can pose significant threats to the health of patients. Michael Murphy, spokesman for the DHS, points to recent problems at health clinics in Las Vegas, where the use of contaminated syringes led to several patients contracting hepatitis C.

Arizona health inspectors say no patients were found to have been harmed at the MIHS center, but McCanna added, "There was a potential for harm because of transmission of diseases found in the blood."

MIHS officials said the problems found in the July inspection were taken seriously.

"When we had this inspection turn up these issues, we took it very seriously," said Warren Whitney, vice president of strategic development at MIHS. "It's a clean, well-run clinic right now."

James Conway, senior vice president for the Institute for Healthcare Improvement based in Massachusetts, said health-care organizations are complex and constantly challenged to keep up with rigorous standards.

Health-care organizations are cited often for a number of deficiencies, he said, but the threat of a loss of Medicare funding is not typical.

Conway said the real challenge for a health-care organization is to mobilize and respond once problems have been pointed out.

MIHS, a taxpayer-funded county-hospital system, includes the Maricopa Medical Center, clinics and behavioral-health centers, and a burn center.

The system serves more than 400,000 people yearly, officials said, and many are poor and uninsured.

Reach Wingett at 602-444-4712 and Crawford at 602-444-4870.

More on this topic

Corrective measures

After the Arizona Department of Health Services found significant problems in July at a Phoenix outpatient-dialysis center, Maricopa Integrated Health System officials quickly responded, and regularly monitored problem areas.

MIHS' plan of correction included:

• Additional leadership oversight, scheduled for twice a week for two months, then once a week for five months, to verify the dialysis unit complied with the correction plan.

• Hired an outside consultant to make sure the unit complied with all federal and state regulations. The consultant was to do unannounced surveys of the unit every other month for six months, and then every quarter.

• Monthly review of all personnel files to verify licensure/certification of each employee.

• Staff "in-serviced" on when/what to do if a transducer becomes "wet/bloody." Review with staff of policy and procedures regarding transducers. Educated staff on documenting an occurrence report if a wet/bloody transducer breached the membrane and potentially contaminated the hemodialysis machine.

• Expired supplies were immediately thrown away, and a monthly checklist was developed to check for future expired supplies.

• Immediate staff training on the use of gowns, masks, gloves and other protective gear.

• Immediate education on the importance of cleaning equipment between each patient.

• Chairs immediately cleaned and new chairs ordered on July 17. Educated staff on properly cleaning chairs, scheduled quarterly deep-cleaning of chairs.

• Immediately called pest control and sprayed the outside of the building, and gel substance was applied in the treatment area where ants were. MIHS entered into a monthly agreement with pest-control company.

• Changed the type of disinfectant used to clean equipment.

• Nightly cleaning of lobby; new chairs ordered.

• Staff coached on importance of proper documentation.

• Made personnel changes.

• Education of staff on pre- and post-assessments. Supplies made available, such as stethoscopes.

Source: Complied from MIHS' plan of correction as filed with Arizona Department of Health Services

http://www.azcentral.com/news/articles/2008/04/11/20080411report0411.html