Fresenius Infection Information

FRESENIUS (FMC)

Bellflower

Recertification 03/4/10

V113 - Infection Control - Gloves and Hand Hygiene

V115 - Infection Control - wearing gowns/shield/masks (hepatitis patient)

V116 - Infection Control - Disinfecting items brought into treatment area

V117 - Infection Control -Medication related (med vials not dated/timed, med area not dedicated for med use only)

V122 - Infection Control - Disinfect Surfaces/Equipement/Written Protocol

** Access sites not in view of staff

** Emergency Training and Equipment

Imperial County Dialysis-El Centro

Recertification 6/18/10 (prior survey 2002)

V 113 - Infection Control - Wearing Gloves and Hand Hygiene

**Information for septicemia hospitalizations not available from CMS

**2009 - 18 deaths - 22.2% due to infection Note: increase in %

2008 - 28 deaths - 7.1% due to infection

2007 - 23 deaths - 8.7% due to infection

Inglewood

Recertification 2/3/10

V111 - Infection Control - Sanitary Environment

V116 - Disinfecting items used for dialysis

V117 - Infection Control - Medication area/

V122 - Disinfecting surfaces/equipment/written protocol

** Mortality - First year death rate versus expected death rate 2006-08 162% worse than expected

Patient death rate versus expected death rate 2006-2009 34% worse than expected

** 2009 - 13 deaths - 23.1% due to infection NOTE: increase %

2008 - 15 deaths - 0 due to infection

2007 - 13 deaths - 7.7% due to infection

2006 - 19 deaths - 31.6% due to infection

** access sites not visible to staff

Recertification 3/26/10 (last survey 2004)

V111 - Infection Control - Sanitary Environment

V114 - Infection Control - Availability of sinks for washing hands

V116 - Infection Control - Disinfecting items used for or in dialysis treatments

V117 - Infection Control - Designating Clean areas to prevent cross contamination

V119 Infection Control - Supply Cart - staff carrying items in their pockets

V124 Infection Control - HBV (Hepatitis B Virus) testing

** necessary equipment not on emergency cart / expired medications/supplies

** 2009 - 19 deaths - 36.8% due to infection - Note: increase %

2008 - 21 deaths - 23.8% due to infection

2007 - 13 deaths - 7.7% due to infection

2006 - 27 deaths - 18.5% due to infection

Recertification - 7/16/10 (last survey 2006)

V117 - Infection Control - Medication Clean to Dirty areas

V122 - Infection Control - Disinfect Surfaces/Equipment/

V143 - Infection Control - Aseptic Technique for medication vials

** 2006-2008 - 12% of patients hospitalized with septicemia (blood infection)

2008 - 41% of patients with vascular access had an infection Note: double the national & state average

** 2009 - total deaths 17 - 23.5% due to infection

2008 - total deaths 14 - 35.7% due to infection

2007 - total deaths 12 - 16.7% due to infection

2006 - total deaths 11 - 0

** access sites not in view (repeat deficiency) / wrong dialyzer

Patient hospitalized for fluid overload (preventable)

Emergency cart did not have operable equipment needed in an emergency

Recertification 1/21/10 (last survey 2006 - serious deficiencies cited -note: infection control cited 10/06, revisit survey 12/06 repeat deficiency in infection control) (not identified on CMS Data)

2008 - 19 patients -- 21.1% had dialysis access-related infection

2007 - 11 patients - 27.3% had dialysis access-related infection

2006 - 12 patients - 25% had dialysis access-related infection

2% higher than state/national average for septicemia/hospitalization

Recertification - 2/11/10

V116 - Infection Control - Disinfecting items used in dialysis

V122 - Infection Control - Disinfecting surfaces/equipment used in dialysis

V132 - Infection Control - Training/Education - Staff

V143 - Infection Control - Outdated medications

** patients access sites not visible to staff

** continued adverse effects during dialysis without appropriate intervention (serious)

TWO REPEAT DEFICIENCIES RELATED TO PATIENT CARE UPON REVISIT

Recertification 4/19/10 (last survey 2002)

V111 - Infection Control - Sanitary Environment

V114 - Infection Control - Sinks available for hand washing

V132 - Infection Control - Training/Education of staff

** patient hospitalized due to infection/change of catheter required

** 2009 - 8 deaths - 37.5% due to infection

2008 - 9 deaths - 33.3% due to infection

2007 - 11 deaths - 36.4% due to infection

2006 - 10 deaths - 40% due to infection

Recertification 4/6/10 (last survey 2003)

V111 - Infection Control - Sanitary Environment

V128 - Infection Control - Hepatitis Is?olation

V143 - Infection Control - Medication Techniques

** 2009 - 6 deaths - 0

2008 - 18 deaths - 22.2% due to infection

2007 - 17 deaths - 5.8% due to infection

2006 - 19 deaths - 5.4% due to infection

** patient’s access sites not in view during treatment