Dci Decatur

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood.) for one of two observations. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 52 in-center patients. Findings include: Observation on 06/18/25 at 3:05 PM, revealed Patient (P) 10 at Station 6 applied pressure to the left upper access site until bleeding had stopped. When the patient was finished, he/she walked to the scale to retrieve weight with Certified Clinical Hemodialysis Technician (CCHT) 1 however the patient did not wash or sanitize hands before leaving the facility and CCHT 1 did not instruct or encourage patient to wash or sanitize hands. During an interview on 06/18/25 at 3:20 PM, CCHT 1 confirmed P 10 did not wash or sanitize hands, and he/she did not instruct or encourage P 10 to wash hands to prevent cross contamination. During an interview on 06/20/25 at 1:45 PM, the Nurse Manager stated patients should wash or sanitize their hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. Review of the facility’s policy titled, “Hand Hygiene” revised 01/09/2018 revealed no information specific to patient hand hygiene. Review of the “Centers for Medicare and Medicaid Services ESRD Core Survey Version 1.6 Infection Control Observation” undated, document “Discontinuation of Dialysis and Post Treatment Access Care for AV Fistula or Graft indicated the following as the last step on the checklist was “Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene.)”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 28297 Based on interview, and medical record review, the facility failed to ensure the dialysis treatment prescription for correct blood flow rates (BFR) was followed for two of six patients (P) 1, and P3. The failure to follow the dialysis prescription blood flow rate had the potential for problems meeting adequacy and could affect 52 in-center patients. Findings include: 1. Review of the medical record for P1 revealed the facility admitted the patient on 04/08/24 with diagnosis including end stage renal disease (ESRD). Review of six dialysis flow sheets from 06/04/25 through 06/16/25 revealed the BFR was prescribed at 500 milliliters/minute (ml/min) however five of six flow sheets reviewed the patients BFR was only 450 ml/min with only one flow sheet dated 06/16/25 had documentation that the BFR was not run as prescribed. Flowsheets for 06/13/25, 06/11/25, 06/06/25, and 06/04/25 the BFR was run at 450ml/min with no documentation of the decreased BFR. 2. Review of the medical record for P3 revealed the facility admitted the patient on 04/10/25 with diagnosis including end stage renal disease (ESRD). Review of six dialysis flow sheets from 06/03/25 through 06/17/25 revealed the BFR was prescribed at 250 ml/min however the BFR was 450 ml/min for all six treatments. During an interview on 06/20/25 at 11:20 AM, the Nurse Manager confirmed the BFRs were not as prescribed for both P1 and P3. He/she confirmed staff should have documented the change in the BFR and why it was not as the prescribed rate. During an interview on 06/20/25 at 12:50 PM, Registered Nurse (RN) 1 stated P3 started at the facility with fistula access (A vein and artery connected in the arm to allow for hemodialysis) and the ordered 250 ml/min BFR was because it was a new access. RN1 stated the patient switched to a Central Venous Catheter (CVC) (a plastic tube inserted in a vein that is used for hemodialysis) that allowed for a 450 ml/min BFR. RN1 stated they should have documented the reason the BFR was not at the prescribed rate for P1 and P3. The Nurse Manager and Nurse Educator stated the facility did not have a policy on following the dialysis prescription for BFR or changes in the dialysis prescription.”