Dci Moulton

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 49603 Based on observations, facility procedure review, and interview, it was determined the facility failed to ensure staff followed the procedure for chlorine and chloramine testing. This deficient practice affected one of two observations of total chlorine testing and had the potential to negatively affect all 26 incenter hemodialysis patients who dialyze at the facility. Findings include: Facility Procedure: Total Chlorine Testing with RPC (brand) Ultra-Low Total Chlorine Test Strip Procedure Number: 151.5a Date Issued: 1/24/24. Purpose: To define the steps involved for testing the presence of Chlorine and Chloramine using the RPC Ultra-Low Total Chlorine Test Strip. ...Procedure ...2. Prior to collecting the sample, rinse the clean, dry sample cup ... 3. Collect a fresh 100 milliliter (ml) sample of water in a plastic sample cup ... 1. An observation of Total Chlorine testing was conducted on 1/6/26 at 11:40 AM with Employee Identifier (EI) # 2, Registered Nurse. EI # 2 collected 100 ml sample of water in a dry sample cup, and without rinsing the clean, dry sample cup, dipped the test strip into the solution. EI # 2 failed to follow the facility procedure for total chlorine testing. An interview was conducted on 1/8/26 at 4:30 PM with EI # 1, Nurse Manager, who verified the staff failed to perform the Total Chlorine test per the facility procedure.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47295 Based on observations, review of the facility policy and procedure, and staff interview, it was determined the facility failed to ensure staff followed the facility policy when accessing the Arteriovenous Fistula/Arteriovenous Graft (AVF/AVG) for initiation of dialysis. This affected Patient Identifier (PI) # 6 and PI # 8 in two of two observations of accessing the AVF/AVG for initiation of dialysis and had the potential to negatively affect all patients dialyzing with an AVF/AVG. Findings include: Facility Policy: Vascular Access Disinfectant Policy Procedure Number: 804 Date Issued: 1/24/24 Purpose: To provide a list of acceptable disinfectants for all vascular access care. To provide disinfection details for each option of acceptable cleansing agents. Policy: ...7. Staff will not touch a disinfected site before cannulation. If so, the cannulation site must be disinfected again before needle insertion... 1. An observation was conducted on 1/6/26 at 10:40 AM with Employee Identifier (EI) # 2, Registered Nurse, accessing the AVF/AVG for PI # 6 at station 11. EI # 2 applied antiseptic to the skin over the cannulation sites, touched the sites, then cannulated without repeating skin antisepsis. 2. An observation was conducted on 1/6/26 at 11:05 AM with EI # 3, Certified Clinical Hemodialysis Technician, accessing the AVF/AVG for PI # 8 at station 1. EI # 3 applied antiseptic to the skin over the cannulation sites, touched the sites, then cannulated without repeating skin antisepsis. An interview was conducted on 1/8/26 at 3:30 PM with EI # 1, Nurse Manager, who confirmed the facility failed to ensure staff followed the facility policy when accessing the AVF/AVG for initiation of dialysis.”