Fmcna - St Francis County Dialysis

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 37145 Based on observation and interview, the facility failed to ensure that the integrity of all physical surfaces were intact, clean, and free from damage. The failed practice promoted the spread of infection and had the likelihood to affect all 56 patients on census and all staff. The findings were: A. On 02/03/25 from 12:10 PM through 12:50 PM, the following observations were made on tour of the facility: 1) The lab area and medication area showed: a) All sinks had stains, dirt and grime, and a white residue buildup on the faucets, and rust colored buildup in the drains. b) The pressboard behind the patient handwashing sink was stained and puckered. c) The medication refrigerators had dirt and grime buildup on the shelves. d) There were taped signs and tape residue on the walls by the lab area. 2) The stock and storage room observations showed: a) Bicarbonate and Granuflo were stored on wooden pallets. b) There was peeling paint and tape residue on the citric acid tank. 3) The Treatment area observation showed: a) Throughout the treatment area, sinks had stains, dirt and grime, and a white residue buildup on the faucets, and rust colored buildup in the drains. b) The pressboard behind the patient handwashing sink was stained and puckered. c) There were multiple holes of various sizes in the walls behind the treatment chairs. d) Behind Station #6 there were several holes in the wall. e) The walls had cracking and peeling toward the bottom. f) The walls throughout the treatment area had dirt and grime build up. g) The cabinets were stained and had tape residue. 4) The Water/Storage room showed: a) There was a buildup of green and rust-colored substance on the pipes in multiple areas throughout the water treatment system. b) The back wall and door frame had peeling paint. c) The acid tank base had a buildup of white residue. d) By Station #13 and #14 there were three large holes. e) By Station #11 there were three holes and chipped laminate. f) By Station #21 there was a large 1 ½ inch hole in the wall. g) There was a sign taped on the side of a supply cart and the handle was completely surrounded by tape. B. During an interview on 02/03/25 at 12:50 PM, the findings in A were verified with the Clinic Manager.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 37145 Based on policy review, observation and interview, the facility failed to ensure blood pressure (BP) cuffs were maintained in that there was a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection. The failed practice promoted the spread of infection from cross contamination. The failed practice had the likelihood to affect all 56 in-center hemodialysis patients on census and staff. The findings were: A. Review of the facility policy titled, “Cleaning and Disinfecting the Dialysis Station” published 09/05/2023 showed, “Use a cloth wetted with 1:100 bleach solution or EPA (Environmental Protection Agency) approved disinfectant to clean and disinfect the dialysis station (chair, bed,tables, machine, television, IV (Intravenous) pole, B/P (blood pressure) cuff, hand sanitizer, dispenser and holder, chaise wall behind the chair). B. On 02/05/25, during observation of initiation and termination of dialysis, showed BP (blood pressure) cuffs at Station #1, #3, #14, and #17 had a build-up of threads in the hook portion of the Velcro which did not allow effective cleaning and disinfection between patients. C. During an interview on 02/05/25 at 12:08 PM the Facility Administrator confirmed the findings in A and B.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical record review, and interview, it was determined the Registered Nurse (RN) failed to re-assess, treat, or notify the physician when one (#3) of seven (#1-#7) clinical records reviewed, had blood pressure (BP) outside of ordered parameters for two of six treatments reviewed. The failed practice placed the patient at risk for complications related to failure to manage blood pressure. The failed practice had the likelihood of affecting all patients receiving dialysis in the facility. Findings follow: A. Review of “MAB Recommended Volume and Hypertension Evaluation and Management Algorithm Decision Support 1.0” dated 03/01/24, showed that systolic blood pressure (SBP) targets pre-dialysis sitting should be “greater than or equal to 100 mmHg (millimeters of mercury) and less than or equal to 160 mmHg. Post-dialysis sitting SBP targets should be “greater than or equal to 100 mmHg and less than or equal to 140 mmHg.” B. Review of Patient #3’s Treatment Flow Sheet (TFS) dated 01/23/25, showed Patient #3’s pre-dialysis SBP was 187 mmHg at 6:26 AM, intradialytic SBP remained greater than 160 mmHg from 6:38 AM to 10:37 AM, post dialysis SBP 180 mmHg at 10:37 AM. Patient #3 had a medication order for as needed Clonidine to reduce BP. No evidence was provided which showed a dose was offered, refused, or administered. Further, the TFS showed Patient #3 refused the recommended additional 15 minutes of pure ultrafiltration. No documentation was provided which showed the provider was notified of hypertension or patient refusal of recommended additional 15 minute treatment. C. Review of Patient #3’s Treatment Flow Sheet (TFS) dated 02/03/25, showed Patient #3’s pre-dialysis sitting SBP was 192 mmHg at 6:25 AM, intradialytic SBP remained above 160 mmHg with several readings greater than 200 mmHg from 6:31 AM to 10:15 AM, and post dialysis sitting SBP 161 mmHg at 10:32 AM. The Medication Administration Record showed that one dose of Clonidine was given at 7:05 AM and that second dose could be given. No evidence was provided which showed a second dose was offered, refused, or administered. Further, Patient #3 refused the recommended additional 15 minutes of pure ultrafiltration. Review of “Chairside Multidisciplinary Note” dated 02/01/25 at 7:11 AM states “provider consulted”, however no documentation was found of provider comments, recommendations, or new/changed orders. D. During an interview with the Clinical Manager on 03/05/25 at 2:30 PM, she confirmed the findings in A-C.”

“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: 37145 Based on observation, review of policy and procedure, and interview, the facility failed to ensure the dressing used to cover the access needle sites until hemostasis was achieved was changed prior to discharge for four patients (#1, #3, #14, and #17) to prevent the loss of access due to the risk of infection. The failed practice had the likelihood to affect all patients with an Arteriovenous Fistula (AVF) or an Arteriovenous Graft (AVG). The findings follow: A. Review of the facility “Post Treatment Fistula Needle Removal” policy and procedure, published 07/01/2024 showed, “Once hemostasis is achieved. Remove the gauze. Apply antibiotic cream if ordered by physician. Place Band-Aid, adhesive dressing or gauze dressing secured with clean tape.” B. On 02/05/25 from 8:15 AM to 11:00 AM, observation of termination and initiation of dialysis showed the arterial and venous needles were pulled with a gauze bandage applied and taped. Patient #1, #3, #14 and #15 held pressure to the needle sites to achieve hemostasis. Once hemostasis was achieved, the patients were allowed to leave without changing the gauze bandage or applying clean tape. The access sites were reinforced with more tape. C. On 02/05/25 at 3:00 PM the Administrator verified the findings in A and B.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical record review, and interview it was determined the facility failed to report adverse events for 12 (January-February 2024, April-December 2024, and January 2025) of 13 (January-December 2024, and January 2025) months reviewed. Failure to report adverse events does not allow the facility to identify trends and/or commonalities through aggregation of events to inform performance improvement and patient safety. The failed practice has the likelihood of affecting all patients receiving care in the facility. Findings follow: A. Review of Policy titled “Patient Safety Event Reporting and Documentation”, dated 02/06/23, showed staff are required to report near misses, safety events, and serious safety events, in a timely manner. Further a reportable list specific to the dialysis population is included in the policy to inform staff of what event types should be entered into the facilities patient safety reporting system. B. Review of the electronic adverse events records on 02/04/25 at 1:30 PM, showed there were no near misses, safety events, or serious safety events were reported for January-February 2024, April-December 2024, and January 2025. C. Review of patient records showed Patient #3 and #6 had a reportable event during a visit in January of 2025. D. During an interview with the Clinical Manager on 03/05/25 at 2:30 PM, she confirmed the findings in A through C.”