Usrc Paragould

“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: 37145 Based on observation, policy and procedure review and interview, the facility failed to ensure two of two (#8 and #9) patients who held pressure on their access sites to achieve hemostasis, performed hand hygiene prior to exiting the treatment area. The failed practice promoted the spread of infection from cross contamination and had the likelihood to affect all 53 in-center hemodialysis patients on census, all direct care staff and all visitors. Findings follow: A. Review of the facility’s policy titled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation,” with a revised date of 10/2023 showed after removing gloves after decannulation of the vascular access, patients and staff were to perform hand hygiene. B. Review of the “Termination of Dialysis treatment revised 04/2023 showed, “ Patient must wear a glove to hold their sites and perform hand hygiene after glove removal.” C. The findings of A and B were confirmed in an interview with the Facility Administrator on 02/07/24 at 11:25 AM. D. Observation of termination and initiation of dialysis treatments on 02/07/24 from 9:30 AM to 11:20 AM showed Patient # 8 and # 9 held their access sites to achieve hemostasis. Patient # 8 and #9 did not perform hand hygiene prior to leaving the treatment area.”

“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 the safety, functionality, cleanliness, and integrity of all surfaces and maintain the physical environment to ensure the safety of the patient and staff in that:.the Biomedical room door facing had a rust colored buildup and missing paint, the janitor supply closet had peeling paint in the right upper corner of the room, and five sinks in the treatment room had brown rust colored and a white buildup around the edges of the sink. The failed practice promoted the spread of infection and had the likelihood to affect all 53 in-center patient on census. Findings follow: A. Observation of the Biomedical room on 02/05/24 at 1:34 PM, showed the door facing had a rust-colored buildup and missing paint. B. Observation of the Janitor supply closet on 02/05/24 at 1:34 PM, showed the right upper corner of the room had peeling paint. C. Observation on 07/05/2024 at 1:40 PM, showed five of five sink drains in the treatment room had brown rust colored substance and white build-up around the corners of the sink. D. During observation on 07/05/2024, at 1:40 PM, the Facility Administrator confirmed the findings in A - C.”

“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: 37145 Based on clinical record review, policy review, and interview, it was determined the Registered Nurse (RN) failed to assess the blood pressure (BP) for five of five (#1-#5) in-center hemodialysis patients. The failed practice placed patients at risk for complications related to unmanaged BP. The failed practice had the likelihood to affect all 53 in-center hemodialysis patients. The findings were: A. Review of policy title “Pre-Treatment Assessment of Patient”, revised 1/2020, showed, “Pre-Dialysis Data Collection: Some data may be collected by Qualified Patient Care Technicians (PCT) during the pretreatment and initiation process, but this data does not replace the nursing assessment. The following may be by the PCT: Blood pressure (sitting completed on all patients followed by standing, (if able); Any data outside of the acceptable facility/patient will be reported to the CN (Charge Nurse) prior to treatment initiation. Predialysis Nursing assessment/evaluation of data collected. Blood pressure above or below acceptable facility/patient specific parameters, Hypo/ Hypertension. Intervention: Notify patient’s physician of any significant changes or problems.” B. Review of policy titled, “Reportable Parameters to CN,” revised 01/20, showed, “PCT/CCHT (Certified Clinical Hemodialysis Technician) Report to charge nurse Pre-Dialysis B/P (blood pressure systolic > (great than) 180 or < (less than) 90, Diastolic > 110; Intra-Dialysis > 180 or < 90, Diastolic > 110; Post-Dialysis > 180 or < 90, Diastolic > 110. l: Euvolemic with blood pressure (BP) 140/90 pre-treatment and BP 130/80 post treatment.” C. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be <140/90 and post-treatment was to be BP < 130/80. D. During an interview on 02/07/24 at 1:50 PM, the Facility Administrator confirmed findings in A and B. E. Patient #1 1) Review of six TFS (treatment flow sheets), five of six treatments, 01/23/24 - 02/03/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment systolic BP. BP Examples: a) 01/23/24 - Pretreatment 163/68, Intradialytic 87/42, Post treatment 104/49 b) 01/25/24 - Pretreatment 162/64 intradialytic, 149/63 and post treatment 156/70 c) 01/27/24 - Pretreatment 174/79, intradialytic92/51, and post treatment /74 d) 01/30/24 - Pretreatment 193/92 intradialytic 149/67 and post treatment 148/70 e) 02/01/24 - Pretreatment 194/87, intradialytic 166/83 and post treatment 180/78 2) There was no evidence of an RN assessment for HTN (hypertension). 3) During the interview, on 02/07/24 at 1:00 PM, the Facility Administrator confirmed the findings in E . F. Patient #2 1) Review of six TFS, six of six treatments, 01/18/24 - 02/01/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment systolic BP. BP Examples: a) 01/18/24 - Pretreatment 222/115, Intradialytic 215/109, Post treatment 183/76. b) 01/20/24 - Pretreatment 161/108, intradialytic, 228/94 and post treatment 183/77. c) 01/23/24 - Pretreatment 248/106, intradialytic 208/104, and post treatment125/62 d) 01/26/24 - Pretreatment 223/102, intradialytic 202/93, post treatment 160/75 e) 01/30/24 - Pretreatment 207/97, intradialytic 184/69, post treatment 166/79 f/ 02/01/24 - Pretreatment 246/122, intradialytic 214/105. 2) There was no evidence of an RN assessment for HTN. 3) During the interview, on 02/07/24 at 1:00 PM, the Facility Administrator confirmed the findings in F. G. Patient #3 1) Review of six TFS, four of six treatments, 01/23/24 - 02/03/24, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 01/23/24 - Pretreatment 170/91, intradialytic 169/85, and Post treatment 177/86 b) 01/25/24 - Pretreatment157/75, intradialytic 172/79, and Post treatment 153/83 c) 01/27/24 - Pretreatment 166/80, intradialytic 163/73, and Post treatment 149/76 d) 01/30/24 - Pretreatment 200/93, intradialytic 181/87, and Post treatment 164/87 e) 02/01/24 - Prtetreatment 200/99, intradialytic 185/99, and Post treatment 179/101 f) 02/03/24 - Pretreatment 154/108, intradialytic 164/75, 2) There was no evidence of an RN assessment for HTN. 3) During interview, on 02/07/24 at 2:05 PM, the Facility Administrator confirmed the findings in G. H. Patient #4 1) Review of three TFS, three of three treatments, 01/30/24 - 02/03/24, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment systolic BP. BP Examples: a) 01/30/24 - Pretreatment 151/90, post treatment 152/84 b) 02/01/24 - Pretreatment 173/97, post treatment 154/87 c) 02/03/24 - Pretreatment 156/90, intradialytic 152/99, and Post treatment 154/93. 2) There was no evidence of an RN assessment for HTN. 3) During interview on 02/07/24 at 2:07 PM, the Facility Administrator confirmed the findings in H. I. Patient #5 1) Review of six TFS, five of six treatments, 01/14/24 - 02/05/24, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 01/14/24 - Pretreatment 1445/50 b) 01/19/23 - Pretreatment 153/63, Post treatment 145/63 c) 01/29/24 - Pretreatment 173/88 d) 02/02/24 - Post treatment 145/69 e) 02/05/24 - Pretreatment 151/64 2) There was no evidence of an RN assessment for HTN. 3) During the interview on 02/07/24 at 2:07 PM, the Facility Administrator confirmed the findings in I.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 37145 Based on review of Facility Quality Management Meetings and interview, it was determined in five of five (July, August, September, October, and November 2023) months, there was no evidence the Interdisciplinary Team (IDT) selected Blood Pressure (BP) and Fluid management for development of measures, performance of root cause analysis and implementation of an action plan to improve outcomes for in-center hemodialysis. The failed practice did not assure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 53 In-Center hemodialysis patients. The findings were: A. Review of the Facility Quality Management Meetings from July 2023 to December 2023 showed there was no evidence the IDT selected BP and Fluid management for development of measures, performance of root cause analysis and implementation of an action plan to improve outcomes for in-center hemodialysis. B. In an interview with the Facility Administrator on 02/07/24 at 1:30 PM, the findings in A were confirmed.”