Usrc Pine Bluff

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 37145 Based on observation and interview, it was determined in one of one (laboratory) area in the Treatment Room there was no signage designating the area as clean or dirty. The failed practice did not ensure measures were in place to prevent contamination of clean equipment or supplies. The failed practice had the likelihood to affect all 116 in center hemodialysis patients on census and all staff. The findings were: A. Observation of the treatment area on 05/13/24 from 9:32 AM to 10:30 AM showed the Laboratory section of the Treatment room had a sink on each end of the counter with supplies in between. There was no signage or clear designation if the area was clean or dirty. B. During an interview on 05/13/24 at 9:32 AM, the Facility Administrator confirmed the findings in A.”

“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 116 in center patients on census and all staff. The findings were: A. On 05/13/24 from 9:32 AM through 10:30 AM, the following observations were made on tour of the facility: 1) The patient waiting room had a yellow, brown colored stain on multiple ceiling tiles and a small section of baseboard was missing from the wall between patient chairs on the window side of the waiting area. 2) Multiple sinks in the treatment area had scattered white buildup inside and around the sinks and on the faucets, all the sinks had rust colored buildup in the drains. 3) Throughout the treatment area, the floor tile had a buildup of dark brown and black colored dirt, grime,and stains. 4) The cabinets below both sinks in the medication area had a buildup of dirt and grime visible down the front sides of the cabinets and the bottom cabinets had brown and black colored buildup on the cabinet shelves where patient supplies were stored. 5) Refrigerator two (2) had a buildup of dirt and grime on the shelves and the top shelf had multiple pieces of white material in different shapes stuck to it. 6) The Tri station counter had a white residue and the corners of the counter around the sink had a brown stain that extended around the entire sink. 7) Refrigerator four (4) had dirt and grime buildup on the shelves where patient medication was stored. 8) Throughout the treatment room the supply carts had a buildup of white residue, the baskets holding acid jugs and bleach bottles all had a white residue. 9) The treatment chairs at stations #4, #9, #13, and #16 had rips and tears in the seats. 10) The treatment chairs at stations #10, #11, #12, #13, #14, and #16 casters above the wheels had a heavy buildup of a brown rust colored substance. 11) The Water/Storage area observations showed: a) The floor had several areas that were lighter in color than other areas and appeared to have a white residue. b) The walls had dirt and grime buildup with stains and some peeling paint in the storage area. B. During an interview on 05/15/24 at 11:05 AM, the findings in A were verified with the Facility Administrator.”

“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 observation, policy and procedure review and interview, it was determined three (#4, #13, and #16) of nine (Stations #4,#8,#9,#10,#11,#12,#13,#14, and-#16) blood pressure (BP) cuffs observed during shift change were not 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 116 in center hemodialysis patients on census and staff. The findings included: A. Review of policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment” revised 07/2023, showed, “Purpose: To provide guidance on proper disinfection of the dialysis station, machine, equipment and surrounding surfaces with the appropriate method prevents the transmission of disease/infection to the dialysis population. Disinfection Procedure: Obtain at least one (1) clean moistened 1:100 bleach cloth for the machine, one (1) for the chair and one (1) for ancillary equipment. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP (blood pressure) cuffs and basket.” B. Observation of shift change on 5/15/24 from 9:00 AM to 11:10 AM showed BP cuffs at Station #4, #13, and #16 had a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection between patients. C. During an interview on 5/15/23 at 11:15 AM, the Facility Administrator confirmed the findings in A.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 37145 Based on clinical record review, and interview, it was determined a Registered Nurse (RN) failed to assess or intervene for one (#2) of eleven (#1-#11) patients with a pulse rate outside of parameters. The failed practice did not ensure the physician was aware of the patient’s health status to determine the course of treatment and had the likelihood to affect all 116 in center hemodialysis patients on census. Findings follow: A.Review of the Facility Policy PCT (Patient Care Technician)/CCHT (Certified Clinical Hemodialysis Technician): Report to Charge Nurse,” showed abnormal findings in pulse rate below (<) 50 beats per minute (BPM) or greater than (>) 110 BPM would be reported to the nurse who would further assess the patient. B. Review of six TFS (treatment flow sheets), 03/27/24 - 04/15/24, for Patient #2 showed no evidence the RN assessed the patient’s pulse rate, provided treatment, and/or notified Physician of findings. C. The TFS dated 04/08/24 showed - Intradialytic pulse 49 at 6:00 AM, 48 at 6:40 AM ,47 at 8:00 AM. CCHT (Certified Clinical Hemodialysis Technician) #1 documented “RN #1 advised to turn U/F (ultrafiltration) off. RN (Registered Nurse) is aware of BP and HR (heart rate).” D. In an interview with the Facility Administrator on 05/15/24 at 4:45 PM, the findings in A-C were confirmed.”

“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, treat, and/or notify Physician of the blood pressure (BP) for five (#2, #3, #5, #6, and #11) of eight (#1-#7, and #11) in center hemodialysis patients. The failed practice placed patients at risk for complications related to un-managed blood pressure. The failed practice had the likelihood to affect all 116 in center hemodialysis patients. The findings were: A. Review of the facility Standing Orders - Hemodialysis Pre and post dialysis - TPR (temperature, pulse, and respirations) and BP (blood pressure) sitting and standing showed: BP and pulse q (every) 30 minutes and prn (as needed) during treatment. Hypertension: Clonidine 0.1 mg (milligrams) PO (by mouth) prn SBP (systolic blood pressure) greater than (>) 180. Repeat BP q 15 minutes for 1 hour after giving medication. Hypotension: SBP less than (<) 90 and/or DBP (diastolic blood pressure) < 50 mmHg (millimeters of mercury), give Normal Saline up to 200 mL (milliliters) X 3. No more than 600 mL total. Place in modified Trendelenburg position. Minimum ultrafiltration rate. B. 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. C. During an interview on 05/15/24 at 3:50 PM, the facility Administrator confirmed findings in A and B. D. During an interview with the Facility Administrator on 05/15/24 at 3:55 PM, she stated, “We follow the standing orders for BP management. Every Patient has the standing orders signed by their Physician in their record. If there are any variances they are written as a separate order and come up on the special instructions area of each treatment flow sheet.” E. Patient #2 1) Review of six TFS (treatment flow sheets), five of six treatments, 03/27/24 - 04/15/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 04/08/24 - Intradialytic 88/61, intradialytic pulse 49 at 6:00 AM, pulse 48 at 6:40 AM, pulse 47 at 8:00 AM. CCHT (Certified Clinical Hemodialysis Technician) #1 documented “RN #1 advised to turn U/F (ultrafiltration) off. RN is aware of BP and HR (heart rate).” b) 04/15/24 - Intradialytic, 85/56 and Post treatment 144/94. RN # 1 documented “Above estimated dry weight (EDW) due to hypotension, instructed to monitor fluid intake.” c) There was no evidence of an RN assessment for hypotension or the low heart rate and no evidence of following the Physician’s standing orders, or notification of the Physician in the intradialytic change in vital signs. 2) During the interview on 05/15/24 at 3:30 PM, the Facility Administrator confirmed the findings in E. F. Patient #3 1) Review of six TFS, six of six treatments, 04/29/24 - 05/10/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 04/29/24 - Intradialytic- 186/98. b) 05/01/24 - Intradialytic- 65/47, 83/39, 90/41, 134/118 and 157/108. RN #1 documented, “Above EDW due to hypotension.” c) 05/03/24 -Intradialytic- 82/42, 85/51, 92,41, 78/48, 87/49, 88/62, CCHT #2 documented, “UF turned off, given 200 ml NS (normal saline) per charge nurse. Patient stated he was light headed, will continue to monitor.” RN #2 documented, “Unable to reach target weight due to patient becoming hypotensive during treatment.” d) 05/06/24 - Pretreatment 170/108. e) 05/08/24 - Pretreatment 178/95, Intradialytic 163/104, Post treatment 176/98. f) 05/10/24 - Intradialytic 152/103, Post treatment 152/103. 2) There was no evidence of an RN assessment for blood pressures out of range, provided treatment, and/or notified Physician of findings. 3) During the interview on 05/15/24 at 3:45 PM, the Facility Administrator confirmed the findings in F. G. Patient # 5 1) Review of six TFS, five of six treatments, 04/30/24 - 05/10/24, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP. BP Examples: a) 04/30/24 - Pretreatment 174/90, Intradialytic 211/104, 215/104, Post treatment 206/93. b) 05/02/24 - Pretreatment 172/77, Intradialytic 192/91, 190/94, Post treatment 120/99 c) 05/04/24 - Pretreatment 177/79, Intradialytic 213/94, 200/76, Post treatment 179/66 d) 05/09/24 - Pretreatment 174/74, Intradialytic 179/164, 215/77, Post treatment 173/72 e) 05/10/24 - Pretreatment 172/74, Intradialytic 181/71, 184/95, Post treatment 178/72 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings. 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in G. H. Patient # 6 1) Review of six TFS, six of six treatments, 05/03/24 - 05/13/24, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP. BP Examples: a) 05/03/24 - Pretreatment 170/101, Intradialytic 156/100, 167/104, 165/103, Post treatment 163/107. b) 05/08/24 - Pretreatment 178/73, Intradialytic 178/109, 188/118, 186/103, Post treatment 186/105 c) 05/09/24 - Pretreatment 174/108, Intradialytic 184/101, 163/98, Post treatment 181/105 d) 05/10/24 - Pretreatment 164/104, Intradialytic 181/109, 181/112, Post treatment 159/100. e) 05/11/24 - Pretreatment 145/91, Intradialytic 156/100, 171/112, 194/113, Post treatment 182/109 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings . 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in H. I. Patient # 11 1) Review of six TFS, six of six treatments, 04/22/24 - 05/04/24, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP. BP Examples: a) 04/22/24 - Pretreatment 180/108, Intradialytic 156/100, 167/104, 165/103, Post treatment 163/107. b) 04/24/24 - Pretreatment 171/100, Intradialytic 165/114, 163/100, 151/104, Post treatment 169/95. c) 04/29/24 - Pretreatment 141/84, Intradialytic 134/107, Post treatment 171/83. d) 05/01/24 - Intradialytic 215/11, Post treatment 159/100. e) 05/03/24 - Pretreatment 164/93, Intradialytic 180/98, 155/118, 183/91, Post treatment 169/92. f)05/04/24 - Pretreatment 163/96, Intradialytic 140/109, 170/87, Post treatment 169/92 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings. 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in I.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 37145 Based on clinical record review, policy review, and interview, it was determined the Interdisciplinary Team (IDT) failed to modify the patient’s plan of care (POC) for five (#2, #3, #5, #6, and #11) of eight (#1-#7, and #11) in center hemodialysis patients when the patients’ blood pressure was outside established parameters. The failed practice placed patients at risk for complications related to un-managed blood pressure and fluid volume. The failed practice had the likelihood to affect all 116 in center hemodialysis. The findings were: A. Review of the facility Standing Orders- Hemodialysis Pre and post dialysis-TPR (temperature, pulse, and respirations) and BP (blood pressure) sitting and standing showed: BP and pulse q (every) 30 minutes and prn (as needed) during treatment. Hypertension: Clonidine 0.1 mg (milligrams) PO (by mouth) prn SBP (systolic blood pressure) greater than (>) 180. Repeat BP q 15 minutes for 1 hour after giving medication. Hypotension: SBP less than (<) 90 and/or DBP (diastolic blood pressure) < 50 mmHg (millimeters of mercury), Give Normal saline up to 200 mL (milliliters) X 3. No more than 600 mL total. Place in modified Trendelenburg position. Minimum ultrafiltration rate. B. Review of the Facility Policy PCT (Patient Care Technician)/CCHT (Certified Clinical Hemodialysis Technician): Report to Charge Nurse, showed, “BP Systolic > 180 or < 100, Diastolic > 110 for Pre-Dialysis, Intra Dialysis, and Post Dialysis.” 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 05/15/24 at 3:50 PM, the facility Administrator confirmed findings in A, B and C. E. During an interview with the Facility Administrator on 05/15/24 at 3:55 PM, she stated, “We follow the standing orders for BP management. Every Patient has the standing orders signed by their Physician in their record. If there are any variances they are written as a separate order and come up on the special instructions area of each treatment flow sheet.” F. Patient #2 1) Review of six TFS (treatment flow sheets), five of six treatments, 03/27/24 - 04/15/24. a) 04/08/24 - Intradialytic BP 88/61, intradialytic pulse 49 at 6:00 AM, pulse 48 at 6:40 AM, pulse 47 at 8:00 AM. CCHT #1 documented “RN # 1 advised to turn U/F (ultrafiltration) off. RN (Registered Nurse) is aware of BP and HR (heart rate).” b) 04/15/24 - Intradialytic, BP 85/56 and Post treatment 144/94. RN # 1 documented “Above estimated dry weight (EDW) due to hypotension, instructed to monitor fluid intake.” c) There was no evidence the IDT modified the POC related to the patient’s heart rate or BPs outside of established parameters. d) During the interview on 05/15/24 at 3:30 PM, the Facility Administrator confirmed the findings in F. G. Patient #3 1) Review of six TFS, six of six treatments, 04/29/24 - 05/10/24. BP Examples: a) 04/29/24 - Intradialytic 186/98. b) 05/01/24 - Intradialytic 65/47, 83/39, 90/41, 134/118 and 157/108. RN #1 documented, “Above EDW due to hypotension.” c) 05/03/24 - Intradialytic 82/42, 85/51, 92,41, 78/48, 87/49, 88/62. CCHT #2 documented, “UF turned off, given 200 ml NS (normal saline) per charge nurse. Patient stated he was lightheaded, will continue to monitor.” RN # 2 documented, “Unable to reach target weight due to patient becoming hypotensive during treatment.” d) 05/06/24 - Pretreatment 170/108. e) 05/08/24 - Pretreatment 178/95, Intradialytic 163/104, Post treatment 176/98. f) 05/10/24 - Intradialytic 152/103, Post treatment 152/103. 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 05/15/24 at 3:45 PM, the Facility Administrator confirmed the findings in G. H. Patient # 5 1) Review of six TFS, five of six treatments, 04/30/24 - 05/10/24. BP Examples: a) 04/30/24 - Pretreatment 174/90, Intradialytic 211/104, 215/104, Post treatment 206/93. b) 05/02/24 - Pretreatment 172/77, Intradialytic 192/91, 190/94, Post treatment 120/99 c) 05/04/24 - Pretreatment 177/79, Intradialytic 213/94, 200/76, Post treatment 179/66 d) 05/09/24 - Pretreatment 174/74, Intradialytic 179/164, 215/77, Post treatment 173/72 e) 05/10/24 - Pretreatment 172/74, Intradialytic 181/71, 184/95, Post treatment 178/72 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in H. I. Patient # 6 1) Review of six TFS, six of six treatments, 05/03/24 - 05/13/24. BP Examples: a) 05/03/24 - Pretreatment 170/101, Intradialytic 156/100, 167/104, 165/103, Post treatment 163/107. b) 05/08/24 - Pretreatment 178/73, Intradialytic 178/109, 188/118, 186/103, Post treatment 186/105 c) 05/09/24 - Pretreatment 174/108, Intradialytic 184/101, 163/98, Post treatment 181/105 d) 05/10/24 - Pretreatment 164/104, Intradialytic 181/109, 181/112, Post treatment 159/100. e) 05/11/24 - Pretreatment 145/91, Intradialytic 156/100, 171/112, 194/113, Post treatment 182/109 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in I. J. Patient # 11 1) Review of six TFS, six of six treatments, 04/22/24 - 05/04/24. BP Examples: a) 04/22/24 - Pretreatment 180/108, Intradialytic 156/100, 167/104, 165/103, Post treatment 163/107. b) 04/24/24 - Pretreatment 171/100, Intradialytic 165/114, 163/100, 151/104, Post treatment 169/95. c) 04/29/24 - Pretreatment 141/84, Intradialytic 134/107, Post treatment 171/83. d) 05/01/24 - Intradialytic 215/11, Post treatment 159/100. e) 05/03/24 - Pretreatment 164/93, Intradialytic 180/98, 155/118, 183/91, Post treatment 169/92. f) 05/04/24 - Pretreatment 163/96, Intradialytic 140/109, 170/87, Post treatment 169/92 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 05/15/24 at 3:50 PM, the Facility Administrator confirmed the findings in J.”