Nea Baptist Clinic - Hilltop

“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, it was determined one (#8) of one ( #8 ) patients who held pressure on their access site for hemostasis, did not perform hand hygiene prior to exiting the treatment area, and one ( Licensed Practical Nurse (LPN) #1) of three (RN #1-#2 and LPN #1) direct patient care staff did not allow alcohol hand sanitizer to air dry by rubbing hands together prior to donning new gloves. The failed practices had the likelihood to spread infection. The failed practice had the likelihood to affect all 41 hemodialysis patients on census and all staff. The findings included: A. Review of the Facility Policy and Procedure titled, “Bacterial Infection Prevention - Revised 4/13,” showed that patients must perform hand hygiene after glove removal following holding access site for hemostasis. B. The findings of “A” were confirmed with the Administrator on 10/23/24 at 1:30 PM. C. Review of the Facility Policy and Procedure titled, “Gloving and Hand Hygiene in Dialysis - Revised 12/2023, showed that alcohol-based hand rub (ABHR) must be rubbed on all surfaces of hand until dried. D. The findings of “C” were confirmed with the Administrator on 10/23/23 at 1:30 PM. E. Observation of termination and initiation of dialysis treatments on 10/23/23 from 9:30 AM to 11:40 AM showed: 1) Patient #8 held pressure on the needle insertion access sites to achieve hemostasis. Patient #8 left the patient treatment area at 10:39 AM with no hand hygiene performed. 2) LPN #1 applied ABHR (alcohol-based hand rub) but did not rub hands until dry before donning gloves. Hands were visibly wet and gloves were difficult to apply during observation of decannulation of Central Venous Catheter . 3) On 10/23/24 at 11:45 AM the Administrator confirmed findings in E.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 37145 Based on observation, policy and procedure review and interview, it was determined all surfaces of the dialysis station (Blood pressure cuff holder, pillow placed on dirty area) were not cleaned/disinfected between patient use for one (9) of four (7, 9, #10 and #11) dialysis stations observed. The failed practice placed the patients at risk of infection from cross contamination and had the potential to affect all 41 in-center hemodialysis patients on census. The findings follow: A. Observation of termination and initiation of dialysis on 03/23/24 from 9:15 AM to11:45 AM, showed, Licensed Practical Nurse (LPN) 1 failed to clean/disinfect the top of the dialysis chair before placing a disinfected pillow on top of it. The pillow placed on the dirty top of the chair was placed in a pillowcase for use with the next patient without disinfecting it again at station # 9. The blood pressure cuff was disinfected and placed in the blood pressure cuff holder on the side of the machine that had not been disinfected. During disinfecting of the station, the bottom of the station was cleansed then the screen of the monitor was cleaned, and then the middle of the station was cleaned in no certain pattern. B. Review of the Facility Policy “Infection Control of Dialysis Related Equipment revised on 12/2023 showed, “Dialysis machine/station is cleaned after each use with a 1:100 bleach solution on all surfaces prior to setting up for the next treatment. This includes all supplies reused at patient stations (chair, pillow,oxygen cylinder/carrier, prime bucket etc.)Surfaces should be allowed to air dry prior to set up for the next patient.” C. The findings of B were confirmed in an interview with the Facility Administrator on 03/23/24 at 11:45 AM.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 37145 V143 Based on observation and policy review, it was determined three of three (Heparin Sodium 50,000 USP(United States Pharmacopeia) units per 10 ml(milliliter) multidose vials) opened multi-dose vials (MDVs) did not have the date opened to determine the 28 day expiration date and the initials of who opened the vial. The failed practice did not assure the MDVs had not expired and were not available for patient use. The failed practice had the likelihood to affect all patients who received Heparin Sodium. The findings were: A. Review of the facility policy, “Guidelines for Medication Administration, “ revised 12/2023, showed: Multi-dose vials shall be labeled when opened with the date, time, and initials of nurse and used within 28 days of opening. Limit open vials of same drug to prevent wastage of unused drug past expiration. This is followed unless manufacturer states otherwise, as in the case of some vaccines. Refer to drug insert for guidance.” B. Observation on 10/21/24 at 11:00 AM with the Administrator showed: Three MDV of Heparin Sodium 50,000 units per 10 ml. vials that were opened and contained approximately 1 to 2 ml of medication did not have the dated opened or the initials of who opened the vial. C. The findings A&B were confirmed with the Facility Administrator on 10/21/24 at 11:35 AM.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 37145 Based on observation, policy and procedure review, review of Centeres for Disease Control (CDC) protocol, it was determined one of one (LPN # 1) Licensed Practical Nurse (LPN) did not use a Chlorhexidine with alcohol (CHD) pad in the process of termination of dialysis to scrub the catheter hub of the venous line after removal of the heparin syringe prior to capping. The failed practice had the likelihood of promoting a BSI (Blood Stream Infection). The failed practice had the likelihood to affect any patient with a Central Venous Catheter (CVC). The findings were: A. Review of the facility policy and procedure, “Accessing/Deaccessing Dialysis Catheters,” revised 12/2023 showed: 1) Supplies for deaccessing the dialysis catheter were exam gloves, paper drape, two CHD pads, two masks, sterile end caps, two Normal Saline syringes and syringes with a heparin flush. 2) Remove heparin syringe and with a (CHD) pad and a friction motion, cleanse the end of hub. With the same antiseptic pad and twisting motion, cleanse the threads of the hub. B. Review of CDCs protocol titled, “Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol,” showed to: 1) Disinfect the catheter hub before applying the new cap. 2) Disconnect the blood line from the catheter and disinfect the hub with a new antiseptic pad. Scrub the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue. 3) Attach the new sterile caps to the catheter aseptically. C. Observation on 10/23/24 at 9:55 AM of the termination of dialysis for Patient #10, who had a CVC, showed: 1) LPN #1 disconnected the blood lines from each catheter lumen and attached a syringe with Normal Saline to each lumen. 2) Each lumen was flushed with 10 milliliters (ml) of Normal Saline and syringes were disconnected from each catheter lumen. 3) Heparin syringes were attached to each catheter lumen. After the Heparin was instilled, the syringe was removed from the venous port and cap was applied without the hub being scrubbed with the CHD. The arterial port was scrubbed with the CHD before a new cap was applied.”

“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 41 in-center hemodialysis patients on census. The findings were: A. On 10/21/24 from 10:56 AM through 11:45 AM, the following observations were made on tour of the facility: 1) The water room showed: a) There was a buildup of white residue on the plastic pipes and a green color buildup on the metal pipes of the entire water treatment system. b) There was a buildup of white residue on an overflow cart in the water room where supplies were stored. c) The sink had a heavy buildup of white residue. d) The floor was wet with puddles of water on the floor and several areas that had a white buildup. 2) The Storage room showed: a) All pallets in the storage area holding supplies were made of wood. b) The painted wooden shelves holding supplies had multiple areas of peeling paint. c) The door leading to outside had multiple areas of paint scrapes and rust-colored areas. 3) The door to the biomed office had multiple paint scrapes and stains and the sink had a heavy buildup of a white substance. 4) The treatment room showed: a) The clean sink had dirt and grime build up underneath, a white buildup inside and on the fixtures, and the caulking around the sink was uneven and had rough edges. b) The wall boxes at stations 1 through 12 had a heavy buildup of white residue. c)The countertop behind station 9 had missing Formica. 5) The Peritoneal Dialysis office area sink had a heavy buildup of white residue and multiple paint scrapes on the walls. 6) The lab area refrigerator had a buildup of dirt and grime on the door and inside of the refrigerator. 7) The medication refrigerator had a buildup of dirt on the door and inside the refrigerator. B. During an interview on 10/21/24 at 11:45 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 review 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 41 in-center hemodialysis patients on census and staff. The findings were: A.Review of the Facility Policy “Infection Control of Dialysis Related Equipment “revised on 12/2023 showed, “Dialysis machine/station is cleaned after each use with a 1:100 bleach solution on all surfaces prior to setting up for the next treatment. This includes all supplies reused at patient stations (chair, pillow, oxygen cylinder/carrier, prime bucket etc.) Surfaces should be allowed to air dry prior to set up for the next patient.” B.Observation of termination and initiation of dialysis on 03/23/24 from 9:15 AM to11:45 AM, showed multiple fibers in the blood pressure cuffs at stations1, 8,10, and 11. C.The findings of B were confirmed in an interview with the Facility Administrator on 03/23/24 at 11:45 AM.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 37145 Based on observation, policy review, and interview, it was determined the facility failed to ensure patients’ faces and vascular access sites were not covered and were visible to direct patient care staff. The failed practice did not allow the direct patient care staff to visualize the face and vascular access site to assure patient safety during the dialysis treatment. The failed practice had the likelihood of affecting all 41 in-center hemodialysis patients on census. The findings were: A. Review of the Facility Policy and Procedure “Initiation of Hemodialysis Treatment” revised 01/2024, showed, Check all connections prior to walking away from patient and assure that connections are secure, and access is visible. Do not cover access sites with a blanket! They must be visible at all times for patient safety.” B. Observation on 10/23/24 at 9:30 AM, showed the patient’s vascular access site at Station #6 was not visible to the staff as the patient had vascular access site covered with a blanket. C. During the interview and observation on 10/23/24 at 9:30 AM, RN # 1 confirmed the findings in 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: 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) out of parameters for three (1,# 2, and #4) of five (#1-# 5) in-center hemodialysis patients reviewed, and notify Physician for elevated heart rate for one (#2) of five (#1-#5) patients reviewed. The failed practice placed patients at risk for complications related to un-managed blood pressure. The failed practice had the likelihood to affect all 41 in-center hemodialysis patients on census. The findings were: A. Review of the facility’s policy and procedure, “Management of BP (Blood Pressure) & Fluid /Review of EDW (Estimated Dry Weight)” showed, “Blood Pressure targets are based upon JNCS (Joint National Committee) guidance as follows: Midweek intradialytic post treatment target < 150/90. BP protocol: APRN (Advanced Practice Registered Nurse) monitors weekly BP trends post treatment and documents on progress note. Challenge EDW over next six treatments to re-establish dry weight which is then revised in the dialysis plan in EPIC. Once EDW is defined, review BP medications for necessary adjustments. Nursing staff alerts charge nurse to single hypertensive episode > or + 180/100 post treatment. Charge nurse investigates the following prior to notifying Advanced Practice Registered Nurse (APRN). Is the patient dry? list of BP meds, list of BP med taken by patient and when. Therapy adjustments are made based on assessment by charge nurse and APRN. EDW review is routinely conducted monthly by charge nurse and documented on monthly progress note.” 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. Review of JNC Guidelines for the Management of Hypertension showed, “For patients 18 years or older with Chronic Kidney Disease (CKD) or Diabetes Mellitus, the treatment threshold and target blood pressures are the same as those for the general population younger than 60 years (i.e.., threshold systolic pressure of 140 mm (millimeters) Hg ( mercury) or threshold diastolic pressure of 90 mm Hg; target systolic pressure of less than 140 mm Hg; target diastolic pressure of less than 90 mm Hg.” D. During an interview on 10/23/24 at 1:50 PM, the Administrator confirmed findings in A and B. E. Patient #1 1) Review of six TFS (treatment flow sheets), six of six treatments, 10/04/24 - 10/21/24, 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) 10/04/24 - Predialytic 158/89, Intradialytic 131/107,174/60, Post treatment 174/63. b) 10/07/24 - Predialytic 193/96, Intradialytic 205/84,188/72,185/69, Post treatment 178/74. c) 10/11/24 - Predialytic 163/72, Intradialytic 209/77,182/66, 194/63, Post treatment 172/73. d) 10/14/24- Predialytic 149/111, Intradialytic 172/63,168/60,177/76, Post treatment 180/65. e) 10/16/24- Predialytic166/86, Intradialytic 180/70,197/70,180/62, Post treatment 180/70. f) 10/21/24- Predialytic169/68, Intradialytic 156/58, Post treatment 146/94. g) There was no evidence of an RN assessment for hypertension or notification of the Physician. 2) During the interview on 10/23/24 at 12:46 PM, the Administrator confirmed the findings in E. F. Patient #2 1) Review of six TFS, five of six treatments, 10/05/24 - 10/19/24, 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) 10/05/24 - Predialytic 155/81, Intradialytic156/94, Post treatment 167/86. b) 10/08/24 - Predialytic 146/108, Intradialytic 157/91, 153/90 c) 10/10/24 - Post treatment 140/97, Intradialytic heart rate 126,132 Post treatment heart rate 131showed HR (heart rate elevated RN aware.” Total treatment minutes 194 Tx (treatment ended due to pt (patient) cramping and clotting in system. Ordered treatment time 240 minutes. d) 10/12/24 -Predialytic 147/93, Intradialytic 171/88, Post treatment 167/79. e) 10/19/24-Predialytic-171/80, Intradialytic 144/100,152/77 2) There was no evidence of an RN assessment for blood pressure or heart rate out of range, treatment provided, and/or notified Physician of findings. 3) During the interview on 10/23/24 at 12:56 PM, the Administrator confirmed the findings in F. G. Patient # 4 1) Review of six TFS, two of six treatments, 09/26/24 - 10/17/24, 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) 10/10/24 -Intradialytic 150/97, 145/121. b) 10/15/24 - Intradialytic 133/117, 119/100,141/100, Post treatment 154/84. 2) There was no evidence of an RN assessment for Hypertension (HTN), provided treatment, and/or notified Physician of findings. 3) During the interview on 10/23/24 at 1:52 PM, the Administrator confirmed the findings in G.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. 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 three (#1, #2, and #4) of five (#1-#5) in center hemodialysis patients#13) patients reviewed 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 41 in center hemodialysis patients. The findings were: A.. Review of the facility’s policy and procedure, “Management of BP (Blood Pressure) & Fluid /Review of EDW (Estimated Dry Weight)” showed, “Blood Pressure targets are based upon JNCS (Joint National Committee) guidance as follows: Midweek intradialytic post treatment target < 150/90. BP protocol: APRN (Advanced Practice Registered Nurse) monitors weekly BP trends post treatment and documents on progress note. Challenge EDW over next 6 treatments to re-establish dry weight which is then revised in the dialysis plan in EPIC. Once EDW is defined, review BP medications for necessary adjustments. Nursing staff alerts charge nurse to single hypertensive episode > or + 180/100 post treatment. Charge nurse investigates the following prior to notifying APRN. Is the patient dry? list of BP meds, list of BP med taken by patient and when. Therapy adjustments are made based on assessment by charge nurse and APRN. EDW review is routinely conducted monthly by charge nurse and documented on monthly progress note.” 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 .Review of JNC Guidelines for the Management of Hypertension showed, “For patients 18 years or older with Chronic Kidney Disease (CKD) or Diabetes Mellitus, the treatment threshold and target blood pressures are the same as those for the general population younger than 60 years (i.e.., threshold systolic pressure of 140 mm (millimeters) Hg ( mercury) or threshold diastolic pressure of 90 mm Hg; target systolic pressure of less than 140 mm Hg; target diastolic pressure of less than 90 mm Hg.” D. During an interview on 10/23/24 at 1:50 PM, the Administrator confirmed findings in A and B. E.. Patient #1 1) Review of six TFS (treatment flow sheets), six of six treatments, 10/04/24 - 10/21/24, 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) 10/04/24 - Predialytic 158/89, Intradialytic 131/107,174/60, Post treatment 174/63. b) 10/07/24 - Predialytic 193/96, Intradialytic 205/84,188/72,185/69, Post treatment 178/74. c) 10/11/24- Predialytic 163/72, Intradialytic 209/77,182/66, 194/63, Post treatment 172/73. d) 10/14/24- Predialytic 149/111, Intradialytic 172/63,168/60,177/76, Post treatment 180/65. e) 10/16/24- Predialytic166/86, Intradialytic 180/70,197/70,180/62, Post treatment 180/70. f) 10/21/24- Predialytic169/68, Intradialytic156/58, Post treatment 146/94. g) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 2) During the interview on 10//23/24 at 12:46 PM, the Administrator confirmed the findings in E. F. Patient #2 1) Review of six TFS, five of six treatments, 10/05/24 - 10/19/24, 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) 10/05/24 - Predialytic 155/81, Intradialytic156/94, Post treatment 167/86. b) 10/08/24-Predialytic 146/108, Intradialytic 157/91, 153/90 c) 10/10/24 - Post treatment 140/97, Intradialytic heart rate 126,132 Post treatment heart rate 131showed HR (heart rate elevated RN aware.” Total treatment minutes 194 Tx (treatment ended due to pt (patient) cramping and clotting in system. Ordered treatment time 240 minutes. d) 10/12/24 -Predialytic 147/93, Intradialytic 171/88, Post treatment 167/79. e) 10/19/24-Predialytic-171/80, Intradialytic 144/100,152/77 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 10/23/24 at 12:56 PM, the Administrator confirmed the findings in F. G. Patient # 4 1) Review of six TFS, two of six treatments, 09/26/24 - 10/17/24, 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) 10/10/24 -Intradialytic 150/97, 145/121. b) 10/15/24 - Intradialytic 133/117, 119/100,141/100, Post treatment 154/84. 2) There was no evidence that the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 10/23/24 at 1:52 PM, the Administrator confirmed the findings in G.”

“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 six of six (March, April, May,June, July, and August 2024) months, there was no evidence the Interdisciplinary Team (IDT) selected Blood Pressure (BP) and Fluid management or Mortality 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 ensure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 41 In-Center hemodialysis patients. The findings were: A. Review of the Facility Quality Management Meetings from March 2024 to August 2024 showed there was no evidence the IDT selected BP and Fluid management or Mortatlityfor development of measures, performance of root cause analysis and implementation of an action plan to improve outcomes for in-center hemodialysis. B. On 10/23/24 at 12:00 PM, the Administrator confirmed the findings in A.”