Lbj Medical Center

“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: 36461 Based on observation, document review, and interview, the facility failed to ensure 14 patients’ out of a total sample of 28 patients (Patients (P)11, P17, P16, P18, P19, P20, P21, P22, P23, P24, P25, P26, P27, and P28) hemodialysis access sites were uncovered and visible during treatment for two of three survey days. The needle insertion sites, line connections for all patients on treatment must always be visible to staff to ensure that lines and needles do not become dislodged or disconnected. This failure could affect all 225 in-center patients receiving treatment in the facility. Findings include: Observation on 12/17/24 from 12:15 PM to 1:10 PM revealed P18, P26, P27, and P28 had their access sites completely covered with a blanket or clothing. Staff were not observed educating the patients to leave their access sites uncovered or to adjust the blankets or clothing, so the access sites were visible. Observation on 12/17/24 from 1:10 PM to 1:50 PM revealed P11, P17, P21, P23, and P25’s access sites were completely covered with a blanket or clothing. Staff were not observed educating the patients to leave the access site uncovered or to adjust the blankets or clothing, so the access sites were visible. Observation on 12/17/24 from 1:50 PM to 2:45 PM revealed P18, P19, P26, P27, and P28’s access sites were completely covered with a blanket or clothing. Staff were not observed educating the patients to leave the access sites uncovered or to adjust the blankets or clothing, so the access site was visible. Observation on 12/18/24 from 11:00 AM to 11:45 AM revealed P16, P20, P22, and P24’s access sites were completely covered with a blanket or clothing. Staff were not observed educating the patients to leave the access sites uncovered or to adjust the blankets or clothing, so the access sites were visible. During an interview with Registered Nurse (RN) 2 on 12/18/24 at 2:30 PM, RN2 stated the expectation was for access sites to always be visible. During an interview with RN1 on 12/18/24 at 2:45 PM, RN1 stated the expectation was for access sites to always be visible. During an interview with the Director of Nursing (DON) on 12/18/24 at 3:00 PM, the DON stated the expectation was for access sites to remain uncovered during treatment and that staff should be educating patients why the access sites need to remain visible. The DON stated they did not have a policy specifically for line of sight with access sites, but it was discussed during the monthly staff meetings. During an interview with the Medical Director on 12/18/24 at 4:00 PM, he/she stated the expectation was for access sites to remain uncovered during treatment. Review of the facility monthly staff meeting agenda dated 11/29/24, revealed, “ ...All patient’s faces and access sites should be made visible during treatment run to visualize bleeding and patient crash during treatment ...””

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 36461 Based on interview and review of the facility personnel file worksheet, the facility failed to provide up-to-date information for cardio-pulmonary resuscitation (CPR) for 50 of 52 current staff members and water, dialysate, and machine training for 29 of 52 current staff members, resulting in the potential for staff CPR certifications and water training to expire and staff not have up to date training. Findings include: During the entrance conference meeting on 12/16/24 at 2:30 PM the Facility Administrator (FA) was provided the “Facility Worksheet: Personnel File” and instructed to have all items on the worksheet filled in. The FA was informed once the worksheet was completed, the survey team would choose staff members from the list to verify the information provided by the facility. The FA acknowledged understanding. On 12/17/24 at 2:00 PM the FA returned the worksheet, however information for CPR expiration dates and water training dates were not completed. The worksheet was returned to the FA, and it was requested by this surveyor to have those dates completed. On 12/18/24 at 5:00 PM the FA presented the worksheet to this surveyor and stated the information for staff CPR and water testing was kept in the employee files in the hospital Human Resources department and staff had left for the day. During an interview on 12/18/24 at 5:10 PM the FA stated no personal information for staff competencies, CPR or water testing was kept in the clinic. The FA stated an outside biomedical consultant came annually to train the staff for their annual water testing but was unable to provide the date when the consultant was there. The FA stated “ ...it was within the last year ...” The FA also stated the hospital human resources department kept track of CPR expirations, license expirations and when competencies were due. The FA further stated all employees were required to have CPR training (all 52), but only licensed employees (29) were required to have water training. This surveyor requested a policy for staff training requirements from the FA. At the time of exit on 12/18/24 at 7:00 PM, no policy was presented regarding staff training requirements.”

“PQ-SW-MSW;GRANDFATHER IF HIRED BEFORE 1976 CFR(s): 494.140(d) The facility must have a social worker who- (1) Holds a master’s degree in social work with a specialization in clinical practice from a school of social work accredited by the Council on Social Work Education; or (2) Has served at least 2 years as a social worker, 1 year of which was in a dialysis unit or transplantation program prior to September 1, 1976, and has established a consultative relationship with a social worker who qualifies under §494.140 (d)(1). This Standard is not met as evidenced by: 26190 Based on interview and policy review, the facility failed to ensure that one Social Services Employee (SSE) of the two social workers providing care for the patients at the dialysis facility held a master’s degree in social work. This failure had the possibility to negatively impact all patients at the dialysis facility. Findings include: During an interview on 12/18/24 at 12:30 PM with the Social Services Director (SSD), he/she stated he/she had been employed by the facility since 2013 and held a master’s degree in social work. SSD stated her major responsibilities were coverage of the Monday, Wednesday, and Friday dialysis shifts, training of new staff in the social service department and at the present time a discharge planner for pediatrics and OB (Obstetrics) in the hospital. When this surveyor inquired about the educational background of SSE that covered the Tuesday, Thursday, and Saturday dialysis shifts, the SSD stated that SSE did not have a master’s degree in social work. This surveyor requested to see the training records for SSE and the SSD stated there were no written training records. The SSD stated he/she provided the training for SSE through shadowing. During an interview on 12/18/24 at 2:15 PM the Facility Administrator stated he/she was aware that one of the two dialysis SSE did not have a master’s degree in social work. The Facility Administrator said the dialysis unit had tried to hire a second master’s prepared social worker to no avail. During an interview on 12/18/24 at 5:40 PM with the SSE, he/she confirmed that he/she did not hold a master’s degree in social work. The SSE said she held a master’s degree in education. The SSE stated he/she had worked for the facility for the past 10 years. The SSE stated when he/she was initially hired he/she was not aware the position required a master’s level social worker. The SSE explained currently he/she provided coverage for the Tuesday, Thursday, and Saturday dialysis shifts. SSE explained his/her current job responsibilities were completing patient assessments/evaluations, completing care plans, making referrals, and providing patient education. A review of the facility’s policy, “ESRD Patient Psychosocial Assessment and Plan of Care” effective 09/11/18 stated, “Policy: The Dialysis patient’s psychosocial needs shall be addressed in the comprehensive patient assessment and be incorporated into the patient’s care plan. Psychosocial needs assessment shall be performed by a qualified, *Master prepared social worker. Social Worker professional requirements: Master’s degree in social work from a school of social work ...*Only a master-prepared social workers may do assessments, develop psychosocial plans of care, provide counseling to patients and families ...””