032545 South Mountain Dialysis Center (Fmc)

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 50568 Based on observation on tour and staff interview, it was determined that the facility failed to ensure that the facility was cleaned and disinfected to prevent, minimize, and control illness and infection. Failure to provide a clean and sanitary environment poses the potential risk of patient exposure to microorganisms and infectious cross-contamination among staff and patients. Findings include: Facility policy titled, “Cleaning and Disinfecting the Dialysis Station” which requires, “ ....Area including .... reusable equipment ....BP cuff ....All work surfaces shall be cleaned and infected with 1:100 bleach solution after completion of procedures ....” Facility policy titled “Infection Control Overview” which states, “....The nature of dialysis, with frequent exposure to blood and body fluids, and close proximity of patients and staff ...makes dialysis a high risk for spreading infectious diseases ....Housekeeping to ensure the environment is clean and sanitary....” On a tour of the facility conducted on 10/21/2024, the following practices were discovered: Employee #11 was seen wearing gloves from the treatment floor to the administrative portion of the facility. Employee #11 was then seen to be wearing a personal protective equipment (PPE) gown from the treatment floor to the administrative area. Employee #10 was seen sanitizing a hemodialysis station after patient use, but did not completely disinfect the ancillary equipment for the station (television arm and back panel was not sanitized). Employee #9 was seen sanitizing a hemodialysis station after patient use, but did not completely disinfect the ancillary equipment for the station (blood pressure cuff tubing contacted used trash can after disinfection and was not sanitized once more). Employee #8 was seen to be using hand sanitizer to sanitize a stethoscope after a patient assessment, Employee #8 then returned the stethoscope for further use for other patients. Employee #1 confirmed on 10/21/2024 that the facility was not following the practice of keeping the environment clean and sanitary.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50568 Based on a review of facility policy, medical records, and staff interviews, it was determined that the facility failed to ensure: 1.That the Registered Nurse (RN) notify the patient’s nephrologist when the patient’s post treatment weight deviated from the estimated dry weight (EDW) as prescribed for the patient. in (3) of (4) patients. Failure to follow nephrologist orders and not reporting abnormalities poses the potential risk of inadequate dialysis, decreased clearances and hospitalizations. 2.That staff followed physicians’ orders for (2) two out of (4) four patients’ hemodialysis treatments as it relates to patient’s prescribed hemodialysis prescription. Failure to follow physicians’ orders poses a risk that patients will not receive adequate care and dialysis treatment. 1. Findings include: Facility policy titled, “Patient Assessment and Monitoring” requires, “ ...Ensure the post weight is consistent with the goal set of the machine ....” Patient #13 Treatment flow sheets: 10/15/2024 Ordered dry weight 59.50 Kg Post weight 60.80 kg A documented weight difference of greater than 1.3 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 10/15/2024 Ordered dry weight 59.50 Kg, Post weight 60.60 kg A documented weight difference of greater than 1.1 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. Patient #10 Treatment flow sheets: Patient discharged 01/2024, treatment sheets reflect last treatments patient received at clinic. 12/1/2023 Ordered dry weight 44 Kg Post weight 42.80 kg A documented weight difference of greater than 1.2 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 12/4/2023 Ordered dry weight 44 Kg Post weight 41.80 kg A documented weight difference of greater than 2.2 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. Patient #11 Treatment flow sheets: Patient discharged 01/2024, treatment sheets reflect last treatments patient received at clinic. 12/1/2023 Ordered dry weight 80 Kg Post weight 82.90 kg A documented weight difference of greater than 2.9 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 11/27/2023 Ordered dry weight 77 Kg Post weight 82.50 kg A documented weight difference of greater than 5.5 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 11/15/2023 Ordered dry weight 77 Kg Post weight 80.40 kg A documented weight difference of greater than 3.4 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 11/13/2023 Ordered dry weight 77 Kg Post weight 84.50 kg A documented weight difference of greater than 7.5 Kg from the estimated dry weight and post weight without any documentation of a physician being notified. 2. Findings include: The facility policy titled “Patient Assessment and Monitoring” requires: “...Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow....” Patient #13: Patient discharged 04/2024, treatment sheets reflect last treatments patient received at clinic. On 04/6/2024 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 300 at 16:49 by a PCT. No documentation was made by the RN on duty to acknowledge the rate change. On 04/4/2024 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 350 at 11:05 by a PCT. The BFR was altered to the rate of 325 at 12:27 by a PCT. At 1313 an RN acknowledges a rate of 350, but does not acknowledge previous rate changes. On 04/2/2024 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 300 at 15:48 by a PCT. The BFR was altered to the rate of 255 at 1702 by a PCT. No documentation was made by the RN on duty to acknowledge the rate change. On 03/30/2024 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 350 at 14:27 by a PCT. The BFR was altered to the rate of 300 at 15:43 by a PCT. No documentation was made by the RN on duty to acknowledge the rate change. On 03/28/2024 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 300 at 14:05 by a PCT. No documentation was made by the RN on duty to acknowledge the rate change. Patient #10: Patient discharged 01/2024, treatment sheets reflect last treatments patient received at clinic. On 12/08/2023 patient’s Blood Flow Rate (BFR) order was ordered at a rate of 400. The BFR was altered to the rate of 350 at 17:21 by a PCT. The BFR was altered to the rate of 250 at 17:55 by a PCT. The BFR was altered to the rate of 200 at 18:24 by a PCT. The BFR was altered to the rate of 300 at 19:03 by a PCT. No documentation was made by the RN on duty to acknowledge the rate change. Employee #1 confirmed on 10/22/2024 that the facility was not following the practice of reporting when the patient’s post treatment weight deviated from the estimated dry weight and adhering to patient’s prescribed hemodialysis prescription.”

“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: 50568 Based on a review of facility policy, medical records, and staff interviews, the department determined that the facility failed to require clinical staff to notify the nurse and provide a documented intervention for (2) two out of (4) four patients’ reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range per the facility policy, which poses the potential risk of cardiovascular compromise and hospitalization. Findings include: Facility policy titled, “ ....Patient Assessment and Monitoring....” which requires, “ ....Monitoring During Treatment....Report to the nurse: Systolic blood pressure greater than 180 mm/Hg, Diastolic blood pressure greater than 100 mm/Hg, Blood Pressure less than or equal to 100 mm/Hg systolic...Heart rates that have dropped below 60 or risen above 100...Report to the nurse any significant findings....” Patient # 10 Patient discharged 01/2024, treatment sheets reflect last treatments patient received at clinic. 12/8/2023 16:39 BP 219/106 17:05 BP 169/103 17:21 161/100 17:42 BP 161/109 HR 58 17:55 BP 161/109 HR 58 18:00 BP 198/125 HR 39 12/13/2023 16:14 BP 228/96 16:26 BP 227/101 17:04 HR 109 Patient # 11 Patient discharged 01/2024, treatment sheets reflect last treatments patient received at clinic. 11/13/2023 06:01 HR 54 06:21 HR 50 06:41 HR 50 07:21 BP 136/100 11/19/2023 06:00 BP 175/106 06:21 BP 181/98 06:42 BP 175/105 07:42 BP 185/98 07:41 BP 174/103 08:00 BP 175/106 08:22 BP 183/102 08:33 BP 173/103 11/21/2023 05:55 BP 185/95 06:05 BP 204/95 06:47 BP 192/106 07:07 BP 183/99 07:29 BP 171/102 08:26 BP 181/107 08:27 BP 180/100 08:42 BP 184/110 08:56 BP 194/89 12/01/2023 07:03 HR 53 07:42 BP100/60 HR 59 08:03 BP 90/60 08:23 BP 88/66 HR 46 08:42 HR 52 08:50 HR 52 Employee #1 confirmed on 10/22/2024 that the facility was not following the practice of reporting vital signs outside of the set parameters to the RN on duty.”