032546 Sun City West Dialysis (Fmc)

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 45999 Based on a review of facility policy and procedure, observation, and staff interview, the Department determined that the facility failed to ensure staff aseptically cleaned (1) of (3) patients’ vascular access prior to cannulation (Patients #15 and #16). Failure to adhere to infection control procedures prior to cannulation poses an increased risk of bloodstream and vascular access infection as bacteria at cannulation sites may not be reduced. The policy/procedure titled “Access Assessment and Cannulation” revealed, “...Disinfect the cannulation site as follows using any of the disinfectants below...07% isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating....” Observation on August 26, 2024, revealed Employee #11, disinfecting patient #15’s vascular access in preparation for cannulation. Employee #11, used one alcohol pad to cleanse the arterial cannulation site for 18 seconds and proceeded to cannulate the arterial site. Then repeated the steps for the venous site with a cleaning time of 20 seconds. Employee #1, confirmed during an interview conducted on August 28, 2024, that staff did not follow appropriate policy and procedures for cannulation of an AV fistula.”

“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: 45999 Based on document review, observation, and interview, it was determined that the facility failed to ensure direct care staff did not have artificial nails while providing patient care. Failure to follow established standards and infection control precautions poses an increased risk of infections for immunocompromised patients through contact transmission and cross-contamination. Findings include: The facility policy titled “Hand Hygiene” revealed: “...Do not wear artificial fingernails, extenders or nail wraps when having direct contact with patients ...Natural fingernail length shall be kept to ¼ inch or less ...Ring and bracelet use should be limited....” The CDC “Morbidity and Mortality Weekly Report, October 25, 2002 / Vol. 51 / No. RR-16, Guideline for Hand Hygiene in Health-Care Settings Recommendations” revealed: “...HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing...Personnel wearing artificial nails also have been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast...These recommendations are designed to improve the hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings...Do not wear artificial fingernails or extenders when having direct contact with patients at high risk....” Observation on August 26, 2024, revealed Employees #10, and #11, providing patient care services in the treatment area for patients on dialysis while wearing artificial nails. Employee #1 confirmed during an interview on August 28, 2024, that Employees #10 and #11, did not follow facility requirements for infection control while wearing artificial nails to provide patient care.”

“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: 45999 Based on a review of facility policy and procedure, observation, and staff interview, the Department determined that the facility failed to ensure staff aseptically cleaned (1) of (1) patients’ catheter exit site prior to the cap and hub connector disinfection. Failure to adhere to infection control procedure prior to connection poses an increased risk of bloodstream infections as bacteria at catheter exit sites may not be reduced. Findings include: The policy titled “Changing the Catheter Dressing Procedure” revealed,” ...Catheter exit site disinfection and dressing change is to be completed prior to cap and hub connector disinfection ...This provides an opportunity to view the exit site for infections or complications and if applicable, notify a team leader or charge nurse, prior to initiating treatment ... When cleaning the catheter exit site, 1- 2% chlorhexidine (CHG)/70% isopropyl swab sticks are to be used for 30 seconds in a concentric circle and a dry time for 30 seconds ....” Observation on August 26, 2024 revealed Employee #10 preparing to disinfect patient #16’s catheter in preparation for use. Employee #10, started by placing a clean barrier underneath the catheter limbs, then proceeded to remove the caps on the catheter limbs, attach 10cc syringes, and pull 10ccs of fluid out. Employee #10 then proceeded to perform a hub scrub of the arterial limb for 18 seconds and the venous for 21 seconds. Employee #10 then gave the heparin. Employee #10 then removed the used catheter dressing performed hand hygiene and proceeded to clean the catheter exit site for 14 seconds and a dry time of 34 seconds. Employee #1, confirmed during an interview conducted on August 28, 2024 that staff did not follow appropriate policy and procedures for changing catheter dressing procedures.”

“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: 45999 Based on a review of facility policy, medical records, and staff interviews, the Department determined that the facility failed to ensure that staff followed the attending physician’s prescribed hemodialysis (HD) order for blood flow rate (BFR) setting for each individual patient. Failure to follow physician orders and not reporting abnormalities poses the potential risk of inadequate dialysis, decreased clearances, and potential hospitalizations. 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 #10 A treatment sheet dated January 5, 2024 revealed that a blood flow rate was prescribed at 450ml/min. At 12:15 the blood flow was set to 300ml/min. then set to 450ml/min at 13:02, with no documentation alerting the RN. Patient #11 A treatment sheet dated June 19, 2024 revealed that a blood flow rate was prescribed at 450ml/min. At 15:07 the blood flow rate was set to 250ml/min. A treatment sheet dated June 28, 2024 revealed that a blood flow rate was prescribed at 450ml/min. At 14:06 the blood flow rate was set to 350ml/min. A treatment sheet dated July 1, 2024 revealed that a blood flow rate was prescribed at 450ml/min. A start of treatment was documented at 300ml/min, at 13:39 the BFR was set to the prescribed rate of 450ml/min with no documentation alerting the RN. A treatment sheet dated July 10, 2024, revealed that a blood flow rate was prescribed at 450ml/min. At 13:16 the blood flow rate was set to 300ml/min with no documentation alerting the RN. Patient #12 A treatment sheet dated August 14, 2024, revealed that a blood flow rate was prescribed at 450ml/min. At 20:11 the blood flow was set to 400ml/min with no documentation alerting the RN. Employee #1 confirmed during an interview on August 14, 2024 that no RN notification was documented as required by facility policy.”

“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: 45999 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 3 out of 4 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....” published December 2022, revealed: “...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....” A facility document titled “2024 AZ Hemodialysis Standing Orders”, revealed, “ ...Intra HD for a significant drop in systolic BP >40mm/Hg ...Notify nurse ....” “...Treatment Sheets....” revealed: Patient # 10 January 5, 2024 revealed: 12:47 HR 55 January 8, 2024 revealed: 12:17 BP 179/101 January 10, 2024 revealed: 12:26 BP 145/102 There was no documentation of the RN being made aware of vital signs out of range. Patient #12 August 14, 2024 revealed: 19:43 BP 186/74 20:00 BP 184/97 20:12 BP 193/94 August 21, 2024 17:20 BP 185/89 August 23, 2024 17:00 BP 183/102 August 26, 2024 17:20 BP 181/86 17:40 BP 192/71 20:18 BP 182/89 There was no documentation of the RN being made aware of vital signs out of range. Patient # 13 August 9, 2024 revealed: 18:17 BP 86/80 August 12, 2024 revealed: 18:21 HR 107 August 26, 2024 revealed: 14:07 HR 117 There was no documentation of the RN being made aware of vital signs out of range. Employee #1 confirmed during an interview on August 29, 2024 that no documentation of RN notification and/or intervention for out-of-range vitals was provided as required per facility policy.”