032587 Deer Valley Dialysis (Fmc)

“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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure: 1. staff performed hand hygiene and donned gloves when providing patient care at the dialysis station; and 2. staff performed hand hygiene prior to preparing and administering medication. Failure to follow established standard and infection control precautions poses an increased risk of infections for immunocompromised patients through contact transmission and cross contamination. Findings include: 1. and 2. The facility policy titled “Hand Hygiene” requires: “...Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content...Before and after direct contact with patients...After contact with inanimate objects near the patient...After contact with other objects within the patient station or treatment space....” Observation on 01/18/2024 at 0931 revealed the nurse (Employee #10) responding to a dialysis machine alarm and stopped blood pump at Station #8. Employee #10 did not perform hand hygiene or don gloves before touching the patient’s machine, resetting the machine to re-start the blood pump, then turned and left the dialysis station without performing hand hygiene after touching the patient’s machine with bare hands. Employee #1 confirmed on 01/18/2024 that Employee #10 did not follow facility policy for wearing gloves and hand sanitizing. 2. The facility policy titled “Medication Preparation and Administration” requires: “...Infection Control...The following steps must be taken to ensure infection control. Perform hand hygiene prior to accessing supplies, handling vials and IV solution and preparing or administering medications....” Observation on 01/18/2024 at 1013 revealed Employee #10 leave the nurse’s station desk, approach the nurse medication preparation station and begin to prepare medication. Employee #10 did not perform hand hygiene after leaving the nurses station desk where s/he was charting on the computer and prior to preparing the medications. S/he completed the medication preparation, then walked to Station #8 and administer the medication to the patient who had started treatment. Employee #10 did not hand sanitize between tasks, did not don gloves, administered the medication with bare hands, left the dialysis station, then returned to the nurse’s station desk prior to using a hand sanitizer. Employee #1 confirmed on 01/18/2024 that Employee #10 did not follow facility policy for hand hygiene.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure Employee #10 cleaned and disinfected his/her stethoscope between and after use on multiple patients which poses a potential risk of increased infection for patients through contact transmission and cross contamination of pathogenic organisms that may be harbored on the dirty stethoscope. Findings include: The facility policy titled “Cleaning and Disinfecting the Dialysis Station” requires: “...The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between used...Also, the nature of dialysis treatments with frequent exposure to blood and body fluids, close proximity of patients and staff, and the immunocompromised status of dialysis patients make dialysis a high-risk area for spreading infectious disease...Dialysis station...General Cleaning...After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station....” Observation on 01/18/2024 revealed Employee #10 use his/her stethoscope to conduct a post-dialysis nursing assessment on a patient from Station #16 at the scale. Employee #10 hung the stethoscope around his/her neck after using it on the patient and did not disinfect the stethoscope upon leaving the patient. Employee #10 walked back to the nurse’s station and placed the dirty stethoscope on the desk top next to the computer keyboard. Employee #10 picked up the dirty stethoscope a few minutes later, hung it around his/her neck, walked to Station #7 and conducted a pre-dialysis nursing assessment on a patient who presented for treatment at the station. Employee #10 retrieved the stethoscope from around his/her neck, used it on the second patient without disinfecting it, and after patient use replaced the stethoscope back around his/her neck, walked back to the nursing station and placed the dirty stethoscope on the desk next to the keyboard. Employee #1 and 2 confirmed on 01/18/2024 that Employee #10 did not disinfect his/her stethoscope between use on multiple patients at different stations during nursing assessments conducted pre and post dialysis treatment as required by policy.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 37489 Based on document review, observation, and staff interview, it was determined that the facility failed to ensure staff secured patient medications when not in use. Failure to secure medications when not in use has the potential risk patient will receive ineffective, contaminated, and/or tampered with medications. Findings include: The facility policy titled “Medication Preparation and Administration” requires: “...Securement...All medication will be kept in a locked cabinet except when in use....” Observation on 01/18/2023 revealed the following unlocked medication boxes on desks and tables on the treatment floor. There were no staff present at the unlocked boxes, nor were the medications in use. Box #1 - Unlocked, contained two (2) 30 ml vials of Heparin Sodium for injection and two (2) 10 ml vials of Xylocaine for injection. Box #2 - Unlocked, contained one (1) 30 ml vial of Heparin Sodium for injection Box #3 - Unlocked, contained two (2) 30 ml vials of Heparin Sodium for injection Box #4 - Unlocked, contained two (2) 30 ml vials of Heparin Sodium for injection Employee #1 confirmed on 01/18/2024 that staff did not lock and secure the aforementioned medications as required by policy.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure a full-time, registered nurse responsible for nursing services was employed at the facility which has the potential risk to the overall health and safety of patients dialyzing at the facility if there is no appropriate nurse manager overseeing patient care. Findings include: Observation on 01/18/2024 revealed that the facility did not have a full-time onsite nurse manager. The facility administrator (Employee #1) who was onsite at the time of the survey confirmed on 01/18/2024, that s/he was not a registered nurse and that the nurse manager has been on leave from the facility since November 2023. The ‘GOVERNING BODY MEETING” dated 11/27/2023 revealed that Employee #5 was governed in as interim nurse manager until Employee #4’s return from leave starting 11/28/2023 through an anticipated date of 01/29/2024. Employee #1 confirmed on 01/18/2024 that the current interim nurse manager (Employee #5) works at a “sister facility” and does not work full time at the facility being surveyed. Additionally, Employee #1 confirmed that the nurse manager duties have been split up between multiple nurses from various facilities within the organization due to the nurse manager’s (Employee #4) leave of absence since 11/28/2023.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 37489 Based on document review and interview, it was determined that the facility failed to ensure the interdisciplinary team (IDT) reassessed Patient #1 after the patient was provided a 30-day notice of involuntary discharge which has the potential risk that the team is unable to identify problems and implement interventions to resolve problems. Findings include: The facility policy titled “Routine and Involuntary Patient Discharge” requires: “...The Medical Director shall ensure that no patient is involuntarily discharged, or transferred from the facility unless: ...The patient’s attending physician or physician group has notified the patient that medical services are being terminated and there is no other attending physician at the facility available or willing to accept the patient...Required Documentation...A patient who is at risk for involuntary discharge must be reassessed by the interdisciplinary team (IDT). The IDT must document in the patient’s medical record the reassessments, ongoing problem(s), and effort(s) made to resolve the problem(s)...Upon notification to the patient of non-immediate involuntary discharge or transfer, the facility must provide a list of all area dialysis facilities. The facility must contact another dialysis facility to help facilitate placement...Documentation of this effort must be included in the patient’s medical record....” Patient #1 The “Psychosocial Progress Note” dated [11/27/2023] revealed: “...MSW as made aware that the patient contacted (Employee #1) by phone last week on [11/21/2023] to inform that s/he is dismissing his/her current physician and does not want to remain a patient under (Provider #3). Due to the risk of involuntary discharge, a meeting was held on [11/27/2023] with the Senior Manager of Social Work Services...Area Manager of Social Work Services...The facility Administrator...and the charge nurse...to discuss next steps...Met with the patient and the FA at the clinic. Patient was informed that the physician’s orders are still valid for 30 days, and the patient has 30 days to find a new physician. Patient was made aware that there is a risk of being discharged from the clinic if he does not have a physician or current physician orders. Patient verbalized understanding. Patient was again provided with a list of physicians who round at this clinic and a list of other nearby dialysis facilities. Patient was encouraged to reach out to the physician offices or dialysis units. Patient was informed to speak with MSW or FA if s/he has further questions or concerns, or if s/he needs support and assistance with contacting other dialysis units....” The “Psychosocial Progress Note” dated [12/06/2023] revealed: “...Patient was provided with the Discharge Notification - No Physician letter today informing him/her that thirty days from this date, Deer Valley Dialysis Clinic will no longer be ale (Sic) to provide him with dialysis treatment. Patient decided to terminate care by his nephrologist, (Provider #1), and currently does not have any physician. (Provider #1) provided the orders for discharge today providing 30 days for the patient to find another physician...Patient stated he was okay with the clinic to refer him to other nearby clinics, including clinics outside of Fresenius, such as Davita or US Renal. Patient was given information about nearby hospitals, and reported s/he still has the list of the nearby clinics and physicians who round at the clinic. Continuity of Care (COC) was notified of the potential involuntary discharge. A message was left with...Network 15...and also left with Arizona Department of Health Services....” The “Psychosocial Progress Note” dated [12/11/2023] revealed: “...MSW inquired if the patient has been able to contact any other physicians or dialysis clinics but the patient has not attempted to contact any other facilities....” The “Psychosocial Progress Note” dated [12/21/2023] revealed: “...Received a call from the pt’s daughter...who stated she had been asked by (Patient #1) to assist...An email was sent to (Patient #1’s) daughter providing the list of clinics, including Davita in the Tempe area, American Renal, Valleywise...and the Life Planning Packet of AZ forms...Currently, pt has a request open through Davita admissions...Received a call form...Davita Admissions requesting additional records....” The “Psychosocial Progress Note” dated [01/05/2024] revealed: “...the patient is pending to start at...Davita on [01/06/2024]....” Patient #1’s hospital records revealed that the patient was hospitalized [12/18/2023 through 01/04/2024]. . The medical record revealed monthly progress notes by the patient’s nephrologist (Provider #3) dated [09/25/2023] and [10/25/2023]. The record did not contain any nephrology progress notes for November and December 2023, or January 2024. A Plan of Care dated [11/27/2023] revealed: “...Patient has been dissatisfied with his treatment, wants to change phsycian’s (sic)...potential involuntary discharge d/t firing physician....” The document titled “Fresenius Kidney Care Deer Valley Discharge Notice Letter” dated [12/06/2023] revealed that the patient was provided a 30-day notice of involuntary discharge from the facility effective [01/06/2024]. Medical records were not provided that contained evidence that the IDT reassessed Patient #1 after providing the patient with a 30-notice of discharge or ongoing assessment of the issue. The last physician progress note in the medical record was dated [10/25/2023]. The nursing notes dated [11/21/2023 through 12/27/2023] did not contain evidence of reassessment or addressing the involuntary discharge or potential problems and interventions. A monthly nursing note dated [12/27/2023] noted that the patient was hospitalized by a checkmark in a form field but did not provide any information about the dates of hospitalization, reason for hospitalization, potential discharge from the hospital, or address the patient’s involuntary discharge from the facility. The social work notes indicated that the patient was provided information multiple times and tasked with the responsibility of finding a new physician and/or new clinic; however, the record did not contain evidence that the facility attempted to facilitate new placement with a physician and/or facility for the patient. Employees #1 and 2 confirmed on 01/18/2024 that Patient #1’s medical record did not contain evidence of ongoing reassessment of Patient #1 by the IDT after the patient was provided a 30-day notice of involuntary discharge as required by facility policy and procedure.”