Bma San Gabriel Valley Pd Clinic

“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: 35561 Based on observation, interview, and policy review, the facility failed to ensure two of two Registered Nurses (Registered Nurse (RN) 1, and RN2) who were observed during care delivery, implemented proper hand hygiene and glove changing infection control measures after the completion of peritoneal dialysis clinic visits. Failure to use recommended hand hygiene and glove changing infection control practices increases the risk for cross contamination and had the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all 33 facility patients currently receiving treatment in the dialysis unit. Findings include: On 11/04/23 at 11:20 AM, RN2 was observed disinfecting the dialysis treatment room 7 after completion of a peritoneal dialysis clinic visit for an unidentified patient. RN2 was observed disinfecting areas of the room, including the dialysis chair, countertops, and bedside table. Needing additional equipment to complete the disinfection, RN2 was observed leaving treatment room 7, still wearing the same, now contaminated gloves, and entering an adjacent treatment room to open drawers in search of the clean disinfecting towels that were needed. RN2 failed to remove contaminated gloves and complete hand hygiene prior to retrieving clean supplies from an adjacent treatment room. On 11/04/23 at 1:50 PM, RN1 was observed disinfecting the dialysis treatment room 5 after completion of a peritoneal dialysis clinic visit for an unidentified patient. RN1 was observed disinfecting areas of the room, including the dialysis chair, countertops, and bedside table. Needing additional equipment to complete the disinfection, RN2 was observed leaving treatment room 5, still wearing the same, now contaminated gloves, and entering an adjacent treatment room to open drawers in search of the clean disinfecting towels that were needed. RN1 failed to remove contaminated gloves and complete hand hygiene prior to retrieving clean supplies from an adjacent treatment room. When questioned regarding failure to remove gloves, RN1 replied, “I forgot.” Review of the facility’s policy titled, “Hand Hygiene,” dated 03/17/2023, revealed “All staff, patients, patient care givers ... must follow the same requirements for hand hygiene. The table below identifies when hands will be washed: Before and after direct contact with patients, entering and leaving the treatment area, after contact with other objects within the patient station or treatment space.” During an interview on 11/03/23 at 3:50 PM, these findings were discussed with the Facility Clinical Manager and Director of Operations who responded, “These observations do not meet the requirements of our infection control policy.””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 35561 Based on record review, interview, and policy review, the facility failed to monitor the implementation of biohazard and infection control policies and activities within the peritoneal dialysis unit for one of one Infection Control Program. Failure to observe, assess, and monitor infection control practices has the potential to allow infection control lapses to remain unidentified and does not enable the facility to ensure infection control practices are rigorously followed by all staff and the 33 patients who were currently receiving dialysis services currently. Findings include: On 11/01/23 at 9:30 AM, a request was made to the Facility Clinical Manager for documentation of the facility’s infection control monitoring and staff infection control audits. During review of the infection control data titled “Clinical Practice Checklist”, from 01/01/23 to 11/01/23, indicated, Registered Nurse (RN) 1 completed the audits. RN1 who completed the audits was the same staff member listed on the infection control audit form as the staff being observed. All audits titled “Clinical Practice Checklist” from 01/01/23 to 11/01/23 had a score of 100% compliance by RN1 who listed himself/herself as the staff being observed. During an interview on 11/03/23 at 9:30 AM, the above concern was discussed with the Facility Clinical Manager who stated that this discrepancy in audits had not been noticed. The Facility Clinical Manager acknowledged it was impossible for anyone to objectively assess one’s own implementation of infection control practices, that this current auditing practice was unacceptable. The Clinical Manager confirmed the auditing currently being done did not meet the intent of the requirement for observation of infection control practices. The Facility Clinical Manager stated that these infection control audits had not been reviewed in detail by the Quality Assessment and Performance Improvement Committee. The Facility Clinical Manager confirmed there was no documented evidence that anyone in the facility had objectively monitored the implementation of infection control audit practice. Review of the facility’s policy titled, “Infection Control Policy,” dated 05/02/22, indicated, “The facility will monitor the effectiveness of the infection control program through the Quality Assessment and Performance Improvement Program.” Review of the facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI),” dated 07/06/2021, indicated, “Quarterly topics include but are not limited to: Infection control audit.” Quality indicators ... can be identified and monitored through: direct observation.””

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 35561 Based on observation, interview, and policy and procedure review, the facility failed to obtain completed home treatment records every two months as required for two of six Peritoneal Dialysis (PD) patients (Patient (P) 1 and P5). Failure to obtain complete and accurate home treatment records had the potential to prevent staff from identifying whether each patient was completing dialysis treatments as ordered, was receiving adequate dialysis or to identify concerns with the home dialysis treatments. This deficient practice had the potential to adversely affect all 33 current home dialysis patients. Finding include: Review of the medical record for P1 revealed the facility admitted the patient on 04/18/22 with the diagnoses of diabetes mellitus, and end stage renal disease (ESRD). The home treatment sheets dated 04/17/23 to 11/01/23 failed to document updated information of the patient’s daily treatments, such as pre dialysis weight, blood pressure, temperature, pulse, and blood glucose. P1’s treatment records from 04/17/23 to 11/01/23 had been marked “reviewed” by the PD nurse to indicate that the data contained within had been reviewed for accuracy and appropriateness. The clinical notes dated 07/26/23, and 08/10/23 indicated that P1 was reminded of the importance of returning complete treatment records. From 08/10/23 to date No improvement was noted, and no further action was initiated by the PD nurse after the 08/10/23 clinic visit. Review of the medical record for P5 revealed the facility admitted the patient on 03/15/22 with the diagnoses of diabetes mellitus, and end stage renal disease (ESRD). The home treatment sheets dated 05/01/23 to 11/01/23 failed to document updated information of the patient’s daily treatments, such as pre dialysis weight, blood pressure, temperature, pulse, and blood glucose. P5’s treatment records from 05/01/23 to 11/01/23 had been marked “reviewed” by the PD nurse to indicate that the data contained within had been reviewed for accuracy and appropriateness. The clinical notes dated 07/26/23, and 10/05/23 indicated that P5 was reminded of the importance of returning complete treatment records. No improvement was noted, and no further action was initiated by the PD nurse after six months of incomplete treatment sheets. During an interview on 11/03/23 at 2:30 PM, Registered Nurse (RN) 1 stated, “sometimes we have to remind the patient to complete the treatment sheets.” When asked if these consistent and continued omissions on treatment sheets were discussed the with the Facility Clinical Manager, with the Medical Director, or with the dialysis Interdisciplinary Team, RN1 stated, “no.” Review of the facility’s policy titled, “Review and Documentation of Home Therapies Patient Health Data,” dated 05/03/2023, indicated “The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home. In instances in which the patient is not transmitting any data electronically, whether due to patient choice or as the result of connectivity issues, they may be required to document treatment data via paper flowsheets and regularly provide the flowsheets for review by the home therapies nurse.” During an interview on 11/03/23 at 3:30 PM, the Facility Clinical Manager stated that it was sometimes a struggle to obtain patient compliance in completing home treatment records, but acknowledged that when this occurred, it was critical to communicate these issues to the interdisciplinary team, so that alternate interventions could be implemented.”