Shc North Sunnyvale

“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: 36623 Based on interview and record review, the facility failed to change a central venous catheter (CVC, a flexible tube placed into a large vein and entering the heart and is used to administer dialysis [medical procedure of removing waste products and excess fluid from a person’s blood through an artificial kidney], medication or fluids) dressing for one of three patients. This failure had the potential to cause health complications. Findings: Review of Patient 1’s Nurses Note, dated 12/14/24 indicated Patient 1 arrived from the hospital with a CVC in her left upper chest. Review of Patient 1’s treatment log, dated 12/10/24 indicated, “Dressing Changed: No.” Review of Patient 1’s treatment log, dated 12/12/24 indicated, “Dressing Changed: No.” Review of Patient 1’s treatment log, dated 12/27/24 indicated, “Dressing Changed: No.” During an interview on 7/11/25 at 3:34 p.m., the interim clinical coordinator (ICC) stated the CVC dressing should be changed when a patient has dialysis treatment. The ICC confirmed there was no documentation that indicated Patient 1’s dressing was changed on 12/10/24, 12/12/24, and 12/27/24 . Review of the facility’s policy, “Dialysis Catheter Dressing Change Procedure,” dated 2/2023 indicated, “Replace sterile gauze dressings every treatment.””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 36623 Based on interview and record review, the facility failed to provide the necessary services to ensure the proper management of volume status for two of three patients (Patients 1 and 2) when: 1. The prescribed blood flow rates (BFR, speed of blood flow through the hemodialysis machine) during dialysis (medical procedure using a machine and an artificial kidney to remove waste and excess water from the blood) were not followed for Patients 1 and 2; 2. Clonidine (medication used to treat high blood pressure [BP, normal BP - systolic pressure (top number) of less than 120 and a diastolic pressure (bottom number) of less than 80]) was not given as ordered for Patient 1; 3. Staff did not inform the nephrologist (kidney doctor) when Patient 1 terminated dialysis treatment early; 4. Dialysis treatment was not provided for Patient 1 when a scheduled treatment was not communicated properly. These failures had the potential to result in health complications for patients. Findings: 1a. Review of Patient 1’s clinical record she was admitted to the facility with a diagnosis of Type 1 diabetes mellitus (a disorder characterized by difficulty in blood sugar control) with other diabetic kidney complication. Review of Patient 1’s dialysis orders indicated Patient 1’s BFR was prescribed to run at 350 milliliters per minute (ml/min, unit of measurement). Review of Patient 1’s treatment log, dated 10/15/24 indicated Patient 1’s BFR was set to 300 ml/min during dialysis treatment. There was no documentation that indicated the reason Patient 1’s BFR was lowered. Review of Patient 1’s treatment log, dated 10/19/24 indicated Patient 1’s BFR was set to 300 ml/min during dialysis treatment. There was no documentation that indicated the reason Patient 1’s BFR was lowered. Review of Patient 1’s treatment log, dated 12/14/24 indicated Patient 1’s BFR was set to 300 ml/min from 1:31 p.m. to 3 p.m. There was no documentation that indicated the reason Patient 1’s BFR was lowered. Review of Patient 1’s treatment log, dated 12/24/24 indicated Patient 1’s BFR was set to 400 ml/min during dialysis treatment. There was no documentation that indicated the reason Patient 1’s BFR was increased. During an interview on 7/11/25 at 10 a.m., the interim clinical coordinator (ICC) confirmed Patient 1’s BFR was not set to the prescribed rate on 10/1/24, 10/19/24, 12/14/24, and 12/24/24. The ICC stated there should be documentation that indicated the reason Patient 1’s BFR was changed. 1b. Review of Patient 2’s clinical record she was admitted to the facility with a diagnosis of Type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control) with diabetic chronic kidney disease. Review of Patient 2’s dialysis orders indicated Patient 1’s BFR was prescribed to run at 350 ml/min. Review of Patient 2’s treatment log, dated 11/23/24 indicated Patient 2’s BFR was set to 300 ml/min from 2:31 p.m. to 4:31 p.m. There was no documentation that indicated the reason Patient 2’s BFR was lowered. 2. Review of Patient 1’s treatment log, dated 10/19/24 indicated Patient 1 had blood pressures that ranged from 196/80 to 267/146 during dialysis treatment. Patient 1’s post dialysis sitting BP was 200/86. There was no documentation that indicated Patient 1 was given clonidine for her high BP. Review of Patient 1’s treatment log, dated 10/24/24 indicated Patient 1 had blood pressures that ranged from 188/85 to 208/95 during dialysis treatment. Patient 1’s post dialysis sitting BP was 188/85. There was no documentation that indicated Patient 1 was given clonidine for her high BP. During an interview on 7/11/25 at 10 a.m., the interim clinical coordinator (ICC) confirmed Patient 1 was not given clonidine on 10/19/24 and 10/24/24. She stated Patient 1 should have been given clonidine and Patient 1’s blood pressure was still high at the end of dialysis. Review of the facility’s policy, Standing Orders - Hemodialysis,” dated 12/2024 indicated to give clonidine 0.1 milligrams (mg, unit of measurement) by mouth as needed for systolic blood pressure greater than 180. 3. Review of Patient 1’s dialysis orders indicated her dialysis treatment is 180 minutes (3 hours long). Review of Patient 1’s treatment log, dated 10/5/24 indicated Patient 1 terminated dialysis treatment about one hour early. Patient 1’s treatment length was 2 hours and 6 minutes long. There was no documentation that the doctor was informed that Patient 1 terminated dialysis early. Review of Patient 1’s treatment log, dated 10/15/24 indicated Patient 1 terminated dialysis treatment about 2 hours early. Patient 1’s treatment length was 1 hour and 13 minutes long. There was no documentation that the doctor was informed that Patient 1 terminated dialysis early. During an interview on 7/11/25 at 2:12pm the ICC confirmed that the doctor should have been notified when a patient does not complete half of their treatment time. Review of the facility’s policy, “Against Medical Advice,” revised 1/2020 indicated when a patient refuses to complete prescribed treatment, staff will encourage the patient to adhere to their treatment prescription and explain the risks of not following physician orders. The policy indicated the nurse will document the interaction including physician notification. 4. Review of Patient 1’s clinical record indicated she was scheduled to receive dialysis treatment Tuesday, Thursday, and Saturday. Review of Patient 1’s treatment logs indicated Patient 1 received dialysis on Tuesday, 12/24/24, Friday, 12/27/24, and Tuesday 12/31/24. During an interview on 6/11/25 at 1:38 p.m., the center manager (CM) stated Patient 1 was supposed to have dialysis on Sunday 12/29/24. She stated there was an issue with transportation, so she came to the facility on Monday, 12/30/24, but did not have dialysis on 12/30/24. The CM stated when she checked with the nurse, the nurse stated Patient 1 was not on the schedule on 12/30/24. During an interview on 7/11/25 at 10:40 a.m., registered nurse A (RN A) stated Patient 1 came to the facility on Monday 12/30/24. RN A stated she checked the patient schedule and checked Patient 1’s notes and there was no documentation that indicated Patient 1 was scheduled to dialyze on 12/30/24. RN A stated there was an open chair, but she did not provide dialysis to Patient 1 because there was no note that indicated the date and time Patient 1 was supposed to dialyze. During an interview on 7/11/25 at 10:46 a.m., the social worker (SW) stated she was helping Patient 1 with transportation during the holidays. She stated during holidays scheduled treatment may be scheduled on a different day. The SW stated she arranged transportation for Patient 1 for Sunday, 12/29/24. She stated when the transportation company did not pick up Patient 1 on 12/29/24, another arrangement was made with the transportation company and the nurse that Patient 1 would be rescheduled be picked up and dialyzed on Monday, 12/30/24. The SW stated she does not think the nurse documented that Patient 1 was on the schedule for Monday, 12/30/24. She stated there was miscommunication between the nurses and Patient 1 should have been dialyzed on 12/30/24.”