062564 Liberty Dialysis - Colorado Springs South (Fmc)

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §494.30 Infection Control, was out of compliance. V122 - §494.130(a)(4) - [Standard: Procedures for infection control. The facility must demonstrate that it follows standard infection control precautions by implementing-] [Maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-](ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. Based on observations, interviews, and document reviews, the facility failed to ensure patient care staff cleaned and disinfected the patient treatment station chair per facility policy in two of three observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned. V146 - §494.30(a) - [Standard: Procedures for infection control. The facility must demonstrate that it follows standard infection control precautions by implementing-] (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Based on observations, interviews, and document review, the facility failed to ensure patient care staff performed hand hygiene when a central venous catheter (CVC)(a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) was accessed according to facility policy in one of three observations. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned in two of three observations.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 49541 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §494.60 Condition: Physical environment, was out of compliance. V-403 §494.60(b) Equipment maintenance. The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer ’ s recommendations. Based on observations, document reviews, and interviews, the facility failed to ensure safe patient care while using the mechanical lift. Specifically, the facility failed to ensure the staff followed manufacturer’s instructions for use (IFU), national guidelines, and facility policy for transferring patients. Additionally, the facility failed to perform preventive maintenance per the manufacturer’s IFU.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document reviews, the facility failed to ensure patient care staff cleaned and disinfected the patient treatment station chair per facility policy in two of three observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned. Findings include: Facility Policy: The Cleaning and Disinfecting the Dialysis Station policy read, the purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Place the chair in Trendelenburg position (flat on the back with the feet elevated above the head) and open side panels so all surfaces are accessible. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry. 1. The facility failed to ensure dialysis chairs were cleaned and disinfected between patient treatments according to facility policy. Direct patient care staff did not place the dialysis chair into the fully reclined position to ensure all surfaces of the chair were cleaned. A. Observations i. On 5/13/24 at 1:10 p.m., patient care technician (PCT) #5 was observed as they disinfected the dialysis chair at station #3. PCT #5 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. ii. On 5/14/24 at 12:38 p.m., PCT #5 was observed as they disinfected the dialysis chair at station #16. PCT #5 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. These observations were in contrast to the Cleaning and Disinfecting the Dialysis Station policy which read, the chair should be placed in Trendelenburg position and side panels should be opened so all surfaces are accessible. B. Interviews i. On 5/15/24 at 1:50 p.m., an interview was conducted with PCT #5. PCT #5 stated the process for a dialysis chair to be cleaned was to pull the lever on the back of the chair to completely recline it. PCT #5 stated it was important to clean dialysis chairs thoroughly between patients because there was a risk of infection, including Human immunodeficiency virus (HIV)(an infection that attacks the body’s immune system) and hepatitis (inflammation of the liver). ii. On 5/15/24 at 2:13 p.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated dialysis chairs were to be cleaned after each use. RN #7 stated dialysis chairs were to be fully reclined with a lever on the back of the chair. RN #7 stated if dialysis chairs were not cleaned appropriately, there was an infection risk to the patients, including the risk of hepatitis, Clostridium difficile (C.diff)(infection of the colon), and Methicillin-resistant Staphylococcus aureus (MRSA)(a bacteria that is resistant to many antibiotics). These interviews were in contrast to the observations which revealed dialysis chairs were not fully reclined when cleaned.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. 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 as 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 This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document review, the facility failed to ensure patient care staff performed hand hygiene when a central venous catheter (CVC)(a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) was accessed according to facility policy in one of three observations. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned in two of three observations. Findings include: Facility policies: The Changing the Catheter Dressing procedure policy read, the purpose of this policy is to provide instruction for cleaning the catheter exit site, changing the catheter dressing, assessing for signs of infection and maintaining a protective barrier in order to prevent infection. Removal of old dressing and inspection of site: Place an underpad under catheter limbs to protect work area and clothing. Apply mask to patient, perform hand hygiene, don clean gloves, inspect and remove the old dressing, visually inspect the exit site, discard dressing and remove gloves, perform hand hygiene. Cleaning the site: Perform hand hygiene, don clean gloves. Chlorhexidine in a gentle back and forth friction for 30 seconds, allow to dry for a minimum of 30 seconds. If patient is allergic to chlorhexidine, use alcohol for 30 seconds and allow to dry. Apply the dressing: Using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing with gloved hands or to any surface. The Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux single use Ebeam Dialyzer policy read, the purpose of this procedure is to provide direction initiating hemodialysis treatment using a CVC with an Optiflux Single use dialyzer. Perform hand hygiene and don full personal protective equipment (PPE). Place an underpad under the access limbs to protect the work area and the patient’s clothing. Put a mask on the patient, remove gloves, perform hand hygiene, then don new gloves. Remove cap from clamped arterial limb. Using a sterile alcohol pad, scrub the threads and end of the hub for 10-15 seconds. Hold the limb while allowing the antiseptic to dry. 1. The facility failed to ensure patient care staff performed hand hygiene before the CVC access site was cleaned according to facility policy. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned. A. Observations i. On 5/13/24 at 1:34 p.m., an observation was conducted of a CVC being accessed at station #15. Patient care technician (PCT) #6 performed hand hygiene, donned gloves, placed an underpad under the CVC limbs and removed the CVC dressing. PCT #6 swabbed the area on and around the CVC access for 60 seconds. Hand hygiene was not observed between these steps. PCT #6 scrubbed the arterial hub with an alcohol swab for 30 seconds, attached a syringe, and withdrew blood from the line. No dry time was observed. PCT #6 scrubbed the venous hub with an alcohol swab for 30 seconds, attached a syringe, and withdrew blood from the line. No dry time was observed. This observation was in contrast to the Changing the Catheter Dressing procedure policy which read, after the old dressing was inspected, removed, and discarded, gloves should be removed and hand hygiene should be performed. This observation was also in contrast to the Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux single use Ebeam Dialyzer policy which read, the threads and end of the hub should be scrubbed for 10-15 seconds. The limb should be held while the antiseptic was allowed to dry. ii. On 5/13/24 at 12:32 p.m., an observation was conducted of a CVC being cleaned at station #4. PCT #5 scrubbed the venous hub with an alcohol swab for 30 seconds. PCT #5 then immediately withdrew blood from the line. No dry time was observed. PCT #5 scrubbed the arterial hub with an alcohol swab for 30 seconds. PCT #5 then immediately withdrew blood from the line. No dry time was observed. This observation was in contrast to the Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux single use Ebeam Dialyzer policy which read, the threads and end of the hub should be scrubbed for 10-15 seconds. The limb should be held while the antiseptic was allowed to dry. B. Interviews i. On 5/15/24 at 1:50 p.m., an interview was conducted with PCT #5. PCT #5 stated after the dressing was removed from the patient, hand hygiene was to be performed and new gloves were to be applied. PCT #5 stated each hub was to be scrubbed with alcohol for 30 seconds, and was not aware of the dry time requirement after the hubs were scrubbed. PCT #5 stated if hand hygiene was not performed, there was a risk of infection. ii. On 5/15/24 at 2:13 p.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated after the dressing was removed, hand hygiene was to be performed and new gloves were to be put on. RN #7 stated there was no specific dry time to the hubs after they were cleaned with alcohol. RN #7 stated it was important to perform hand hygiene when initiating treatment because the CVC was a straight line to the patient’s heart and infection could cause death. These interviews were in contrast to the Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux single use Ebeam Dialyzer policy which read, the threads and end of the hub should be scrubbed for 10-15 seconds. The limb should be held while the antiseptic was allowed to dry. iii. On 5/15/24 at 1:21 p.m., an interview was conducted with Director #8. Director #8 stated CVC care there was a risk of infection if CVC care was not performed correctly. Director #8 stated a CVC was the number one risk of infection, which could cause death.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 49541 Based on observations, document reviews, and interviews, the facility failed to ensure safe patient care while using the mechanical lift. Specifically, the facility failed to ensure staff followed manufacturer’s instructions for use (IFU), national guidelines, and facility policy for transferring patients. Additionally, the facility failed to perform preventive maintenance per the manufacturer’s IFU. Findings include: Facility policy: The Guidelines for Use of the Hoyer Lift Policy read, there must be two staff members by the patient during the transfer process. Prior to each use of the Hoyer Lift, staff will follow the 15 seconds of Safety Hoyer Pre-Flight Checklist to ensure the lift is safe to use. Direct patient care staff will receive training on use of the Hoyer Lift at hire and annually thereafter. References: The Occupational Safety and Health Administration (OSHA) Back Injury Training Video screenshot provided by the facility read, using a hoyer lift is always a two person job. The Hoyer Lift: Positioning and Transfer Guide read, lifters may tip over if used improperly. Failure to observe the following warnings may result in serious injury to the patient and/or attendant. Never push or pull on the lifter boom. Pushing or pulling on boom can cause the lifter to tip over. If transporting over a short distance, ensure the patient is facing attendant and keep patient as low as possible. Lower center of gravity reduces the risk of tipping over. Lifters may tip over if used improperly. The Joerns Lifting and Repositioning HPL402 Hoyer Power Patient Lift User Manual read, regular maintenance of lifters and accessories is necessary to assure proper and safe operation. Before each use ensure the wheels swivel and roll easily. Bi-Monthy preventative maintenance: check all nuts, bolts and screws for wear and tightness; lubricate the top of mast where boom attaches; lubricate the top and bottom of actuator mounting; use a light grease to lubricate base adjustment lock plate and all rotating hardware; lubricate wheel and swivel bearings. Do not use any other manufacturer’s sling with the HPL Lifter. 1. The facility failed to ensure staff followed the Hoyer Lift IFU, national guidelines, and facility policy during a mechanical lift patient transfer. A. Observations i. On 5/13/24 at 12:37 p.m., observations were conducted in the dialysis unit. Observations revealed registered nurse (RN) #1 operated the mechanical lift independently to raise the patient. At 12:39 p.m., the patient remained suspended in the air until patient care technician (PCT) #2 was able to remove the patient’s electric wheelchair and assist with transporting the patient to the dialysis chair. During the transfer, RN #1 used their hand to push the boom to position the patient in the dialysis chair. At 12:41 p.m., RN #1 lowered the patient into the dialysis chair and PCT #2 aided in repositioning the patient. This observation was in contrast to the Hoyer Lift: Positioning and Transfer Guide which read, never push or pull on the lifter boom. Pushing or pulling on boom can cause the lifter to tip over. This observation was also in contrast to the Guidelines for Use of the Hoyer Lift policy which read, there must be two staff members by the patient during the transfer process. Additionally, this observation was in contrast to the OSHA Back Injury Training Video screenshot which read, using a hoyer lift was always a two person job. B. Interviews i. On 5/13/24 at 4:36 p.m., an interview was conducted with RN #1. RN #1 stated they operated the Hoyer Lift independently to raise the patient out of their wheelchair. RN #1 stated they knew the use of the Hoyer Lift required two staff members to be present, but they felt they knew the patient and was comfortable lifting the patient independently. RN #1 stated Hoyer Lifts that were operated alone could lead to accidents, such as the patient falling out of the sling or mechanical failures that could have caused the patient to be injured. RN #1 stated they were not trained on the 15 seconds of Safety Hoyer Pre-Flight Checklist. RN #1 also stated different types of lift slings were used when patients came to dialysis from outside facilities. RN #1 stated sometimes the lift slings were too large and required adjustments such as folding slings to fit properly. RN #1 stated incorrect lift sling size could lead to safety issues, such as the patient’s discomfort or risk of falling from the sling. The interview with RN #1 was in contrast to the Guidelines for Use of the Hoyer Lift Policy which read, there must be two staff members by the patient during the transfer process. Prior to each use of the Hoyer Lift, staff followed the 15 seconds of Safety Hoyer Pre-Flight Checklist to ensure the lift was safe to use. Direct patient care staff received training on use of the Hoyer Lift at hire and annually thereafter. The interview with RN #1 was also in contrast to the OSHA Back Injury Training Video screenshot which read, using a hoyer lift was always a two person job. ii. On 5/14/24 at 4:18 p.m., and interview was conducted with Manager #4. Manager #4 stated Hoyer Lift training was provided annually through OSHA and included the use of the Hoyer Lift and back injury prevention. Manager #4 stated they saw RN #1 lift a patient independently with the Hoyer Lift while Tech #2 retrieved an oxygen concentrator. Manager #4 stated they estimated the patient was suspended in the air for 40 seconds with only one staff member present. Manager #4 stated it was against the facility’s policy to use the Hoyer Lift independently. Manager #4 stated Hoyer Lifts operated with only one person could lead to patient falls, slips, and other injuries due to improper handling. Manager #4 stated some patients from nursing homes brought their own lift slings. Manager #4 stated they did not know if the lift slings provided by the patients were Hoyer brand. The interview with Manager #4 was in contrast to the Joerns Lifting and Repositioning HPL402 Hoyer Power Patient Lift User Manual which read, do not use any other manufacturer’s sling with the HPL Lifter. 2. The facility failed to ensure mechanical lift preventive maintenance was performed per the manufacturer’s IFU. A. Observations i. On 5/13/24 at 12:55 p.m., observations were conducted in the dialysis unit. Observations revealed a mechanical (Hoyer) lift with hair and other debris between the axle and hub of the wheel. Further observation revealed the debris intermittently restricted the movement of the wheel. This observation was in contrast to the Joerns Lifting and Repositioning HPL402 Hoyer Power Patient Lift User Manual which read, regular maintenance of lifters and accessories was necessary to assure proper and safe operation. Before each use ensure the wheels swiveled and rolled easily. B. Interview i. On 5/14/24 at 9:59 a.m., an interview was conducted with Manager #3. Manager #3 stated the equipment IFU outlined what preventative maintenance needed to be completed and how often. Manager #3 stated the preventative maintenance for the Hoyer Lift was completed yearly with a contracted company. Manager #3 stated it was important to perform preventative maintenance on the equipment to make sure the equipment functioned properly. However, after multiple requests, the facility was unable to provide evidence of bi-monthly maintenance. The interview with Manager #3 was in contrast to the Joerns Lifting and Repositioning HPL402 Hoyer Power Patient Lift User Manual which read, regular maintenance of lifters and accessories was necessary to assure proper and safe operation. Preventative maintenance was to be completed bi-monthly.”