062583 Parker Kidney Center (Ara)

“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 allowed dry time after the hub of the central venous catheter (CVC, a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) was cleaned in one of four observations of CVC procedures. Findings include: Facility policy: The CVC Initiation and Discontinuation of Treatment policy read, wash hands, and don new clean gloves. Place a clean field under the catheter limbs/caps. Disinfect according to manufacturer’s instructions. Allow disinfectant to air dry. Prior to cap removal, disinfect the arterial cap and limb. Using the same antiseptic pad, apply antiseptic with friction to the catheter. Hold the limb until the catheter is dry. Repeat for the venous limb, using a new disinfectant pad. Ensuring the limb clamp is closed, remove the arterial cap and disinfect the hub with a new disinfectant pad. Scrub the sides (threads) and end of the hub thoroughly with friction. Antiseptics should be allowed to dry for maximum effect. This step decreases the risk of microorganisms entering the catheter lumen. 1. The facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned. a. On 10/28/24 at 9:03 a.m., an observation was conducted of a CVC end of treatment procedure at station #15. After the dialysis lines were removed from the patient the CVC was prepared for the patient to leave the facility. Patient care technician (PCT) #1 scrubbed the red hub for 30 seconds, no dry time was observed, then a syringe that contained heparin was attached to the red hub and administered. PCT #1 scrubbed the blue hub for 30 seconds, no dry time was observed, then a syringe that contained heparin was attached to the blue hub and administered. The heparin syringe was then removed and the hub was again scrubbed with an alcohol pad for 30 seconds and no dry time was observed. PCT #1 removed the syringe from the red hub, scrubbed the hub for 30 seconds, and immediately applied a red cap. PCT #1 then removed the syringe from the blue hub, scrubbed the hub for 30 seconds, and immediately applied a blue cap. Both hubs were visibly wet when the new caps were applied. When asked if there was a dry time to the hubs after alcohol scrub, PCT #1 stated there was no dry time. This was in contrast to the CVC Initiation and Discontinuation of Treatment policy which read, antiseptics should be allowed to dry for maximum effect. b. On 10/30/24 at 8:26 a.m., an interview was conducted with patient care technician (PCT) #2 stated CVC hubs were to be scrubbed with alcohol for 30 seconds and allowed to fully air dry for 15 seconds because alcohol needed dry time to disinfect the area. PCT #2 stated it was important to follow facility policy for CVC care because the CVC line went directly to the patient’s heart and there was a risk of infection and sepsis (a severe response to infection). c. On 10/30/24 at 8:51 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated CVC hubs were to be scrubbed with alcohol for 30 seconds and allowed to air dry for 15 seconds. RN #3 stated CVC hubs were to be scrubbed with alcohol and allowed to air dry because alcohol needed dry time to disinfect the area. RN #3 stated the risk of an infection to a CVC site included bloodstream infections and sepsis.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45020 Based on document review and interviews, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for two of four in-center patients reviewed (Patient #2 and #4). Specifically, the facility failed to ensure the prescribed blood flow rate (BFR) and dialysis flow rate (DFR). Findings include: Facility policy: The Monitoring and Documentation of Patient Care During Treatment policy read, The purpose of this policy is to ensure that patients are monitored to ensure safety during the hemodialysis treatment. Data that must be documented (by direct entry and/or by data feed from the dialysis machine) at least every 30 minutes and PRN depending on the patient’s condition includes, but is not limited to: Blood flow rate (BFR) and .Dialysate flow rate (DFR). Patient status - some notes must be entered to indicate how the patient is tolerating the treatment, and any patient problems, complaints or observations about the patient’s status must be documented. In addition, any interventions provided to the patient and the patient’s response must be documented. Information that must be entered manually includes, but is not limited to: interventions for unexpected situations, such as slowing blood flow for access problem or if the patient’s prescription was not met for any reason. A detailed progress note must be entered explaining why the prescription was not met and actions taken to address the situation. 1. Direct patient care staff failed to ensure the hemodialysis machine settings for the BFR or DFR were adhered to as ordered. a. A review of Patient #2’s treatment flowsheet from 10/28/24 revealed staff failed to follow the prescribed DFR of 700 milliliters per minute (ml/min). On 10/28/24 Patient #2’s treatment started at 6:15 a.m. The DFR remained at 600 ml/min until treatment ended at 10:19 a.m. There was no documented rationale for the changes to the prescribed DFR. b. A review of Patient #4’s treatment data flowsheet from 10/26/24 revealed staff failed to follow the prescribed BFR of 450 ml/min. On 10/26/24 Patient #4’s treatment started at 11:22 a.m. The BFR remained at 350ml/min until 11:58 a.m. At 11:58 a.m. the BFR was decreased to 300 until 2:00 p.m., when the BFR was increased to 450 until treatment ended at 2:56 p.m. There was no documented rationale for the changes to the prescribed BFR. On 10/19/24 Patient #4’s treatment flowsheet revealed treatment started at 11:28 a.m. The prescribed DFR was 800 ml/min. The DFR remained at 500 ml/min until 2:58 p.m., when the DFR was increased to 600 ml/min until treatment ended at 3:13 p.m. There was no documented rationale for the changes to the prescribed DFR. On 10/15/24 Patient #4’s treatment flowsheet revealed treatment started at 11:26 a.m. The prescribed DFR was 800 ml/min. The DFR remained at 600 ml/min until treatment was terminated at 3:18 p.m. There was no documented rationale for the changes to the prescribed DFR. This was in contrast to the Monitoring and Documentation of Patient Care During Treatment policy which read, Information that must be entered manually includes interventions for unexpected situations, such as slowing blood flow for access problem or if the patient’s prescription was not met for any reason. A detailed progress note must be entered explaining why the prescription was not met and actions taken to address the situation. c. On 10/30/24 at 8:26 a.m., an interview was conducted with patient care technician (PCT) #2. PCT #2 stated it was important to follow the physician’s orders to ensure the patients received adequate treatment. PCT #2 stated the BFR and DFR were a prescription and if either were decreased, it was to be documented and the nurse was to be notified. PCT #2 stated if the BFR or the DFR was decreased there was a risk the patient would not get adequate dialysis to remove the toxins from the blood. d. On 10/30/24 at 8:51 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated the BFR and the DFR were a prescription. RN #3 stated it was their expectation to be notified by the PCT if the BFR or DFR was decreased and it was to be documented. RN #3 stated if the BFR or DFR were to be decreased the patient’s blood might not be cleaned as well, which could have caused the patient to retain fluid or have negatively affected the potassium in their blood.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 45020 Based on document review and interviews, the facility failed to ensure the social worker (SW) completed a Kidney Disease Quality of Life (KDQOL, standardized mental and physical assessment) in the required timeframe in 2 of 4 in-center dialysis patients records reviewed (Patient #5 and Patient #6) and 2 of 2 home peritoneal dialysis patient records reviewed (Patient #7 and Patient #8). Findings include: Facility policy: The Comprehensive Patient Assessments policy read, The purpose of this policy is to ensure that care provided to patients is appropriate based on the individual patient’s needs and current status. The KDQOL-36 is the standardized mental and physical assessment tool designated by the facility for use by social workers to determine the patient’s perceived physical and mental functioning and incorporate findings in the patient’s comprehensive assessment and treatment plan. This survey should be administered within 4 months of initiating treatment at the facility. Subsequently, it should be administered annually at minimum with the patient’s comprehensive assessment to ensure that accurate patient data is incorporated into the comprehensive patient assessment and treatment plan. References: Common Psychosocial Issues in the ESRD population, provided by the facility, read, because an ESRD diagnosis impacts a patient’s daily life in many ways, it is important that the interdisciplinary team keep track of changes in the impact of the disease in various patient life spheres. The primary tool for this process is the KDQOL-36 survey. Exclusions include: patients under age 18, those who cannot complete a KDQOL-36 due to cognitive impairment, dementia, active psychosis, patients on dialysis less than 3 months and patients who refuse to complete the KDQOL-36. For patients who are ineligible or refuse to participate, it is the responsibility of the social worker to document the refusal. The social worker job description read, provides comprehensive psychosocial assessments on each patient at admission and yearly thereafter. 1. The facility failed to ensure the social worker completed the required KDQOL annual assessments. a. Review of Patient #5’s medical record revealed the patient was admitted to the facility on 6/6/23 for incenter dialysis. On 10/23/23 an initial KDQOL assessment was completed. There was no evidence the patient had received an additional KDQOL assessment since the one conducted on 10/23/23, which was greater than a year. b. Review of Patient #6’s medical record revealed the patient was admitted to the facility on 3/14/22 for incenter dialysis. On 7/21/23 an initial KDQOL assessment was completed, however, there was no evidence the patient had received a KDQOL assessment after the one conducted on 7/21/23, which resulted in a one year and three month gap. c. Review of Patient #7’s medical record revealed the patient was admitted to the facility on 5/12/23 for home peritoneal dialysis training and treatment. On 8/11/23 an initial KDQOL assessment was completed. There was no evidence the patient had received a subsequent KDQOL assessment after the one completed on 8/11/23, which resulted in a one year and two month gap. d. Review of Patient #8’s medical record revealed the patient was admitted to the facility on 3/20/23 for home peritoneal training and treatment. On 6/6/23 an initial KDQOL assessment was completed. There was no evidence the patient had received a subsequent KDQOL assessment after the one completed on 3/20/23, which resulted in a one year and four month gap. This was in contrast to the Comprehensive Patient Assessments policy, which instructed to administer the KDQOL assessment on an annual basis. e. On 10/30/24 at 10:34 a.m., an interview was conducted with SW #4. SW #4 stated a KDQOL was an evaluation performed to determine whether the patient’s needs were met. SW #4 stated a KDQOL was to be performed within 90 days of admission to the facility and then annually. SW #4 stated if a patient refused a KDQOL it was to be documented that the patient refused. SW #4 stated there was a risk a patient need could be missed if a KDQOL was not performed. f. On 10/30/24 at 10:58 a.m., an interview was conducted with clinic manager (Manager) #5. Manager #5 stated a KDQOL was a depression screening performed by the social worker within the first four months of admission and on an annual basis. Manager #5 stated it was their expectation for KDQOLs to be performed, or documented if the patient refused. Manager #5 stated the facility was required to offer patients the KDQOL assessment and the results were discussed at patient care conferences.”