Davita Bridgeport Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 44675 Based on facility documentation review, interview and review of facility policy for staffing, the facility failed to provide staffing that meets the requirements of the Connecticut Public Health Code. The finding included: A sample review of staffing identified the following: 1. On 4/16/24 treatment floor side 1, there were two licensed staff and six technicians for 24 stations (one licensed nurse and three technicians for each pod of ten patients). On treatment floor side 2 there were two licensed staff and five technicians for 24 stations (one licensed nurse and three technicians for pod 1 of nine patients and one licensed nurse and two technicians for pod 2 of ten patients). On treatment floor side 1 there were a total of two licensed staff to six unlicensed staff and on treatment floor side 2 there were a total of two licensed staff to five unlicensed staff. 2. On 4/18/24 treatment floor side 1, there were two licensed staff and six technicians for 24 stations (one licensed nurse and three technicians for each pod 1 of ten patients and pod two of twelve patients). On treatment floor side 1 there were a total of two licensed staff to six unlicensed staff. 3. On 4/19/24 treatment floor side 1, there were two licensed staff and six technicians for 24 stations (one licensed nurse and three technicians for pod 1 of nine patients and pod 2 ten patients). On treatment floor side 2 there were two licensed staff and five technicians for 24 stations (one licensed nurse and three techniques for pod 1 of nine patients and one licensed nurse and two technicians for pod 2 of twelve patients). On treatment floor side 1 there were a total of two licensed staff to six unlicensed staff and on treatment floor side 2 there were a total of two licensed staff to five unlicensed staff. 4. On 4/23/24 treatment floor side one, there were two licensed staff and six technicians for 24 stations (one licensed nurse and three technicians for pod 1 of ten patients and pod 2 of eleven patients). On treatment floor side 1 there were a total of two licensed staff to six unlicensed staff. 5. On 4/27/24 treatment floor side one, there were two licensed staff and six technicians for 24 stations (one licensed nurse and three technicians for pod 1 of ten patients and pod 2 of twelve patients). On treatment floor side 1 there were a total of two licensed staff to six unlicensed staff. Interview with the Clinical Coordinator and Clinical Specialist on 5/2/24 at 2:30 PM identified half of the staffing should be licensed and the other half unlicensed, and the aforementioned dates required more licensed staff. Additionally, the licensed nurse can oversee two technicians at one time. Review of the Connecticut Public Health Code Section 19-13-D dated 11/21/22 directed that at all times, at least fifty percent (50%) of the unit’s patient care staff shall be licensed nurses. The nurse manager shall implement a patient acuity system which is used to determine the appropriate numbers ant types of patient care staff to meet predicted needs of patients on each shift.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, facility policy, and interviews, the facility failed to provide a clean and sanitary environment. The findings include: Observations conducted of the facility treatment floor one (1) on 4/29/24 at 9:15 AM identified the following: 1. The crash cart contained an exposed uncapped ultrasound gel on the top of the cart. 2. The emergency evacuation box was not maintained in a clean manner with a white crusted substance throughout the external box. 3. The clean sink had blue/green crusted substance around pipe and a drip path down onto the floor. . 4. The nursing station counters (total of two) contained tape residue throughout the countertops. Observations conducted of the facility treatment floor two on 4/29/24 at 9:15 AM identified the following: 5. The clean utility cart holding acid concentrations was brown and appeared rusted. 6. The nursing station counters (total of two) contained tape residue throughout the countertops. Observations conducted of the facility treatment floor one (1) on 4/30/24 at 9:45 AM identified the following: 7. Station #16 was observed with a drain fly on the wall behind the hemodialysis machine. 8. Station #17 was observed with yellow/brown crusted drainage from the wallbox and a drain fly on the wall behind the hemodialysis machine. 9. Station #18 was observed with three drain flies on the wall behind the hemodialysis machine. 10. Station #19 was observed with three drain flies on the wall behind the hemodialysis machine. 11. Station #21 was observed with a drain fly on the wall behind the hemodialysis machine. 12. The drain pipe behind Station #22 was observed with a white/yellow frothy substance with multiple drain flies on the pipe. The floor around the opening to the drain appeared dirty. 13. A drain fly was observed flying around the nursing station. 14. Dried brown/red dried substance throughout the wall behind the biomedical waste container. Observations conducted of the facility treatment floor two (2) on 4/30/24 at 9:45 AM identified the following: 14. Station #40 was observed with yellow/brown crusted drainage from the wallbox. 15. Station #46 was observed with yellow/brown crusted drainage from the wallbox. 16. Station #49 was observed with yellow/brown crusted drainage from the wallbox. Interviews with multiple staff members on 4/30/24 identified drain flies have been a longstanding problem in the facility. It was identified that one staff member had complained numerous times to management and was told that it is an old building with drains and drain flies are expected. It was identified that a staff member complained about the drain flies at the last team meeting a few months ago with no resolution. It was further identified that patients have complained about flies on the facility treatment floor. Observation and interview with the Clinical Specialist on 4/30/24 at 2:00 PM identified the drain pipe behind Station #22 contained a white/yellow frothy substance and when touched, multiple drain flies came flying out around Station #22, one landing on the station’s clean hemodialysis machine. She identified she was unsure of what the substance on the pipe/around the drain was. . Interview with the FA on 4/30/24 at 2:10 PM identified an outsourced drain company comes quarterly to flush the drains. He identified the drain flies are more active in the warmer months and the company comes monthly when they are most active. He identified the company last came to the facility on 1/30/24 and flushed the lines and provided the invoice. He identified the company is scheduled to come to the facility on 5/7/24. Review of the emergency management plan directed that the evacuation kit will be kept clean, free of dust, dirt, etc. Review of the infection control for dialysis facilities policy directed that the policy’s purpose is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. It further directed at the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include the wallbox, drain and water supply lines. It further directed teammates will monitor and address wallbox residue/build up and patency issues. The policy directed cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potential infectious materials. Cleaning of visible blood should be preformed when first observed.”

“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: 44675 Based on observations, facility documentation, facility policy, and interviews, the facility failed to perform hand hygiene after contact with the station wall box, in between patient stations, and prior to leaving the treatment floor in accordance with facility policy. The findings include: a. Observations conducted on 4/30/24 at 1:45 PM identified Staff Person #4 entered Station #5 and placed a clamp on the hemodialysis machine IV pole and proceeded to Station #4 and placed a clamp on the hemodialysis machine IV pole and finally proceeded Station #7 and placed a clamp on the hemodialysis machine IV pole with the benefit of performing hand hygiene between patient stations. b. Observations conducted on 5/1/24 at 10:43 AM of Station #4, Machine #13, identified Staff Person #5 cleaned and disinfected the wallbox, discarded the bleach cloth, and continued to clean the rest of the hemodialysis machine without the benefit of discarding her gloves and completing hand hygiene after contact with the wallbox. c. Observation on 5/2/24 at 9:43 AM identified Patient #22 removing the disposable glove from his/her right hand after holding his/her hemodialysis site following treatment. Patient #22 was then observed proceeding to the scale to obtain a post dialysis weight and leaving the building without performing hand hygiene or being reminded by staff to perform hand hygiene. d. Observations conducted on 5/2/24 at 10:23 AM of Station #38, Machine #3, identified Staff Person #5 donned clean gloves on both hands and took the sharps container handle and brought it to Station #38. Staff Person #5 proceeded to remove the tape on the patient’s access without the benefit of discarding her gloves and completing hand hygiene before touching the patient’s access. e. Observation on 5/2/24 at 10:55 AM identified Staff Person #2 initiating Patient #23’s hemodialysis treatment. During the cannulation preparation process (when dialysis needles are inserted into the access), Staff #2 was observed touching the areas he/she planned to cannulate after disinfecting the areas, and inserted the needles into the areas she touched without again disinfecting the cannulation sites. Interview with the Clinical Specialist on 5/2/24 at 2:00 PM identified the sharps container is considered dirty and hand hygiene should be performed before coming into contact with a a patient access. Review of the infection control policy directed all teammates will perform hand hygiene after patient and dialysis delivery system contact and between patients’ event if the contact is casual. It further directed to perform hand hygiene after interacting with the wall boxes. Review of The Infection Control for Dialysis Facilities policy directs that hand hygiene should be performed after treatment and before leaving the treatment area. .”

“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: 44675 Based on observations, facility documentation, facility policy and interviews, the facility failed to clean and disinfect the hemodialysis station after patient treatment thoroughly per facility policy. The findings include: a) Observations conducted on 5/1/24 at 10:43 AM of Station #4 Machine #13 identified Staff Person #5 cleaning and disinfecting the hemodialysis station after a patient’s treatment. Staff Person #5 failed to clean and disinfect the IV pole, the stethoscope and clamp hanging off the IV pole. b) Observation on 5/2/24 at 10:10 AM identified Staff Person #3 disinfecting Station #17 and had omitted cleaning the outside of the dialysis chair, intravenous pole, stethoscope, Hansen tubing, and the tubing in front of the dialysis machine. Furthermore, Staff Person #3 had cleaned the back counter and wall box utilizing the same bleach cloth. Review of the infection control policy directed at the end of each treatment, the dialysis station will be clean and disinfected. Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel (control panel, top, front, sides of dialysis machine). It further directed non-disposable items are to be disinfected after each patient use. Stethoscopes will be disinfected with an alcohol prep pad and or 1:100 bleach solution. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 32738 Based on clinical record review, facility documentation, and interviews, for one (1) of sixteen (16) patients reviewed for vaccinations, (Patient #2), the facility failed to ensure that a Hepatitis Vaccination was administered in accordance to facility policy. The findings include: Patient # 2 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Review of a vaccination report for Patient #2 identified that the patient’s last antibody level was drawn on 1/12/23 and resulted at 16 ( indicated that the resident was immune to the Hepatitis virus). The antibody level drawn on 1/11/24 identified that the antibody level had dropped to 6 (anything below 10 indicates that the patient is susceptible to the Hepatitis virus). Further review of the vaccination report identified that the Patient received one series of the Energix (Hepatitis vaccine) vaccine series starting on 9/14/19 and ending on 1/16/2020. Interview with the Clinical Coordinator on 5/1/24 at 10:30 AM identified that once a patient has been identified as non-immune, the facility should have offered another vaccination series or a booster, however, Patient #2 was not given another vaccination series or a booster. Review of the hepatitis B surveillance, vaccination, infection control measures and isolation guidance policy directed for a patient with antibodies less than ten, the patient is susceptible and to offer vaccination series.”

“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: 32738 Based on observations, review of clinical records, and facility policy for one (1) of six (6) patients observed during the initiation of hemodialysis treatment, the facility failed to ensure infection control procedures were followed during Central Venous Catheter Care (CVC). The findings include: 1. Patient #20 had end stage renal disease, required hemodialysis three times weekly, and had a central venous catheter (CVC) dialysis access in the upper right chest. Observation on 5/1/24 at 10:37 AM identified Staff Person #3 initiating Patient #20’s hemodialysis treatment. During the CVC disinfection and connection process, Staff Person #3’s face mask was observed only covering his/her mouth through the entire process (the nostrils were not covered), including exit site care, creating an opportunity for cross contamination when blood lines and catheter limbs were uncovered and exposed. Interview with Staff Person #3 at 10:41 AM identified the face mask should cover from the bridge of the nose to under the chin throughout the treatment initiation process and indicated the reason his/her nose was exposed was because it kept sliding down. Review of the CVC procedure directs the teammate and patient to wear masks covering the nose and mouth during treatment initiation process.”

“DI-CONTIN MONITOR/LOGGED 2X/DAY CFR(s): 494.40(a) 5.2.8 Deionization: continuous monitor resistivity/logged 2 X day Refer to RD62:2001, 4.3.6 Deionization: Deionization systems, when used to prepare water for hemodialysis applications, shall be monitored continuously to produce water of one megohm/cm or greater specific resistivity (or conductivity of one microsiemen/cm or less) at 25°C. 6.2.8 Deionization Deionizers shall be monitored continuously using resistivity monitors that compensate for temperature and are equipped with audible and visual alarms. Resistivity monitors shall have a minimum sensitivity of 1.0 megohm-cm. Patients shall not be dialyzed on deionized water with resistivity less than 1.0 megohm-cm measured at the output of the deionizer Resistivity monitor readings should be recorded on a log sheet twice each treatment day. This Standard is not met as evidenced by: 47640 Based on observations, and interviews the facility staff failed to follow facility procedures for chlorine testing. The findings included: On 4/29/24 at 12:25 PM Staff Member #1 (SM#1) and Staff Member #2 (SM#2) were observed during routine chlorine testing. Observations of the piping into the water sampling port identified signage that directed staff to run the water for two (2) minutes before taking the water sample from the test port. Staff member #1 and Staff Member #2 were observed each conducting their own water test on separate Reverse Osmosis (RO) machines. SM #1 and SM #2 were noted to fill the test cup with water in a tilted manner and let the water flow over the sides for a period of approximately 15 seconds. SM #1 and SM #2 continued with the test, and verified with the test the licensed nurse (SM#1 and SM #2 were not noted to run the RO for 2 minutes prior to testing for chlorine). Interview with the Regional Biomedical Technician on 4/29/24 12:45 PM identified that this particular RO has longer than usual piping to reach the test port, therefor it requires the water to run 2 minutes prior to taking the test sample. He further identified that this is not included in the facility policy, however, he will be amending the policy to be site specific to include to this RO which requires a water run time of 2 minutes . Interview with the Clinical Specialist on 4/29/24 identified that if the water is not run for the full two (2) minutes the sample may come back with a more concentrated result and the sample would be tested again, furthermore, there would be no patient impact if the water was not run for 2 minutes, however, she would ensure all staff were educated on the two (2) minute run time prior to obtaining the water sample.”

“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: 47640 Based on observation during tour on 04/29/2024, the surveyors, while accompanied by the Facility Representative identified that the facility failed to maintain a safe, functional, and comfortable treatment environment. The findings include the following: 1. At 10:00 AM the surveyors observed station #5, 42, and 43 was said to be ready for treatment based on interviews with staff observation identified that there were items on the ground all around the treatment area (i.e.-treatment supply wrappers). 2. At 10:20 AM and at other times throughout the tour, the surveyors observed the growth of unknown substances around the clean sinks on both sides of the facility. 3 . At 10:25 AM and at other times throughout the tour, the surveyors observed the accumulation of rust on storage carts and racks both on the treatment floor and in clean storage areas. 4. At 10:30 AM the surveyors observed the flooring welds by station #33 where separating. 5. At 10:35 AM the surveyors observed water staining on the wall under the hose bibs at station #49.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47640 Based on a documentation review on 04/29/24 at 09:00 AM, the facility failed to maintain a building that was constructed and maintained to ensure the safety of the patients, the staff and the public. The findings include the following: The surveyors, were not provided with documentation to indicate that the fire suppression system within the facility was being maintained in accordance with NFPA 25, “Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems” i.e. There were two (2) inspections completed within the 4th quarter of 2023, and no inspections conducted within the 3rd quarter of 2023.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47491 Based on review of clinical records, facility policy and interview for three (3) of seven (7) patients reviewed for blood pressure and fluid balance the facility failed to inform/consult with the registered nurse when a patient’s blood pressure was determined to be abnormal and the treatment goal was adjusted, and failed to give a treatment for hypotension in accordance with facility policy. The findings included: 1. Patient #14 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous graft dialysis for hemodialysis access. Review of Patient #14’s treatment record dated 4/12/24 at 7:04 AM identified a Patient Care Technician (PCT) had addressed a blood pressure of 94/45 and reduced the treatment goal from 1400 milliliters to 900 milliliters, the documentation failed to identify that a registered nurse was informed of the decreased blood pressure or adjustment in the treatment goal. 2. Patient #16 had end stage renal disease, required hemodialysis three times weekly, and had a right upper extremity arteriovenous fistula dialysis access. Review of Patient #16’s treatment record dated 4/26/24 at 3:32 identified a blood pressure of 209/98 while receiving hemodialysis treatment. Further review of the treatment record identified a PCT had signed off on the blood pressure without retaking Patient #16’s blood pressure and informing a registered nurse of the elevation. 3. Patient #16 had end stage renal disease, required hemodialysis three times weekly, and had a right upper extremity arteriovenous fistula dialysis access. Review of the Treatment Details Report dated 3/29/24 identified Patient #16 had registered a blood pressure of 70/35 at 4:03 PM, became unresponsive while receiving dialysis treatment, and was given 500 milliliters of normal saline. Patient #16 had then regained consciousness and his/her blood pressure had improved to 135/59 at 4:11 PM. Further review of the 3/29/24 Treatment Details Report identified Patient 16’s blood pressure had again dropped at 4:21 PM to 88/49 and was given 200 milliliters of normal saline. A follow-up blood pressure check at 4:23 PM registered at 117/61 with the notation the patient was hypotensive, to withhold further fluid removal, and to monitor the patient’s vital signs every fifteen minutes. A total of 700 milliliters was given to the patient during this hypotensive event. Interview with the Clinical Coordinator (CC) on 5/1/24 at 2:23 PM indicated facility practice was to administer 200 milliliters twice, if needed, in response to a patient’s hypotensive episode and to follow up with the physician if more fluid needed to be given. The CC further indicated it was the responsibility of the nurse to communicate the hypotensive event with the physician and was not aware of why the policy wasn’t followed. Review of the Hypotension policy directs to administer a normal saline bolus of 100-200 milliliters for severe hypotensive episodes and if the patient continued to show signs and symptoms of hypotension, the licensed nurse would notify the physician and follow physician’s orders.”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 47491 Based on review of clinical records, facility policy, and interview for one (1) of three (3) patients reviewed for anemia, the facility failed to ensure hemoglobin levels for patient who was administered an erythropoietin stimulating agent (ESA)were drawn in accordance with the facility protocol. The findings included: Patient #3 had end stage renal disease, required hemodialysis treatments three times weekly, and had a left upper arm arteriovenous graft dialysis access. A physician’s order dated from 9/16/23 to 1/14/24 directed Micera 150 micrograms (stimulates red blood cell growth), intravenous push every two (2) weeks. Review of Patient #3’s lab results identified a hemoglobin level was drawn on 12/13/23, 1/10/24, and 1/26/24 however failed to indicate a hemoglobin level was drawn between 12/13/23 and 1/10/24 (a total of three 3 missed hemoglobin draws). Interview with the Clinical Coordinator on 5/3/24 at 11:09 AM identified hemoglobin lab draws should be conducted bi-weekly when a patient is receiving ESA therapy. Review of the SHAPE protocol (directs the ESA protocol) directs biweekly hemoglobin lab draws for patients currently receiving ESA therapy.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44675 Based on clinical record review, facility documentation, interview, and facility policy for 16 hemodialysis patients, the facility failed to ensure that for three (3) patients, (Patient #7, 9, and 16) tuberculosis testing was completed in accordance with facility policy, and for two (2) patients reviewed for intradialytic vital signs (Patient #7 and 9), the facility failed to ensure abnormal vital signs were addressed, for four (4) patients reviewed for post treatment assessments (Patient #3, 10, 12, and 14) the facility failed to ensure post treatment blood pressures were taken, for one (1) patient reviewed for low potassium dialysate (Patient #10), the facility failed to ensure weekly potassium levels were drawn, for two (2) patients reviewed for pre-treatment assessments (Patient #6, and 10), the facility failed to ensure that assessments were completed timely, and for one (1) patient reviewed for prescription (Patient # 8) the facility failed to ensure prescription orders were administered in accordance with physician orders. The finding included: 1. a) Patient #7 was admitted to the facility on 1/10/24 with diagnoses that included end stage renal disease. Patient #7’s physician orders included hemodialysis treatment three times a week for three hours and thirty minutes, 2.0 K ( potassium) 3 Ca (Calcium) dialysate, estimated dry weight (EDW) of 51 kilograms and Blood Flow Rate (BFR) (the amount of pressure it takes to push blood through the dialyzer and back to the body) of 400. Review of Patient #7’s Tuberculin purified protein derivative (PPD) test (which helps diagnose a tuberculosis infection) results identified Patient #7 had a PPD planted on 1/10/24 and read on 1/12/24 resulted as 0 mm (negative result). The medical record failed to identify a second PPD test was administered and read within twenty-eight (28) days per facility policy. b) Patient #6 had end stage renal disease, required hemodialysis treatment three times weekly, had a central venous catheter in the left upper chest, and was admitted to the facility on 10/18/23. Review of Patient #6’s vaccination record identified a tuberculin purified protein derivative (PPD) test was planted upon admission to the facility on 10/18/23 and read on 10/20/23, however a second PPD test was not performed. c) Patient #16 had end stage renal disease, required hemodialysis three times weekly, had a right upper extremity arteriovenous fistula dialysis access, and was admitted to the facility on 1/15/24. Review of Patient #16’s vaccination record identified a PPD test was planted within the first month of admission to the facility on 1/15/24, however the facility was unable to assess the result 48-72 hours following administration. Furthermore, the facility failed to identify if second PPD test was administered to Patient #16 since his/her initial test on 1/15/24. Interview with the Clinical Coordinator (CC) on 5/1/24 at 2:23 PM identified that she was unable to find documentation that Patient #6, 7 and 16 had their second PPD, or the results of Patient #16’s first PPD. Review of the Tuberculosis Infection Control policy directed patients with chronic kidney disease be screened for tuberculosis prior to their first treatment or as soon as possible following admission, and to perform a second tuberculosis screening test (TST) one to three weeks following the initial TST. The Tuberculosis Infection Control policy further indicated a chest x-ray obtained for any purpose that was interpreted by a radiologist as clear, negative, normal, or unremarkable, was acceptable to rule out tuberculosis infection. 2. a) Patient #7 had diagnoses that included end stage renal disease. Patient #7’s physician orders included hemodialysis treatment three times a week for three hours and thirty minutes, 2.0 K ( potassium) 3 Ca (Calcium) dialysate, estimated dry weight (EDW) of 51 kilograms (kg) and blood flow rate (the amount of pressure it takes to push blood through the dialyzer and back to the body) of 400. i. On 4/5/24 during hemodialysis treatment Patient #7’s heart rates were between 50 and 57 Beats Per Minute (BPM) (a normal heart rate is between 60 and 100 BPM) throughout treatment, all were signed off by the patient care technician (PCT) and were not documented as addressed by the registered nurse. ii. On 4/10/24 Patient #7’s post assessment identified that although the heart rate was documented as regular rate and rhythm, Patient #7’s sitting heart rate was 47 BPM and standing heart rate was 55 BPM. iii. On 4/15/24 Patient #7’s heart rates were less than 60 BPM during the duration of the hemodialysis treatment. Patient #7’s post assessment identified that although the heart rate was documented as regular rate and rhythm, Patient #7’s sitting heart rate was 57 BPM. iiii. On 4/17/24 Patient #7’s pre treatment assessment identified that although the heart rate was documented as regular rate and rhythm, Patient #7’s sitting heart rate was 58 BPM. Patient #7’s heart rate remained less than 60 BPM for the duration of treatment. Patient #7’s post assessment identified Patient #7’s heart rate was bradycardic (slow heart rate) and 50 BPM. iiiii. On 4/22/24 during hemodialysis treatment Patient #7’s heart rates were 41 BPM at 1:25 PM and 36 BPM at 4:34 PM and although they were signed off by the registered nurse, no further follow up or assessment of Patient #7’s heart rates were documented. Patient #7’s post assessment identified that although the heart rate was documented as regular rate and rhythm, Patient #7’s sitting heart rate was 57 BPM. iiiiii. On 4/24/24 during hemodialysis treatment Patient #7’s heart rates were 57 BPM at 2:32 PM and 55 BPM at 3:02 PM, were signed off by the PCT and were not documented as addressed by the registered nurse. Patient #7’s post assessment identified that although the heart rate was documented as regular rate and rhythm, Patient #7’s sitting heart rate was 49 BPM and standing heart rate 52 BPM. Review of Patient #7’s nursing progress notes and treatment records for April 2024, failed to identify that Patient #7’s low heart rates during treatment and/or post treatment were addressed. b. Patient #9 had diagnoses that included end stage renal disease. Patient #9’s physician orders included hemodialysis treatment three times a week for four hours, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 73 kg and blood flow rate of 450. i. On 4/16/24 during hemodialysis treatment Patient #9’s heart rate was 39 BPM at 11:30 AM, was signed off by the patient care technician and was not documented as addressed by the registered nurse. ii. On 4/18/24 during hemodialysis treatment Patient #9’s heart rates were 50 BPM at 11:03 AM, 59 BPM at 11:32 AM, 56 BPM at 12:03 PM and 57 BPM at 1:33 PM, were signed off by the PCT and were not documented as addressed by the registered nurse. Review of Patient #9’s nursing progress notes for April 2024, failed to identify that Patient #9’s low heart rates during treatment and/or post treatment were addressed for 4/16/24 and 4/18/24. Review of the pre-intra-post treatment date collection, monitoring and nursing assessment policy directed abnormal findings should be reported to the licensed nurse and documented in the patient’s medical record. An abnormal heart rate finding pre/intra/post would be less than 60 beats per minute The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary and the physician will be notified of any concerns that may preclude the initiation of dialysis. 3. a) Patient #3 had end stage renal disease, required hemodialysis three times weekly, and had a left upper extremity arteriovenous graft dialysis access. Review of Patient #3’s Treatment Details Report dated 3/18/24, 3/22/24, and 4/1/24 indicated a mobility status of ambulatory with no assistance needed, however review of the post treatment nurse assessment failed to indicate a standing blood pressure was obtained, or that the patient refused to take a standing blood pressure. b. Patient #10 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous fistula dialysis access. Review of Patient #10’s Treatment Details Report dated 4/4/24, 4/11/24, and 4/25/24 indicated a mobility status of ambulatory with no assistance needed, however review of the post treatment nurse assessment failed to indicate a standing blood pressure was obtained, and/or the patient refused to take a standing blood pressure. c. Patient #12 had end stage renal disease, required hemodialysis three times weekly, and had right upper arm arteriovenous fistula dialysis access. Review of Patient #12’s Treatment Details Report dated 4/4/24, 4/11/24, and 4/27/24 indicated a mobility status of ambulatory with no assistance needed, however review of the post treatment nurse assessment failed to indicate a standing blood pressure was obtained and/or the patient refused to take a standing blood pressure. d. Patient #14 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous graft dialysis access. Review of Patient #14’s Treatment Details Report dated 4/1/24 and 4/12/24 indicated a mobility status of ambulatory with no assistance needed, however review of the post treatment nurse assessment failed to indicate a standing blood pressure was obtained and/or the patient refused to take a standing blood pressure. Interview with the Clinical Coordinator on 5/1/24 at 1:49 PM identified it was standard practice to obtain both seated and standing blood pressures after treatment, however if the patient refused a standing blood pressure, the staff should have notated the refusal in the treatment record. Review of the Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy directs a standing blood pressure should be obtained for patients who are able to stand, and if unable to stand, should document the reason and the sitting blood pressure. 4) Patient #10 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous fistula dialysis access. A physician’s order dated 1/19/24 to 5/2/24 directed to use a 1.0 potassium 3.0 calcium dialysate solution with treatment. Review of Patient #10’s lab results dated 3/1/24 through 3/13/24 and 3/29/24 through 4/10/24 failed to identify weekly potassium was drawn although Patient #10 received dialysis treatment at the facility on 3/5/24, 3/9/24, 4/2/24, 4/4/24, and 4/9/24. Interview with the Clinical Coordinator on 5/1/24 at 1:43 PM identified serum potassium lab draws were drawn weekly for patients who utilized a 1.0 potassium dialysate solution with treatments so as to continuously monitor their blood potassium levels. The Clinical Coordinator further indicated weekly lab draws were missed due to Patient #10’s non-compliance in attending his/her scheduled treatments, however, if a potassium level is missed it should be drawn on the patients next treatment date. Review of the Use of Low Potassium Dialysate policy directs patients with orders for less than 2.0 potassium dialysate will have follow-up pre-dialysis serum potassium levels checked weekly. 5) a) Patient #6 had end stage renal disease, required hemodialysis treatment three times weekly, and had a central venous catheter in the left upper chest. i. Review of Patient #6’s 4/24/24 treatment record identified a pre-treatment assessment was documented at 3:27 PM when treatment was initiated at 11:12 AM (4 hours subsequent to the start of treatment). b. Patient #10 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous fistula dialysis access. i. Review of Patient #10’s 4/16/24 treatment record identified a pre-treatment assessment was documented at 2:33 PM when treatment was initiated at 5:39 AM (3 hours subsequent to the start of treatment). Interview with the Clinical Coordinator on 5/1/24 at 2:43 PM indicated pre-treatment assessments should be entered into the patient chart no later than one hour after the patient started their dialysis treatment and was unsure as to why that did not occur. Per facility policy, pre-treatment assessments are to be entered into the patient’s chart no later than one hour following treatment initiation. 7) a. Patient #8 had end stage renal disease, required hemodialysis treatment three times weekly, and had a left lower extremity arteriovenous fistula dialysis access. A physician’s order dated 4/13/24 directed hemodialysis treatment three times weekly, at two- and three-quarter hours per treatment, was administered at a Blood Flow Rate (BFR) of 400 milliliters per minute and a Dialysate Flow Rate (DFR) of 800 milliliters per minute. i. Review of Patient #8’s 4/14/24 treatment sheet identified treatment was administered at a BFR of 300 milliliters per minute the entire treatment versus at 400 milliliters per minute without notation of the decrease. ii. Review of Patient #8’s 4/18/24 treatment sheet identified treatment the Dialysis Flow Rate (DFR) was administered at 600 milliliters per minute the entire treatment instead of 800 milliliters per minute without notation of the decrease. iii. Review of Patient #8’s 4/25/24 treatment sheet identified treatment was administered at a BFR of 300 to 350 milliliters per minute blood flow rate versus 400 milliliters per minute for the entire treatment without notation for the decrease. Interview with the Clinical Coordinator on 5/1/24 at 1:42 PM indicated facility practice was to follow the physician’s order regarding both the blood flow and dialysate flow rate and if an adjustment to the blood flow and/or dialysate flow rate needed to be made, a notation indicating the reason for the change should have been noted. The Clinical Coordinator further indicated it was the nurse’s and/or patient care technician’s responsibility to notate any change in blood flow or dialysate flow rate and was unsure as to why that did not occur. Review of Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy directed to follow the physician’s orders.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 44675 Based on clinical record review, interview and review of facility policy for one (1) of three (3) Patients (Patient #15), reviewed for treatment compliance, the facility failed to document missed treatments and interventions in the medical record, and for Patient # 5, the facility failed to ensure that the clinical record was accurate. The finding included: 1. Patient #5 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Review of Patient #5’s allergy list identified an allergy to sodium bicarbonate. Review of Patient #2’s plan of care dated 5/25/23 identified that the resident was allergic to sodium bicarbonate. Observation on 4/30/24 at 11:45 AM identified Patient #5 dialyzing with a 2 K (potassium) 2 Ca (calcium) bath with and a bicarb bag labeled sodium bicarbonate (the buffer used in dialysis fluid). Interview with the Clinical Coordinator (CC) on 4/30/24 at 12:00 PM identified that the only option for a buffer in dialysis is sodium bicarbonate, and the resident had been receiving dialysis since 2018 and has never had any reaction to the sodium bicarbonate. The CC further identified that he had contacted the patients doctor who had no concerns because the patient had been on dialysis for so long without any issues, the allergy to sodium bicarbonate was removed from the clinical record and determined to be an error. 2. Patient #15 was admitted to the facility with diagnoses that included end stage renal disease. Patient #15’s physician orders included hemodialysis treatment three times a week for three hours and thirty minutes, 2.0 K 2 Ca dialysate, Estimated Dry Weight (EDW) of 57.5 kg and a right chest Central Venous Catheter (CVC). Review of Patient #15’s treatment log dated March 2024 identified Patient #15 missed hemodialysis treatments on 3/11/24, 3/15/24, 3/18/24, 3/25/24 and 3/27/24 (a total of 5 treatments). A nursing progress note dated 3/27/24 identified Patient #15 skipped treatment on 3/27/24 and remained non-compliant in his/her attendance to dialysis despite repeated teaching on the importance of dialysis. Review of the progress notes failed to identify a progress note for 3/11/24, 3/15/24, 3/18/24 and 3/15/24 of Patient #15’s missed treatment and interventions provided. Review of Patient #15’s treatment log dated April 2024 identified Patient #15 missed hemodialysis treatments on 4/1/24, 4/5/24, 4/8/24, 4/15/24 and 4/26/24 (a total of 5 treatments). Review of the Patient #15’s progress notes for April failed to identify a progress note for 4/1/24, 4/5/24, 4/8/24, 4/15/24 and 4/26/24 of Patient #15’s missed treatment and interventions provided. Interview with the Clinical Coordinator on 5/1/24 at 2:30 PM identified if a patient misses hemodialysis treatment, the patient should be contacted, attempt made to reschedule the hemodialysis treatment and document it in the medical record.”