Fmc Central Ct Dialysis Center

“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: 32738 Based on findings during a tour on 12/13/23 at 11:00 AM, the surveyors, while accompanied by the Bio Med Technician and the Regional Biomed Manager, observed that the facility failed to maintain a safe, functional, and comfortable treatment environment. The findings include the following: On 12/13/23 at 11:30 AM, the surveyors, while accompanied by the Bio Med Technician and the Regional Biomed Manager, observed treatment areas that were made ready for use were unkept and visibly soiled. i.e., There was discarded bandage wrappers, discarded medical supplies found all around treatment areas ready for use as well as, visible staining of the floor from spilt bi-carb products that were not cleaned and sanitized properly.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 32738 Based on observation during document review on 12/13/23 at 09:00 AM, the surveyors were not provided with documentation from the Biomed Tech, the Regional Biomed Manager, or the Clinical Manager, to show that the facility is maintaining its fire alarm system in accordance with section# 14.3.1 of NFPA 72 “National Fire Alarm Code”. i.e., Only one of the required semi-annual inspections was completed in the past year. Based on observation during document review on 12/13/23 at 09:00 AM, the surveyors were not provided with documentation from the Biomed Tech, the Regional Biomed Manager, or the Clinical Manager, to show that the facility is maintaining its fire alarm system in accordance with section# 14.3.1 of NFPA 72 “National Fire Alarm Code”. i.e., There was no documentation provided to indicate that a sensitivity test of the smoke detection devices was completed within the past two years.”

“PE-LSC-SPRINKLERS CFR(s): 494.60(e)(2) (2) Notwithstanding paragraph (d)(1) of this section, dialysis facilities participating in Medicare as of October 14, 2008 that require sprinkler systems are those housed in multi-story buildings construction Types II(000), III(200), or V(000), as defined in the Life Safety Code, section 21.1.6.1, which were constructed after January 1, 2008, and those housed in high rise buildings over 75 feet in height, which were constructed after January 1, 2008. This Standard is not met as evidenced by: 32738 Based on observation during document review on 12/13/23 at 09:00 AM, the surveyors were not provided with documentation from the Biomed Tech, the Regional Biomed Manager, or the Clinical Manager, to show that the facility is maintaining the automatic sprinkler system in accordance with NFPA 25. i.e., There was no 2nd quarter sprinkler inspection preformed in 2023.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for 1 of 3 hemodialysis patients reviewed for hemodialysis prescriptions, (Patient #9), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: Patient #9 had diagnoses that included End Stage Renal Disease. Review of the physician’s orders directed hemodialysis three times weekly with a blood flow rate (BFR) of 500. Review of Patient #9’s treatment flowsheets identified the following: 1. On 11/15/23 Patient #9’s BFR during treatment was 400 with no rationale as to why the prescribed BFR of 500 was not met. 2. On 11/24/23 Patient #9’s BFR during treatment was 450 with no rationale as to why the prescribed BFR of 500 was not met. 3. On 12/4/23 Patient #9’s BFR during treatment was 400 with no rationale as to why the prescribed BFR of 500 was not met. Observation on 12/13/23 at 1:00 PM of Resident #9 during hemodialysis treatment identified Resident #9’s BFR was being administered at 400. Interview and observation of Resident #9 during treatment with Staff Person #2 on 12/13/23 at 1:28 PM identified Resident #9’s BFR was running at 400. Subsequent to surveyor inquiry, Staff Person #2 changed Resident #9’s BFR to 500. He further identified Resident #9’s blood pressure is better when his/her BFR is at 400. He further identified he had previous discussions with the physician and it was okay for him to change the BFR if the patient was meeting adequacy. Subsequently, he changed Resident #9’s BFR orders to 400. Review of the patient assessment and monitoring policy directed during treatment to check the prescribed blood flow is being achieved or the reason is documented in the medical record if unable to meet the prescribed blood flow.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 32738 Based on clinical record review, facility documentation, and interviews, for 1 of 3 patients reviewed for stability, (Patient #3), the facility failed to assess the patient for stability after multiple hospitalizations, in accordance with facility policy. The findings include: Patient #3 had a diagnosis of End Stage Renal Disease and required hemodialysis three times weekly. Review of the clinical record identified that the resident has hospitalizations from 5/31-6/3/23, from 6/6 to 6/9/23 and from 6/24-6/26/23 (three hospitalizations within 30 days). Review of the clinical record identified that Patient #3 last had a care plan completed on 1/10/23. The clinical record failed to identify that subsequent to the three hospitalizations in 30 days an assessment was completed for stability. Interview with the Facility Administrator on 12/13/23 at 2:00 PM identified that if a patient is hospitalized three times in 30 days, the care plan should be reviewed to determine if the resident is stable or unstable. The FA could not identify why this had not been done for Patient #3. Review of the Plan of Care policy identified that if a resident has three hospitalizations in 30 days an assessment must be completed to determine stability.”

“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 observations, staff interview, and facility policy for one (1) of three (3) patients, Patient #1, the facility failed to ensure that the patient’s hemodialysis access site remained visible in accordance with facility policy, and the facility failed to appropriately label pre-drawn medications, complete intradialytic treatment monitoring every thirty minutes, follow policy for a patient not showing up for treatments, and ensure the emergency evacuation was checked monthly and contained no expired solutions per facility policy. The findings included: 1. Patient #1 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly. Review of Patient #1 hemodialysis treatment orders identified Patient #1 had a left upper arm arteriovenous fistula. Observation of Patient #1 at Station 4 on 12/12/23 at 9:28 AM identified Patient #1’s access was covered by a blanket and not visible. At 9:30 AM Staff Person #1 entered Patient #1’s station to check his/her blood pressure and re-adjusted the blood pressure cuff on Resident #1’s right arm. Staff Person #1 exited Patient #1’s station while Patient #1’s access remained covered. At 9:36 AM the surveyor inquired to Staff Person #1 what type of access Patient #1 had and if it was visible. Staff Person #1 identified the site was visible. The surveyor asked Staff Person #1 to show her Patient #1’s access and identified it was covered by the blanket and subsequent to surveyor inquiry, Staff Person #1 pulled down Patient #1’s blanket and uncovered Patient #1’s access site. Interview with the Facility Administrator on 12/12/23 at 10:00 AM identified that dialysis accesses should be visible at all times. Interview with the Medical Director on 12/13/23 at 12:00 PM identified that dialysis access sites should be visible at all times during hemodialysis treatment. He further identified staff have ongoing discussions with the patients on having the access visible no matter how cold it is. He identified if an access is not visible, the staff should make it visible. An action plan was requested by the state department on 12/12/23 at 10:00 AM that included education and audits of both staff and patients on the importance of keeping the dialysis access sites visible at all times. Review of the patient assessment and monitoring policy directed for monitoring a patient during treatment, staff are to ensure the access remains uncovered throughout the treatment. It further identified to observe and ensure the tape is secure, the needles are intact and no bleeding or infiltration is noted. 2. Observations conducted during the flash tour on 12/12/23 at 9:10 AM identified the following pre-drawn medications in syringes without the staff member’s initials of who drew the medication and the time drawn: 1. Patient #6 heparin 6000 units bolus 2. Patient #7 heparin 5000 units bolus 3. Patient #8 heparin 3000 units bolus 4. Patient #9 heparin 2400 units bolus 5. Patient #10 heparin 3000 units bolus 6. Patient #11 heparin 2100 units arterial and 2200 units venous 7. Patient #12 heparin 1600 units arterial and 1700 units venous Interview with Staff Person #2 on 12/12/23 at 9:40 AM identified she drew the aforementioned heparin syringes around 8:45 AM. Subsequent to surveyor inquiry, Staff Person #2 initialed and timed the pre-drawn heparin. Review of the medication preparation and administration policy directed that all medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication. 3. a) Patient #1 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly. Review of Patient #1’s treatment sheet dated 11/22/23 identified Patient #1 had a blood pressure and pulse check at 8:08 AM and next at 9:04 AM. The record failed to identify a blood pressure and pulse were measured in between. Review of Patient #1’s treatment sheet dated 12/97/23 identified Patient #1 had a blood pressure and pulse check at 6:32 AM and next at 7:33 AM. The record failed to identify a blood pressure and pulse were measured in between. Review of Patient #1’s treatment sheet dated 12/9/23 identified Patient #1 had a blood pressure and pulse check at 8:35 AM and next at 9:32 AM. The record failed to identify a blood pressure and pulse were measured in between. b. Patient #6 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly. Review of Patient #6’s treatment sheet dated 12/5/23 identified Patient #6 had a blood pressure and pulse check at 2:05 PM and next at 3:02 PM. The record failed to identify a blood pressure and pulse were measured in between. The Patient Assessment and Monitoring policy identified to obtain blood pressure and pulse rate every thirty minutes or more as needed during treatment. It further identified to document the machine parameters and safety checks every thirty minutes or more often as needed during treatment. 3. Patient #4 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly on Tuesday, Thursday and Saturday. Review of the unstable care plan dated 5/25/23 identified Patient #4 had a care plan for treatment adherence with interventions that included to identify barriers to missed treatments. Review of Patient #4’s absence record identified the following: a. On 5/13/23 Patient #4 was a no show for treatment. b. On 5/16/23 Patient #4 was a no show for treatment. The nursing progress note dated 5/16/23 identified Patient #4 was a no show, a call was placed with no voicemail set up and the team leader and FA were updated. c. On 5/18/23 Patient #4 was a no show for treatment. d. On 5/20/23 Patient #4 was a no show for treatment. e. On 5/23/23 Patient #4 was a no show for treatment. The nursing progress note dated 5/23/23 identified Patient #4 was called and asked why he/she hadn’t been to treatment and Patient #4 stated he/she didn’t feel good when he/she did dialysis and will be present for his/her next treatment. Patient #4 was told he/she could not go to treatment on Thursday without a stat potassium level being drawn and Patient #4 verbalized understanding and stated he/she would go to the emergency department the next day. Patient #4 was told to answer his/her phone calls or call the clinic back because they were concerned of his/her wellbeing. The conversation relayed to the physician, Charge Nurse and FA. f. On 6/1/23 Patient #4 was a no show for treatment. The nursing progress note dated 6/1/23 identified Patient #4 was a no show for treatment, was called and stated he/she would not be in because he/she had treatment in the hospital yesterday and would be in on Saturday. g. On 6/3/23 Patient #4 was a no show for treatment. Review of Patient #4’s nursing progress notes identified it was not documented that the physician was notified of Patient #4’s no shows to treatment between 5/13/23 - 5/20/23 (3 treatment’s in one week with no contact with Patient #4) and 6/1/23 - 6/3/23 (two treatments). The clinical record further failed to identify documentation of actions taken to locate Patient #4, and when Patient #4 missed three consecutive treatments that the physician was notified, a missed treatment letter was sent and the network was notified per policy. Interview with Regional Operations Director on 12/12/12 at 1:30 PM identified a missed treatment letter was not sent to Patient #4 and the network was not notified of Patient #4’s missed treatments after Patient #4 missed three consecutive scheduled treatments. Interview with the Charge Nurse on 12/13/23 at 1:00 PM identified the physician should be notified when at least when two treatments are missed. He identified he could not remember the specifics of the time frame of when or if the physician was notified about Patient #4’s missed treatments. He did identified multiple wellness checks were completed but did not provide dates. Interview with the Medical Director on 12/21/23 at 12:00 PM identified he was getting updates when Patient #4 was not showing up for treatments. He identified he had multiple conversations over time with Patient #4 about the dangers of missing treatments. He further identified staff should always document attempts to reach patients. Review of the managing missed treatments due to non-adherence policy directed that the attending nephrologist must be notified when a patient misses a scheduled treatment(s), if staff are unable to reach the patient or their emergency contact, to notify the attending nephrologist of the patient’s absence and inquire if it is known whether the patient was admitted to the hospital. Staff may also attempt to locate the patient and determine if they are safe by checking the nearby hospitals and contacting the police for a home check and to document the missed treatment and all actions taken to locate the patient in the medical record., and if a patient missed three consecutive treatments to notify the attending nephrologist, and send missed 3 Treatments letter to the patient’s last known address and notify the network of the situation. 4. Observation during the flash tour on 12/12/23 at 9:50 AM identified the emergency evacuation kit had a plastic snap lock that was not engaged. There were two bags of sodium chloride 0.9% 1000 ml bags with an expiration date of November 2023. Interview with the Staff Person #2 on 12/12/23 at 10:00 AM identified the emergency evacuation box plastic snap lock can be hard to lock and it probably came loose. He further identified he missed the emergency check in November 2023. Review of the Emergency Box Supplies policy identified the emergency box needs to be checked monthly or after use for contents, expiration dates and cleanliness. It further identified an itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.”