Dci - Uconn Dialysis Center

“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, for two (2) of six (6) patients (Patient #9 and Patient #10), reviewed for hand hygiene, the facility failed to ensure hand hygiene was performed going from a dirty task to a clean task during Central Venous Catheter (CVC) care and failed to place a glove on a patient’s hand who held his access sites following treatment per facility policy. The findings include: 1. Patient #9 was admitted to the facility with diagnosis that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right jugular central venous catheter (CVC) and 3,000 heparin loading lose. Observation conducted on 2/5/25 at 11:13 AM identified Staff Person #3 performing catheter initiation for hemodialysis treatment. Staff Person #3 with clean gloves, removed Patient #9’s previous CVC exit site dressing and then proceeded to clean Patient #9’s exit site and apply a new clean dressing without the benefit of removing gloves and performing hand hygiene after removing the previous dressing and providing catheter care and applying a new dressing. Interview with the Clinical Educator on 2/5/25 at 12:30 PM identified the process for catheter care should be the following: hand hygiene is performed, and gloves applied, remove previous dressing, remove gloves and perform hand hygiene, don gloves, clean the exit site and then apply a clean dressing. Staff Person #3 should have removed her gloves and performed hand hygiene after removing Patient #9’s previous dressing. Review of the catheter initiation and termination for hemodialysis policy directed to wash hands and put on gloves, perform the central line dressing change per policy and procedure. Review of the tunneled catheter routine care and dressing change policy directed to wash hands, use universal precautions as appropriate, apply facemask to yourself and patient and don fresh pair non-sterile gloves, carefully remove old dressing and change gloves. 2. Resident #10 had diagnoses that included end stage renal disease. Review of physician’s orders identified in-center hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes each, to administer a blood flow rate (BFR) of 450 and dialysate flow rate (DFR) of 800 using a left upper arm arteriovenous fistula. Observation on 2/5/25 at 10:00 AM identified Patient #10 at Station #1 was applying pressure to the top of the clamps that were applied to his/her access following dialysis treatment with an ungloved right hand. At 10:03 AM, Staff Person #5 approached Patient #10 to check his/her access and removed both clamps and Patient #10 was observed holding both sites directly on top of the bandages with his/her ungloved right hand. Patient #10 left the dialysis station and performed hand hygiene prior to leaving the facility. Interview with the Nurse Educator on 2/6/25 at 11:20 AM identified patients were to wear gloves when holding their access sites post dialysis treatment, regardless if they were applying pressure onto the clamp or directly onto the bandages covering the cannulation site. The Nurse Educator further identified that although the facility did not have a policy specifically identifying patients were to don gloves when applying pressure to their access sites following treatment, best practice was for patients to wear glove to prevent cross contamination.”

“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 and interviews, the facility failed to appropriately clean and disinfect the dialysis station after a hemodialysis treatment. The findings included: a. Observation conducted on 2/5/25 at 10:05 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #3 failed to open the chair fully to disinfect between the seat and back of the chair. b. Observation conducted on 2/5/25 at 10:11 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #4 failed to clean and disinfect the wall box. c. Observation conducted on 2/5/25 at 10:13 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #4 failed to clean and disinfect the wall box. Interview with the Nurse Educator on 2/5/25 at 12:30 PM identified the wall boxes are cleaned after each hemodialysis treatment. Review of the surface cleaning and disinfection in the dialysis setting policy directed the outside if the dialysis machine, chair, BP cuff and clamps will be disinfected after each patient use. It identified, in part, to take the disposable cloth saturated with 1:100 bleach solution and wash the entire surface thoroughly including the wall boxes. It further identified the back of the chair and legs will be fully extended to clean the gap in the back of the chair and seat.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 44675 Based on observation, interview and review of facility policy, the facility failed to ensure the medication room and medication administration trays were maintained in a sanitary and clean manner. The finding included: a. Observation on 2/3/25 at 9:40 AM during the flash tour identified the medication room had brown splatter (identified as iron medication) and sticky residue throughout the medication room cabinets. There were four (4) medication trays on the cabinet that had label residue and sticky residue throughout the entirety of the trays. b. Observation on 2/4/25 at 12:49 PM identified Staff Person #2 with a purple tray containing patient medications. The tray was not in a sanitary condition with labels and label residue throughout the entirety of the tray. c. Observation on 2/4/25 at 2:21 PM identified Staff Person #5 with a red tray containing patient medications. The tray was not in a sanitary condition with labels and label residue throughout the entirety of the tray.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 47491 Based on review of clinical records, interview, and review of facility documentation on one (1) of four (4) patients (Patient #4) reviewed for Hepatitis B, the facility failed to ensure patients had been tested for Hepatitis B prior to admission in accordance with policy. The findings included: Patient #4 was admitted to the facility on 1/11/25 and had diagnoses that included end stage renal disease. The physician’s order directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes each using a 4.0 potassium/2.5 calcium bath, run at a blood flow rate (BFR) of 250 milliliters per minute, a dialysate flow rate (DFR) of 600 milliliters per minute, using a left upper arm arteriovenous fistula. Review of Patient #4’s Hepatitis B results dated 12/6/24 at 1:54 PM, which were used for admission to the dialysis facility, identified the patient tested negative for Hepatitis B Surface Antigen, Antibodies, and Core. Interview with the Nurse Manager on 2/5/25 at 2:30 PM identified the standard of practice was to accept Hepatitis B test results that were completed no greater than thirty (30) days from the patient’s date of admission. The Nurse Manager further indicated the results used for Patient #4’s admission to the facility were outside of that thirty (30) day window. Review of the New Patient Referral Check Off List identified a Hepatitis Panel (which included the Hepatitis B Antigen, Antibody, and Core testing) was to be completed within thirty (30) of admission to the facility.”

“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: 44675 Based on observations, facility documentation, facility policy and interviews, for two (2) of three (3) patients (Patient #7 and #8), reviewed for catheter care, the facility failed to ensure patient and staff masks were worn appropriately per facility policy. The findings include: 1. Patient #7 was admitted to the facility with diagnosis that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right jugular central venous catheter (CVC). Observation on 2/4/25 at 11:31 AM identified Staff Person #1 performing catheter care for Patient #7. Patient #7 was observed without a mask on and there was no mask identified in the station. The hemodialysis lines were connected to the patient’s CVC at 11:33 AM without the benefit of Patient #7 wearing a mask during the procedure. 2. Patient #8 was admitted to the facility with diagnosis that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right jugular central venous catheter (CVC). Observation on 2/4/25 at 11:56 AM identified Staff Person #1 performing catheter care for Patient # 8. Patient #8 was observed with his/her mask on below his/her nose (not covering the nostrils). The hemodialysis lines were connected to the patient’s CVC at 11:57 AM. Review of the catheter initiation and termination for hemodialysis policy directed when initiating or discontinuing treatment with a central venous catheter or performing CVC site care, the caregiver will wear a mask in addition to a full-face shield or safety goggles. The patient will also wear a mask during these procedures.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of four (4) patients (Patient #5), reviewed for fluid balance, the facility failed to document notification of the physician for a patient not meeting the prescribed target weight in the medical record per physician orders and for one (1) of four (1) patients (Patient #4), reviewed for treatments, the facility failed to inform the nurse when a patient’s systolic blood pressure exceeded one hundred eighty (180). The findings included the following:. The findings include the following: 1. Patient #5 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a left upper arteriovenous graft (AVG) and an Estimated Dry Weight (EDW) of forty-nine (49) kilograms (kg). The annual care plan dated 4/19/24 identified Patient #5 had the current problem of fluid overload with interventions that included to educate regarding sodium and fluid restrictions and discuss with the MD extra treatment or EDW adjustment. Patient #5’s 2025 physician annual standing order sheet directed to notify the physician if the patient is coming in 0.5 kg below or leaving 2 kg greater than EDW. Review of Patient #5’s hemodialysis treatment sheets identified the following: a. On 1/10/25 Patient #5’s post weight was 55.4 kg (6.4 kg above prescribed EDW). Patient #5’s post treatment nursing assessment identified Patient #5 had right lower extremity edema. Review of the flowsheet and nursing notes failed to identify Patient #5’s EDW not being achieved, interventions, and if the physician was notified. b. On 1/15/25 Patient #5’s post weight was 56.7 kg (7.7 kg above prescribed EDW). Patient #5’s post treatment nursing assessment identified Patient #5 had facial and abdominal edema. Review of the nursing note dated 1/15/25 identified Patient #5 was 7.7 kg above EDW post treatment and scheduled for fluid removal tomorrow. It identified the Charge Nurse was aware but failed to identify if the physician was notified. c. On 1/17/25 Patient #5’s post weight was 53.5 kg (4.5 kg above prescribed EDW). Review of the flowsheet and nursing notes failed to identify Patient #5’s EDW not being achieved, interventions, and if the physician was notified. d. On 1/20/25 Patient #5’s post weight was 54 kg (5 kg above prescribed EDW). Review of the flowsheet and nursing notes failed to identify Patient #5’s EDW not being achieved, interventions, and if the physician was notified. e. On 1/22/25 Patient #5’s post weight was 53.3 kg (4.3 kg above prescribed EDW). Patient #5’s post treatment nursing assessment identified Patient #5 had facial edema. Review of the nursing note dated 1/22/25 identified Patient #5 was 4.3 kg over EDW post treatment. Patient #5 was educated on fluid and sodium restriction, physician was notified and scheduled for an extra treatment tomorrow. f. On 1/24/25 Patient #5’s post weight was 52.4 kg (3.4 kg above prescribed EDW). Patient #5’s post treatment nursing assessment identified Patient #5 had trace edema. Review of the flowsheet and nursing notes failed to identify Patient #5’s EDW not being achieved, interventions, and if the physician was notified. g. On 1/27/25 Patient #5’s post weight was 51.9 kg (2.9 kg above prescribed EDW). Patient #5’s post treatment nursing assessment identified Patient #5 had facial edema. Review of the flowsheet and nursing notes failed to identify Patient #5’s EDW not being achieved, interventions, and if the physician was notified. Interview with the Clinical Educator on 2/5/25 at 2:30 PM identified there is not a specific policy on patients being over EDW. She identified staff are to follow the physician’s annual standing order sheet (which identified to notify the physician if a patient is leaving 2 kg greater than EDW). 2. Patient #4 was admitted to the facility on 1/11/25 and had diagnoses that included end stage renal disease. The physician’s order directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes each using a 4.0 potassium/2.5 calcium bath, run at a blood flow rate (BFR) of 250 milliliters per minute, a dialysate flow rate (DFR) of 600 milliliters per minute, using a left upper arm arteriovenous fistula. Review of Patient #4’s treatment flow sheet dated 1/18/25 identified intradialytic blood pressures of 184/87 at 1:30 PM, 187/93 at 2:30 PM, and 187/85 at 2:45 PM without notation the nurse was informed of the elevated systolic blood pressure. Review of the Patient #4’s treatment flow sheet dated 2/1/25 identified intradialytic blood pressures of 192/89 at 2:30 PM and 198/93 at 3:00 PM without notation the nurse was informed of the elevated systolic blood pressure. Interview with the Nurse Manager on 2/5/25 at 12:34 PM identified staff should be documenting the nurse was informed when a patient’s systolic blood pressure exceeds one hundred eighty (180) to indicate the patient was assessed. Review of the DCI Staff Parameter Reporting Guidelines Check List directed staff to inform the charge nurse if the patient’s intradialytic systolic blood pressure exceeded one hundred eighty (180).”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of four (4) hemodialysis patients reviewed for prescriptions (Patient #7), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders resulting in inadequate dialysis. The findings include the following: 1. Patient #7 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and forty-five (45) minutes with a left central venous catheter (CVC) and a blood flow rate (BFR) of 450. A sample review of Patient #7’s treatment flowsheets identified the following: a. On 1/9/25 Patient #7’s CVC was accessed successfully, however for the entirety of the treatment Patient #7’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. b. On 1/11/25 Patient #7’s treatment was initiated at 6:52 AM with a BFR of 400. At 8:01 AM the BFR decreased to 375 and then 350 at 9:01 AM with no rationale as to why the prescribed BFR of 450 was not met. c. On 1/16/25 Patient #7’s treatment was initiated at 6:44 AM with a BFR of 450. At 7:34 AM the BFR decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. d. On 1/18/25 Patient #7’s treatment was initiated at 7:05 AM with a BFR of 450. At 8:01 AM the BFR decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. e. On 1/21/25 Patient #7’s treatment was initiated at 7:28 AM with a BFR of 450. At 9:01 AM the BFR decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. f. On 1/23/25 Patient #7’s CVC was accessed successfully, however for the entirety of the treatment Patient #7’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met . Patient #7’s Kt/v (shows the adequacy of hemodialysis) on 1/23/25 was 1.14 (goal for adequate dialysis is 1.2). g. On 1/28/25 Patient #7’s treatment was initiated at 6:54 AM with a BFR of 450. At 7:31 AM the BFR decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. h. On 1/31/25 Patient #7’s treatment was initiated at 11:08 AM with a BFR of 400. At 12:08 PM the BFR decreased to 370 and then 350 at 1:31 PM with no rationale as to why the prescribed BFR of 450 was not met. Review of the nursing notes for the aforementioned dates failed to identify documentation of why Patient #7’s hemodialysis prescribed BFR was not achieved. Interview with the Clinical Educator on 2/5/25 at 2:30 PM identified if a patient is not meeting their prescribed BFR, the reason should be documented on the flowsheet vital line. Review of the physician annual standing order sheet identified the BFR will run at 450 for all catheters.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 47491 Based on review of clinical records, interview, and review of facility documentation for two (2) of three (3) peritoneal dialysis patients (Patient #1 and #3) reviewed for treatment records, the facility failed to ensure patient flowsheets were reviewed to ensure treatments were completed in accordance with physician’s orders. The findings included: a. Patient #1 had diagnoses that included end stage renal disease. Physician’s orders dated 10/14/24 directed for four (4) manual exchanges (CAPD - continuous ambulatory peritoneal dialysis) daily using both 1.5% dialysate solution (for two exchanges) and 2.5% dialysate solution (for two exchanges) daily when systolic blood pressure was greater than 100. Review of Patient #1’s treatment sheets dated 10/1/24 through 12/6/24 failed to identify the concentration of dialysate used with each treatment and Patient #1’s daily blood pressure on several treatment days. b. Patient #3 had diagnoses that included end stage renal disease. Physician’s orders dated 6/12/23 directed for four (4) exchanges on the Fresenius Liberty Cycler (APD - automated peritoneal dialysis treatments) using one (1) 1.5% dialysate solution and one 2.5% dialysate solution for a total of four (4) exchanges (the instillation, dwell, and draining of dialysate solution) over a seven (7) hour and twenty (20) minute treatment. Review of Patient #3’s treatment sheets dated 10/1/24 through 1/8/25 failed to identify the concentration of dialysate used with treatments on various dates. Interview with Staff Person #6 on 2/5/25 at 1:05 PM identified facility practice was to review patient’s peritoneal dialysis treatment flow sheets monthly. Staff Person #6 further identified the patient’s failure to complete the flowsheet properly to include the dialysate concentrations used and vitals prevented her from being able to verify the patient was completing their dialysis treatments in accordance with physician’s orders, especially when patients failed to bring in their treatment sheets for review. Staff Person #6 indicated patient’s on APD complete a written flow sheet (APD Record) in addition to the electronic treatment record to record blood pressures, dialysate concentration used, and total volume of fluid removal (ultrafiltration). Review of the CAPD Flowsheet Completion Sheet directs all sections of the flow sheet much be completed, which includes blood pressure, pulse, and dextrose concentration used with treatment.”

“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, facility documentation, facility policy and interviews, for one (1) of four (4) patients (Patient #2), review for hemodialysis treatments, the facility failed to ensure patient vitals were completed every thirty (30) minutes while receiving treatment in accordance with facility policy and for one (1) of three (3) patients (Patient #9), reviewed for treatment initiation, the facility failed to ensure pre-treatment heparin was administered in accordance with facility policy. The findings include: 1. Patient #2 had diagnoses that included end stage renal disease. Review of physician’s orders directed to in-center hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes each treatment with a 3.0 potassium/2.5 calcium bath, a blood flow rate (BFR) administered at 350 and dialysate flow rate (DFR) administered at 600, and using an arteriovenous graft in the right forearm. Review of Patient #2’s treatment sheets identified the following: a. The 1/11/25 treatment sheet failed to identify vitals were collected/documented between 6:45 AM and 7:30 AM. b. The 1/18/2025 treatment sheet failed to identify vitals were collected/documented between 9:30 AM and 10:35 AM. Interview with the Nurse Manager on 2/5/25 at 12:36 PM identified vitals should be documented/collected at least every thirty (30) minutes while the patient is receiving treatment. Review of the Intradialytic Patient Assessment and Monitoring policy directed blood pressures, vascular access, heart rate, volume status, level of consciousness, and subjective response will be assessed/monitored/evaluated at least every thirty (30) minutes during treatment and documented. 2. Patient #9 was admitted to the facility with diagnosis that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right jugular central venous catheter (CVC) and 3,000 heparin loading lose. Observation conducted on 2/5/25 at 11:13 AM identified Staff Person #3 performing catheter initiation for hemodialysis treatment. At 11:20 AM Patient #9’s loading dose of heparin was administered. At 11:21 AM treatment was initiated without the benefit of waiting three (3) to five (5) minutes per facility policy. Interview with the Clinical Educator on 2/5/25 at 12:30 PM identified heparin needs to dwell at least three (3) to five (5) minutes before treatment is initiated. Review of the catheter initiation and termination for hemodialysis policy directed to allow the patient to become systematically heparinized for at least 3 - 5 minutes before the initiation of dialysis. 47491”