Davita Vernon Dialysis Center

“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: 47491 Based on observations, interviews, and review of facility policy for one (1) of three (3) patients, (Patient #10), reviewed for treatment termination, the facility failed to ensure the supplies used for the patient’s access remained clean. The findings included: Patient #10 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly with a right upper arm arteriovenous fistula (AVF; connection between an artery and a vein that is accessed for hemodialysis treatments). Observation conducted on 4/11/24 at 9:54 AM identified Staff Person #7 preparing to remove Patient #10’s access needles following dialysis treatment. Staff Person #7 had attached strips of tape (used to adhere gauze to the patient’s access sites) along the edge of the side table of Patient #10’s dialysis chair, but over extended the barrier strip of tape, causing the strips of tape to come into direct contact the side table and contaminating the tape. Interview with the Clinical Coordinator on 4/11/24 at 9:55 AM identified the strips of tape had come into direct contact with Patient #10’s side table and should not be used to attach the bandage to Patient #10’s access for infection control purposes.”

“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: 32738 Based on observation, review of clinical records, interview, and policy review the facility failed to ensure appropriate hand hygiene after touching the hemodialysis machine was performed, ensure patient’s performed hand hygiene once hemodialysis was completed and prior to leaving the treatment floor and between tasks in accordance with facility policy. The findings include the following: a. Observation on 4/9/24 at 10:12 AM Patient #11 finished dialyzing at station #1 and was walked to the scale by a staff person, the staff person assisted the patient onto the scale and then assisted the patient to put h/her jacket on and then Patient #11 left the treatment floor without washing h/her hands or reminders from staff to wash h/her hands. b. Observation on 4/9/24 at 10:35 AM Patient #13 finished dialyzing at station #15, was assisted into a wheelchair by a staff person, brought to the scale and weighed and then brought into the lobby without washing h/her hands or reminders from the staff to wash h/her hands. c. Observation on 4/9/24 at 2:30 PM identified Patient #14 at Station #7 removing his/her glove after holding his/her needle sites following dialysis treatment and not being offered hand sanitizer by Staff Person #5. Furthermore, Patient #14 proceeded to the scale to obtain his/her post dialysis weight and left the clinic without performing hand hygiene or being offered hand sanitizer. d. Observation on 4/9/24 at 2:32 PM identified Staff Person #6 discontinuing the dialysis treatment of Patient #15, who had an arteriovenous fistula, at Station #11. Staff Person #6 was observed removing the arterial needle from Patient #15, walking the needle to discard of it in the sharps container, pushing the sharps container with his/her gloved hand to Station #11, and then proceeding to remove the second needle from Patient #15’s access without changing his/her gloves and performing hand hygiene. Staff Person #6 was observed removing his/her gloves after removing the second needle and failed to perform hand hygiene before typing information into the computer and getting supplies from the clean storage closet. e. Observation on 4/9/24 at 2:36 PM identified Staff Person #6 removing his/her gloves and failing to perform hand hygiene after rinsing out the prime container and after removing the used dialysis set up from the dialysis machine from Station #11. f. Observations conducted on 4/11/24 at 8:25 AM identified Staff Person #3 walk into Station #15 where Patient #13 was currently having hemodialysis treatment and Patient #13’s machine was alarming. Staff Person #3 proceeded to take a glove wrapped around his finger and reset the machine without correctly applying the glove to his hands. Staff Person #3 exited Station #15 to the chairside keyboard next to Station #15 and proceeded to type without the benefit of hand hygiene. Staff Person #3 left the chairside keyboard without the benefit of hand hygiene. Review of the infection control policy identified that patients will wash their hands before leaving the treatment floor. Review of the infection control policy directed that all teammates and physicians will perform hand hygiene prior to gloving and immediately after removal of gloves, after patient and dialysis delivery system contact, between patients even if the contact is casual and before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47491 Based on observation, interviews and review of facility policy, the facility failed to ensure staff wore proper protective equipment when cannulating a hemodialysis patient per facility policy. The findings included: Patient #12 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly with a left upper arm arteriovenous fistula (AVF). Observations conducted on 4/11/24 at 10:45 AM identified the Clinical Coordinator cannulated (placed two needles into Patient #12’s AVF for hemodialysis treatment) without wearing a mask and goggles. Interview with the Clinical Coordinator on 4/11/24 at 10:47 AM indicated policy directed staff to wear proper protective personal equipment, including a gown, mask/face shield, and or goggles when cannulating a dialysis patient. The Clinical Coordinator further identified he/she cannulated the patient without thinking to apply personal protective equipment.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 32738 Based on observation, interview, and policy review, the facility failed to ensure that the dialysis station was disinfected in its entirety after use. The findings include: a. Observations of Station 1 on 4/9/24 at 10:43 AM identified that the staff member disinfected the hemodialysis machine, and left to tend to another patient. Another teammate came to station #1 and continued to disinfect the station however failed to disinfect the wall box, back of the station and the TV or TV arm. Review of the infection control for dialysis facilities policy identified surfaces to disinfect include but are not limited to all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel. It further directed the wall box, drain, and water supply lines are considered part of the dialysis delivery system and should be clean with 1:100 bleach as part of the routine station disinfection between each patient treatment. It further identified non-disposable items are to be disinfected after each patient use.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of three (3) hemodialysis patients reviewed for Hepatitis B status (Patient #5), the facility failed to ensure the patient’s offer and refusal of the Hepatitis B vaccine was documented in the medical record per facility policy. The findings include the following: Patient #5 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for four hours with a right upper arteriovenous graft (AVG). Review of Patient #5’s Hepatitis B antibodies dated 7/22/22 identified his/her antibodies were less than three (3) indicating that the patient was susceptible to the Hepatitis B virus. An Annual comprehensive plan of care dated 3/27/23 identified Patient #5 received a complete Hepatitis B vaccine series. However, interview with the Clinical Coordinator on 4/11/24 at 11:15 AM identified that was an error and that Patient #5 has not received a Hepatitis B vaccination series. Review of Patient #5’s medical record vaccinations notes failed to identify the Hepatitis B vaccine was offered to Patient #5 and that Patient #5 refused. Interview and record review with the Clinical Coordinator on 4/11/24 at 11:15 AM identified she discussed the hepatitis vaccine with Patient #5 and that he/she refused. She identified she failed to document Patient #5’s refusal. She further identified Patient #5 failed to have a vaccination consent form for the hepatitis vaccine in his/her chart. 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. It further directed that the patient is provided with the vaccination information sheet and a consent form. The patient will consent to the vaccination or will decline and the completed form will be kept in the patient’s medical record.”

“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 clinical record review, facility documentation, and policy review, the facility failed to ensure that infection control guidelines were in place during Central Venous Catheter (CVC) care. The findings in cluded: Patient #11 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Review of physician’s orders identified that the patient had a CVC in the right chest for hemodialysis access. Observation of Patient #11 on 4/9/24 at 10:56 AM identified Staff Person #1 disconnecting Patient #11 from the hemodialysis machine and providing care to the CVC, and although the Staff Person was wearing a mask, the mask was not covering her nose. Interview with Staff Person #1 on 4/9/24 at 11:06 AM identified that during CVC care the nurse should have her mouth and nose covered by a mask, however, she did not realize that her nose was not covered while providing CVC care.”

“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 04/09/24 at 9:30 AM while accompanied by the facility Bio-Med Technician, the facility failed to maintain a safe environment. The findings include the following: a) It was observed that there was trash on the ground around stations six (6) and seven (7), that were “ready” for patient treatment, not maintaining a safe and sanitary environment as required by the Public Health Code. b) It was observed that there was a black substance accumulating around the faucet handles on the “dirty sink” on the treatment floor, not maintaining a safe and sanitary environment as required by the Public Health Code. c) It was observed that there was a break in the floor near the scale area, not maintaining a safe and sanitary environment as required by the Public Health Code. d) It was observed that the return vents throughout the facility were loaded with dust and debris, not maintaining a safe and sanitary environment as required by the Public Health Code. e) It was observed that the vent in Home Training Room #2 was peeling, and a piece of the countertop was broken, not maintaining a safe and sanitary environment as required by the Public Health Code.”

“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 observation during tour on 04/09/24 at 9:30 AM while accompanied by the facility Bio-Med Technician, the facility failed to maintain a safe environment. The fire extinguisher on the loading dock had not been checked off for the month of March in 2024, not compliant to the requirements of the Public Health Code.”

“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: 32738 Based on a review of clinical records, interview, and policy review for four (4) of seven (7) hemodialysis patients reviewed for prescriptions (Patient #2, Patient #3, Patient #4 and Patient #13), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders and ensure the physician was contacted prior to a dialysate prescription change. The findings include the following: 1. Patient #2 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three hours and fifteen minutes with a blood flow rate (BFR) of 400. A review of Patient #2’s treatment flowsheets identified the following: a. On 2/28/24, 3/1/24, and 3/6/24 Patient #2’s BFR during treatment was 300 with no rationale as to why the prescribed BFR of 400 was not met. b. On 3/22/24 Patient #2’s treatment was initiated with a BFR of 390 and at 2:14 PM the BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. e. On 3/29/24 Patient #2’s treatment was initiated with a BFR of 400 and at 2:00 PM the BFR was decreased to 360 with no rationale as to why the prescribed BFR of 400 was not met. f. On 4/5/24 Patient #2’s BFR during treatment was 350 with no rationale as to why the prescribed BFR of 400 was not met. 2. Patient #4 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three hours and thirty minutes with a blood flow rate (BFR) of 400. A review of Patient #4’s treatment flowsheets identified the following: a. On 3/25/24 Patient #4’s treatment was initiated with a BFR of 400 and at 5:54 PM the BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. b. On 3/27/24 Patient #4’s BFR during treatment was 450 with no rationale as to why the prescribed BFR of 400 was exceeded. c. On 3/29/24 Patient #4’s treatment was initiated with a BFR of 400 and at 5:56 PM the BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. d. On 4/1/24 Patient #4’s BFR during treatment was 450 with no rationale as to why the prescribed BFR of 400 was exceeded. e. On 4/3/24 Patient #4’s treatment was initiated with a BFR of 400 and at 6:39 PM the BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. 3. Patient #3 had end stage renal disease, required hemodialysis treatments three times weekly, and utilized central venous catheter in the upper right chest. Physician’s orders directed a four hour and fifteen-minute dialysis treatment run at a blood flow rate of 400 milliliters (ml)/minute and dialysate flow rate of 800 ml/min. Review of Patient #3’s Treatment Reports identified a dialysate flow rate of 500 mil/min. during treatments on 3/6/24 and 3/8/24, and a blood flow rate of 350 millimeters/minute during treatments on 3/29/24 and 4/1/24 without justification noted for the change in the dialysate flow rate or blood flow rate. Interview with the Facility administrator on 4/11/24 at 8:25 AM identified the facility practice was to perform dialysis treatment per physician’s orders and if unable, to note the reason on the treatment record. Review of the pre-intra-post treatment data collection policy identified that the dialysis prescription will be administered in accordance with physician orders. Review of the pre-intra-post treatment data collection and monitoring and nursing assessment policy directed the physicians components are confirmed by a licensed nurse within one hour of treatment initiation and include the blood flow rate. It further identified if the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 4. Patient #13 had a diagnosis of end stage renal disease and required hemodialysis three times weekly. Review of the physician’s orders dated 4/4/24 directed that a 1 K (potassium) dialysate bath was ordered on 4/4/24 and then discontinued. A physician’s order dated 4/4/24 directed to administer a 2K 2.5 Ca (Calcium) dialysate for three hours and fifteen minutes. A dietician’s note dated 4/4/24 identified that the patient’s potassium level was elevated at 5.7 and the patient was placed on a 1 K bath. The dietician discussed the dangers of hyperkalemia with the patient as well as her nurse aide, also reviewed were foods that were high in potassium to avoid. Interview with the clinical coordinator on 4/11/24 at 10:00 AM identified that when she came in on 4/4/24 she noted that Patient #13 had a potassium of 5.7 and was dialyzing on a 1 K bath. She informed Staff Person #4 that there is a protocol that is in place that any potassium level above 6 requires a dialysate bath change to a 1K, and Patient #13 did not have a potassium level of above 6 and needed to be changed back to a 2 K bath. At that time the order was changed back to a 2K bath and Patient was taken off of the 1K bath and started back on the 2K bath. Interview Staff Person # 4 on 4/11/24 at 2:07 PM identified that she was the charge nurse on 4/4/24 and noted that Patient #13 had a potassium level of 5.7 (normal range is 3.5 to 5.5) and she changed the patients potassium bath to a 1K, however she did this without informing the physician. Staff Person #4 identified that when the CC came in at 7:00 AM she informed her that the potassium baths are not changed to 1K unless the potassium level is above 6, so the order was discontinued and changed back to a 2K bath. Interview with APRN #1 on 4/11/24 at 11:30 AM identified that the protocol is for any potassium level that is above 6.0 for the patient to be started on a 1K bath and it was not appropriate for Patient #13 to have been started on a 1K bath with a potassium of 5.7 without contacting the physician. Review of the low potassium dialysate policy identified that a low potassium dialysate less than 2 K will be initiated when a pre-dialysis potassium level is above 6.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 32738 Based on clinical record review, facility documentation, and interviews, for a patient that resided at a skilled nursing facility, (Patient #13), the facility failed to ensure that the dialysis dietician collaborated with the skilled nursing facility in regards to the patients dietary status. The findings include: 1. Patient #13 had a diagnosis of end stage renal disease and required hemodialysis three (3) times a week. a) A care plan dated 10/30/23 identified that the patient’s albumin level trends will move toward and remain within recommended and appropriate clinical ranges with interventions that included to provide ongoing nutritional related coaching. Review of a dietician’s monthly note dated 12/18/23-1/17/24 identified that that labs were placed in the Skilled Nursing Facility (SNF) dialysis binder. An email has been sent to the SNF dietician as she was back from leave with a copy of the patients labs and how patient has been doing on dialysis, awaiting return email from SNF dietician. The patients albumin in 3.6 and is not meeting goal, the patient is on ONS protocol and spoke with the patient about incorporating more proteins sources in h/her meals such as chicken, fish and eggs. Review of a dietician’s monthly progress note dated 2/18-3/19/24 identified that the patient reports a good appetite. The albumin level was noted to be 3.7 and was not meeting the goal, however, is increased from 3.5 from last month. The resident is on the oral nutritional supplement protocol. Dietician spoke with the patient regarding the importance of eating more protein such as eggs, chicken, turkey, and fish. b) A dietician’s note dated 4/4/24 identified that the patient’s potassium level was elevated at 5.7 and the patient was placed on a 1 K bath. The dietician discussed the dangers of hyperkalemia with the patient as well as her nurse aide, also reviewed were foods that were high in potassium to avoid. Interview with the dietician on 4/11/24 at 8:45 AM identified that she had not ever spoken to the dietician at the SNF in regards to the patients albumin or potassium levels. She stated that she has attempted calls to the SNF with no success, she also attempted to email and never received a response. She further identified that although the patient is cognitively impaired she has done dietary counseling with the patient to involve h/her in the plan of care. Additionally, the dietician has not reported to the dialysis center or the SNF that she has had difficulty reaching the dietician at the SNF to collaborate care. Review of the Provision of Nurtritional Services identified that the dietician will coordinate care with the extended care facilities when appropriate.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 32738 Based on a review of clinical records, interview, and policy review for 5 of 5 hemodialysis patients reviewed for psychosocial needs (Patient #2, #4, #5, #7, #13), the facility failed to ensure that quarterly social work assessments were completed in accordance with facility policy. The findings include the following: 1. Patient #2 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three hours and fifteen minutes with a right central venous catheter (CVC). Review of Patient #2’s progress notes identified a MSW quarterly progress note dated 3/23/23 but further failed to identify subsequent social worker quarterly progress notes until Patient #2’s comprehensive plan of care assessment was completed on 10/18/23. The progress notes failed to identify social worker quarterly progress notes subsequent to the plan of care assessment. 2. Patient #4 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three hours and thirty minutes with a left upper arteriovenous graft (AVG). Review of Patient #4’s progress notes identified a MSW quarterly progress note dated 8/31/23 but further failed to identify subsequent social worker quarterly progress notes until Patient #7’s comprehensive plan of care assessment was completed on 2/26/24. 3. Patient #5 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for four hours with a right upper arteriovenous graft (AVG). Review of Patient #5’s progress notes identified a MSW quarterly progress note dated 6/26/23 but further failed to identify subsequent social worker quarterly progress notes. 4. Patient #7 was admitted to the facility with diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three hours with a right upper arteriovenous fistula (AVF). Review of Patient #7’s progress notes identified a comprehensive assessment was completed on 10/27/23 and had fulfilled the need for a MSW progress note for that period. Review of the record failed to identify subsequent social worker quarterly progress notes. 5. Patient #13 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. Review of Patient #13’s progress notes identified the last MSW quarterly social work note was written on 10/23/23 but further failed to identify subsequent social worker quarterly assessments/progress notes. Interview with SW #2 (the facilities covering social worker) on 4/10/24 at 1:45 PM identified she was covering for this facility but was only working with patients over the phone. She identified she would call patients at home or when they were in the facility. She identified she was completing plan of care triggers, depression screens and assessments. She further identified she was not completing quarterly social worker notes and that this was agreed upon when she took the covering social worker role in July 2023. Interview with the Regional Operations Director on 4/10/24 at 1:55 PM identified there is a vacant position for a social worker at this facility and there was a social worker covering this facility from another facility. He identified the social worker was doing the majority of the work virtually but was not aware she was not coming into the facility at all. He identified he expect her to come into the facility at least once per month. He further identified the covering social worker would be responsible for the social workers duties including documenting quarterly social worker notes with the patients. Interview with FA #2 (Facility Administrator who oversees SW #2) on 4/10/24 at 2:00 PM identified she spoke with SW #2 on 6/30/23 to discuss the details of being the covering social worker for this facility. She identified SW #2 would not be able to provide in person services, only virtual and the plan was originally for it not to be long term. She identified they discussed and wrote down that the expectation would be to complete plan of care triggers, PAQ9, depression screenings and care plans. She identified they did not discuss completing quarterly progress notes. She further identified on 1/31/24 the FA reached out to FA #2 and SW #2 and asked how the quarterly progress notes were going and SW #2 told her she was not doing them and the expectation was not discussed with SW #2. Interview with the FA on 4/11/24 at 2:36 PM identified when SW #2 began covering for this clinic in July 2023, she was only able to provide services virtually. She identified she had asked her to come in the facility once a month but received no response. She identified she would have expected SW #2 to complete all the social duties, including quarterly social worker progress notes. She further identified she was not aware SW #2 was not completing quarterly social worker progress notes and was not aware SW #2 was under the impression she did not have to complete quarterly social worker progress notes. Review of the Social Worker I job description identified one of the essential duties and responsibilities of the social worker is to identify, assess and document psychosocial evaluations quarterly and annually and evaluate and monitor ongoing psychosocial issues and patient goals. Review of the social worker intervention and documentation requirements policy directed social worker progress notes are completed quarterly or more frequently as needed.”

“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: 32738 Based on clinical record review, facility documentation, policy review and interview, for one patient reviewed for peritoneal dialysis, (Patient #8), the facility failed to ensure that peritoneal dialysis treatment sheets were monitored to ensure the dialysate guidelines were followed per physician’s orders. The findings include: Patient #8 had end stage renal disease, required daily peritoneal dialysis treatments and had a peritoneal dialysis catheter in her lower abdomen. Review of Patient #8’s Personal Fluid Balance guidelines identified use of two 1.5% dialysate solution bags for weight of 150 lbs. or lower, use of one 1.5% dialysate solution and one 2.5% dialysate solution for weight between 150.1 lbs. and 157 lbs., use of two 2.5% dialysate solution bags for weight between 157 lbs. and 160 lbs., and use of one 2.5% dialysate solution and one 4.25% dialysate solution for weight of 160.1 lbs. and above. Review of Patient #8’s treatment report which lists patient’s weight, blood pressures, and dialysate solutions used with treatment identified 14 treatments completed in February 2024, 18 treatments completed in March 2024, and 7 treatments completed in April 2024 where the Fluid Balance guidelines were not followed and review of the correct use of dialysate concentrations per the Fluid Balance guidelines were not completed or documented by the peritoneal dialysis nurse. Interview with the Facility Administrator on 4/11/24 at 8:25 AM identified facility practice was to follow the physician’s orders and if unable to follow them, to document the reason orders were not followed.”

“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: 32738 Based on observation, interview and policy review, the facility failed to ensure that expired medical supplies and medications were discarded, and the emergency evacuation cart was secured in accordance with facility policy. The findings included: 1. Observations on 4/10/24 at 9:45 AM identified: a. The medication room identified thirty-nine (39) one-gram vials of Cefazolin with an expiration date of 3/2024 and a 100-count bottle of acetaminophen, 325 mg dose, with an illegible expiration date. b. Inspection of the supply cabinet located at the far end of pod three identified a full box of Microbial endcaps with an expiration date of 3/10/24. c. Inspection of the emergency cart identified eight (8) 30 ml syringes with an expiration date of 10/31/22 and four 5 ml syringes with an expiration date of 7/31/22. e.Observations of the “dirty cart” identified that there were 2 containers of blood leak strips with the expiration date of 2/28/22, and 1 container of blood leak strips with the expiration date of 3/31/24. The cart further identified a bottle of bleach with an expiration date of 4/3/24, with an open date of 4/8/24, and a “mess kit” containing germicidal disposable cloths dated 9/14/1999. Interview with the Clinical Coordinator on 4/9/24 at 9:36 AM identified expired supplies and medications should be disposed of, heparin syringes should not be prepared greater than 4 hours prior to use, and medications with illegible expiration dates should be disposed of. She further identified that it is the responsibility of the PCT’s and CCHT’s to remove expired items, however, she was unsure how often it should be done. Review of the Medication Policy directs all syringes prepared from multidose vials should be prepared and administered with a four hour period and expired medications to be removed from treatment and inventory areas and disposed of. Review of the medication policy identified that expiration dates will be checked monthly. 2. Observation and interview with the Clinical Coordinator on 4/9/24 at 10:20 AM identified the emergency cart was not appropriately locked. The Clinical Coordinator indicated the emergency cart should always be locked with the exception of monthly inventory checks and use. Review of the Emergency Equipment Checks policy directs the part of the emergency cart containing medications and other supplies will be sealed with a break away lock and was only to be opened in the event of an emergency or the replacement of an outdated item.”