Usrc North Haven Dialysis

“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 four (4) hemodialysis patients reviewed for hepatitis (Patient #6), the facility failed to ensure Hepatitis B antigens were drawn monthly and the Hepatitis vaccine was administered in according to the facility policy for a Hepatitis B susceptible patient. The findings include the following: Patient #6 was admitted to the clinic on 11/12/24 with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a right internal jugular Central Venous Catheter (CVC). Review of the bloodwork dated 11/12/24 identified Patient #6’s hepatitis B antibody (indicates immunity from Hepatitis B) was less than eight (8) (less than ten (10) indicates susceptibility for Hepatitis B virus). Patient #6’s Hepatitis B antigen (indicates past or present Hepatitis B infection) was negative. Patient #6 had no further Hepatitis antigens after 11/12/24 in his/her medical record. Patient Hepatitis B vaccine consent form dated 11/12/24 identified Patient #6 consented to receive the Hepatitis B vaccination series. Review of the energix vaccination (Hepatitis B vaccination) administration report identified Patient #6 received energix 40 micrograms on 12/5/24 and 3/7/25 (administration schedule was not followed in accordance with facility policy). Interview with the Facility Administrator on 4/2/25 at 2:30 PM identified Patient #6 was admitted to the facility as an acute kidney injury (AKI). When Patient #6 changed from AKI to ESRD in December 2024, all of Patient #6’s hepatitis orders were deleted. She identified although the Hepatitis audit is to be conducted monthly, the Hepatitis manager identified Patient #6’s Hepatitis orders were missing and put the next energix dose in for April 2025. The FA identified the Hepatitis vaccination is to be administered at 0 (first dose), 1 (next month following initial), 2 (second month following initial), and 6 months (six months after initial dose. Further the patient should have had antigen levels drawn monthly subsequent to the susceptible result on 11/12/24. Review of the patient hepatitis B testing/vaccination/seroconversion policy identified a patient with a Hepatitis B antibody less than ten (10) is susceptible of the hepatitis B virus. Patients who are susceptible are to have a monthly hepatitis B antigen drawn. Patients are to receive 40 mcg (total of four doses) within the first thirty (30) days of admission, then at months one (1), two (2) and six (6).”

“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 a review of clinical records, interview, and policy review for one (1) out of four (4) hemodialysis patients (Patient #2) reviewed for fluid balance, the facility failed to ensure the registered nurse was notified/patient was assessed for blood pressures that were out of range (greater than 200 systolic during treatment). The findings included the following: Patient #8 had diagnoses that included end stage renal disease. Physician’s orders directed to hemodialysis treatment three (3) times weekly for three (3) hours and thirty (30) minutes per treatment, with a 2.0 potassium/2.5 calcium bath, a blood flow rate of 450 and dialysate flow rate of autoflow 1.5, and utilizing a left upper arm Arteriovenous Graft (AVG). Review of Patient #8’s 3/19/25 treatment sheet identified intradialytic (during treatment) blood pressures of 200/75 at 11:31 AM, 215/84 at 12:34 PM, and 209/84 at 1:07 PM without notation that a registered nurse was informed of the elevation in blood pressure. Interview with the Facility Administrator on 4/2/25 at 2:18 PM identified the registered nurse should be notified of systolic blood pressures exceeding 200 during treatment to assess if antihypertensive medication needs to be administered or if any further intervention needs to occur. Review of the Reportable Parameter protocol directs intradialytic blood pressures above 200 to be reported to the charge nurse.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for two (2) of four (4) hemodialysis patients reviewed for assessments (Patient #6 and Patient #10), the facility failed to ensure the ninety-day care plan was completed after the initial care plan for a new admission in accordance with facility policy. The findings include the following: 1. Patient #6 was admitted to the clinic on 11/12/24 with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a right internal jugular Central Venous Catheter (CVC). Review of the initial care plan dated 12/12/24 identified Patient #6 transitioned from an acute kidney injury (AKI) to ESRD. Review of Patient #6’s care plan failed to identify a ninety (90) day care plan was completed following the initial care plan. 2. Patient #10 was admitted to the facility company on 10/22/24 with diagnoses that included ESRD. Patient #10’s first treatment in the facility was on 12/6/24. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right internal jugular central venous catheter (CVC). Review of the initial care plan identified it was completed on 11/8/24 in Patient #10’s ESRD admitting facility. The facility failed to complete a ninety (90) day assessment following the initial care plan. Interview with the Facility Administrator on 4/2/25 at 2:30 PM identified Patient #6 and Patient #10’s care plan were missed. She identified it was discovered during an internal survey preparation audit and they are on the schedule to be completed in April. She identified a follow up care plan is expected to be completed within ninety (90) days of the initial care plan. Review of the comprehensive assessment/plan of care policy directed comprehensive assessments are to be completed within three (3) months after the completion of the initial assessment. For transfer for in patients, if a stable comprehensive assessment was completed within the last twelve (12) months or per state regulations, is received from the transferring facility, complete the reassessment ninety (90) days from admission.”

“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 review of clinical records, interview, and review of facility documentation and records for one (1) of two (2) patients (Patient #11) reviewed for peritoneal dialysis treatments, the facility failed to ensure the patient was completing their peritoneal dialysis treatments in accordance with physician’s orders. The findings included: Patient #11 had diagnoses that included end stage renal disease. A physician’s order dated 12/18/24 directed peritoneal dialysis treatments five (5) times weekly, consisting of five (5) 2000 milliliter exchanges while using 1.5% dialysate solution over a nine (9) hour period. Review of January, February and March 2025 treatment sheets identified Patient #11 completed his/her dialysis treatments, however the dialysate solutions utilized with treatments was either one (1) 1.5% and one (1) 2.5% solution or two (2) 2.5% solutions (as compared to the 1.5% dialysate solutions ordered). Further review of Patient #11’s treatment orders failed to identify changes to physician’s orders or documentation reflecting the patient was directed to use alternate solutions with their treatments. Interview with the Peritoneal Dialysis Nurse on 4/1/25 at 1:45 PM identified Patient #11’s order stated that Patient #11 could utilize different solution concentrations with treatments to reach euvolemia (the proper amount of fluid in the body), however the order failed to list specific parameters in which alternate solutions (2.5% and/or 4.25%) were to be used. The Peritoneal Dialysis Nurse further identified he/she should have discussed alternate solution use with the physician and documented the instruction/updated the order given by the physician prior to directing Patient #1 on which solutions to use with treatments. Interview with the Facility Administrator for the Home Program on 4/2/25 at 2:00 PM identified any changes in a patient’s dialysis orders should first be discussed with the physician, changed/updated in patient’s dialysis order, and then electronically sent to the physician for a signature. Although requested, the facility did not have a policy regarding physician’s orders or changes to physician’s orders.”