Dci - Manchester 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: 44675 Based on observation, interview and review of facility policy, the facility failed to ensure the facility was maintained in a sanitary, clean environment in accordance with facility policy. The findings included: Observations conducted on 3/10/25 at 9:30 AM of the clinic floor POD A identified the following: 1. Station’s #3, # 4, #5, #6 and #8 wallbox (contains connections for the dialysis machine to receive acid and base concentrations, treated water and dispose of waste products) had a clear label that identified bicarb and water that was peeling up and had yellow/white crusted buildup throughout the label. The screws holding the acid labels were rusted. 2. Crack along the wall facing the entrance and crack along the wall of the clean sink. Observations conducted on 3/10/25 at 9:40 AM of the clinic floor POD B identified the following: 3. Station’s #11, #12, #13, #14 and #17’s wallbox had a clear label that identified bicarb and water that was peeling up and had yellow/white crusted buildup throughout the label. The screws holding the acid labels were rusted. 4. Crack along the wall of the clean sink. 5. Two supply carts with rusted wheels/bottoms of the carts. 6. Tape residue throughout the counters. Observations conducted on 3/10/25 at 9:50 AM of the clinic floor POD C identified the following: 8. Station’s #21, #24 and #25’s wallbox had a clear label that identified bicarb and water that was peeling up and had yellow/white crusted buildup throughout the label. The screws holding the acid labels were rusted. 9. Cracks along the wall of nursing station. Interview and observation with the Area Operations Manager on 3/11/25 at 3:11 PM identified that some of the screws on the wallboxes are rusted and need to be replaced. He identified the stickers on the wallboxes were placed by the manufacture and he will work on a plan to get them in sanitary condition. He further identified there was a crack previously in one of the nursing stations that was repaired but was not aware of the cracks identified on survey.”

“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, reviewed for hand hygiene, the facility failed to ensure a patient was offered hand hygiene after holding their access site and removing gloves. The findings include: 1. Patient #11 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 forearm arteriovenous fistula (AVF). Observations conducted on 3/12/25 at 10:20 AM identified Patient #6 holding his/her dialysis access without a glove on. At 10:32 AM Patient #6’s access was taped by Staff Member #3 and hand hygiene was not offered and/or performed. 2. Patient #12 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for (4) hours with a left forearm arteriovenous graft (AVG). Observations conducted on 3/12/25 at 10:30 AM identified Patient #12 holding his/her dialysis with a glove. At 10:50 AM Patient #12’s access was taped by Staff Member #3. Patient #12 removed his/her gloves and hand hygiene was not offered and/or performed. Review of the patient education on hand washing policy directed that staff should remind patients to perform hand washing to be done after a patient holds their access site and after removing gloves.”

“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: 47491 Based on observations and policy review, the facility failed to ensure adequate disinfection of the dialysis station in between patient use. The findings included: a) Observation on 3/12/25 at 10:40 AM of the disinfection of Station # 24 identified that the Hansen tubing on the side of the machine, IV pole, left side of the machine (closest to the patient’s chair), and both the outer sides of the patient’s chair (under the side tables), were not disinfected following a patient’s treatment. b) Observation on 3/12/25 at 10:50 AM of the disinfection of Station #20 failed to identify that the chair was extended when disinfected and that both outer sides of the patient’s chair (under the side tables) were not disinfected following a patient’s treatment. c) Observation on 3/12/25 at 10:53 AM of the disinfection of Station #21 failed to identify that the Hansen tubing, part of the side of the machine the Hansen tubing was located on, and outer sides of the patient’s chair (under the side tables) were disinfected following a patient’s treatment. Review of the Surface Cleaning and Disinfection in the Dialysis Setting policy directs the outside of the dialysis machine, chair, BP cuff and clamps (any ancillary equipment used) will be disinfected with (Bleach 1:100 water solution) after each patient use.”

“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: 47491 Based on observation, interview, and review of facility policy for one (1) of three (3) patients (Patient #10) observed during turnover, the facility failed to ensure staff and patient masks were donned properly when performing exit site care and connecting treatment lines to a patient’s Central Venous Catheter (CVC). The findings included: Patient #10 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and forty-five (45) minutes per treatment utilizing a central venous catheter (CVC). Observation conducted on 3/12/24 at 11:23 AM identified Staff Person #1 initiating Patient #10’s dialysis treatment. Staff Person #1 uncapped each limb CVC and applied a syringe to each end to extract the instilled heparin from the last treatment, instilled heparin into the venous limb of the CVC, removed the bandage from the CVC exit site, performed exit site care, and redressed the exit site all with Staff Person #1’s mask and the patient’s mask only covering their mouths. Interview with the Clinical Manager on 3/12/25 at 1:55 PM identified a face mask was to be worn by both staff and the patient when initiating dialysis treatment with a CVC, when performing exit site care, and should cover both their nose and mouth. Review of the Tunneled Catheter: Routine Care and Dressing Change policy directed to apply a facemask to both staff and the patient to decrease the risk of infection, Review of the Catheter Initiation and Termination for Hemodialysis policy directed to staff to apply a surgical mask on themselves, the patient, and anyone else close to the catheter during the procedure to decrease the risk of infection.”

“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: 47491 Based on clinical record review, interview, and review of facility documentation and policy for two (2) of five (5) patients (Patient #5 and Patient #8) reviewed for hemodialysis prescriptions, the facility failed to ensure a patient’ treatments were administered in accordance with physician’s orders. The finding included: 1. Patient #5 with an admission date of 12/14/24 had diagnoses that included end stage renal disease. A physician’s order directed hemodialysis treatments three (3) times weekly for four (4) hours with a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, a dialysate flow rate (DFR) of 800, using a left upper arm Arteriovenous Fistula (AVF). Review of Patient #5’s dialysis treatment records identified the following: a. On 2/18/25, Patient #5’s treatment was administered at a DFR of 600 throughout treatment rather than at the physician’s ordered DFR of 800 without documenting the reason the prescribed DFR was not attained. b. On 2/20/25, Patient #5’s treatment was administered at a DFR of 600 for one (1) hour and fifty-five (55) minutes of treatment without documenting the reason the prescribed DFR was not attained. c. On 2/22/25, Patient #5’s treatment was administered at a DFR of 600 throughout treatment rather than at the physician’s ordered DFR of 800 without documenting the reason the prescribed DFR was not attained. d. On 3/4/25, Patient #5’s treatment was administered at a DFR of 600 throughout treatment rather than at the physician’s ordered DFR of 800 and without documenting the reason the prescribed DFR was not attained. Interview with Clinical Manager 2 on 3/12/25 at 1:45 PM identified staff should be documenting why the ordered DFR was not being achieved and that the team leader should be informing the charge nurse when this occurs in order for him/her to review if this has been an ongoing issue and to inform the physician, if needed. The facility was unable to provide a policy regarding the management of dialysate flow rates. 2. Patient #8 had diagnoses that included end stage renal disease. A physician’s order dated 8/13/23 to present directed use of one (1) five (5) liter bag of 2.5% dialysate solution and one (1) five (5) liter bag of 1.5% dialysate solution with each treatment, a directive to use 1.5% dialysate solution when systolic blood pressure was less than 110, and if weight was two (2) kilograms above or below their estimated dry weight (85 kilograms from 8/25/23 to 2/12/25, 80 kilograms from 2/13/25 to 3/6/25, and 75 kilograms 3/7/25 to present day) to call the clinic or physician. Review of Patient #8’s treatment sheets dated October 1, 2024 through December 29, 2024, February 12, 2025 through February 28, 2025, and March 1, 2025 through March 9, 2025 identified Patient #8 had used two (2) 2.5% dialysate solution with each treatment. The documentation in the clinical record as to the reason why physician’s order was not followed, the reason for the change in dialysate concentrations used with each treatment, or updating physician’s order (or treatment parameters) as the patient was consistently using two (2) 2.5% dialysate solutions with each treatment. Interview with the Peritoneal Dialysis Nurse on 3/12/25 at 9:07 AM identified Patient #8 was not ultra filtrating (removing additional fluid with treatments) sufficiently, had failed to meet his/her adequacy goals, and was placed on two (2) 2.5% dialysate solutions with treatments to achieve this. However, the physician’s order was never updated to reflect this change and should have been adjusted to reflect what the patient was using/instructed to use for his/her dialysis treatments. The Peritoneal Dialysis Nurse further identified that changes to the patient’s prescription necessitated a change in the physician’s order, with the physician approving the change/signing off on the order, and this was missed. Review of the Daily Home Treatment Record policy directed the home training staff member to review the completed daily home treatment records to assist in evaluating the patient’s progress and self-care decision making process, which will assist staff in making changes to the plan of care if and when warranted or to focus retraining as needed.”

“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 clinical records, facility policy and interviews for one (1) of three (3) patients (Patient #4), reviewed for intradialytic assessments, the facility failed to ensure an abnormal vital sign was addressed with the physician per facility policy. Patient #4 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right internal jugular central venous catheter (CVC). Sample review of Patient #4’s hemodialysis flowsheets identified the following: a. On 3/6/25 at 12:30 PM Patient #4’s heart rate was 123 beats per minute (range 60 - 100 BPM) and at 12:31 PM Patient #4’s heart rate was 120 BPM. The medical record failed to identify that the physician was notified. b. On 2/22/25 at 2:01 PM Patient #4’s heart rate was 120 BPM, at 2:31 PM was 129 BPM, at 2:37 PM was 126 BPM, at 3:01 PM Was 120 BPM and at 3:06 PM (end of treatment) was 122 BPM. The flowsheets did not identify if the nurse was notified. The post treatment assessment at 4:07 PM identified Patient #4 was tachycardic. The medical record failed to identify that the physician was notified. Staff parameter reporting guidelines directed heart rate less than sixty (60) or greater than one hundred and twenty (120) require the PCT/LPN to notify the RN. The charge nurse is to notify the physician for a heart rate less than fifty (50) or greater than one hundred and twenty (120).”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of four (4) hemodialysis patients reviewed for anemia (Patient #6), the facility failed to draw a weekly and stat hemoglobin for a decrease in hemoglobin. The findings include the following: Patient #6 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and thirty (30) minutes with a left arteriovenous fistula (AVF) and an estimated dry weight (EDW) of 66.5 kg. A physician’s order dated 11/14/24 directed Mircera (increase red blood cell production) 300 mcg once a week. Review of Patient #6’s labs identified on 2/4/25 Patient #6’s hemoglobin was 7.2 and on 2/20/25 Patient #6’s hemoglobin was 7.1 (expected lab range 10-12). A nurse’s note dated 2/22/25 identified Patient #6’s hemoglobin was 7.1, the physician was notified and weekly hemoglobin’s are to be drawn. If Patient #6’s hemoglobin is less than 7, Patient #6 is to be referred to the emergency department for a transfusion. The stable care plan dated 2/25/25 identified Patient #6 had a low hemoglobin. Interventions included to assess for signs and symptoms of bleeding, monitor labs and ensure ESA (treats anemia) protocol is implemented. Review of Patient #6’s labs failed to identify a weekly hemoglobin was drawn the week on 2/23/25 - 3/1/25. Review of Patient #6’s labs identified on 3/4/25 Patient #6’s hemoglobin was 6.9. MD note dated 3/6/25 identified Patient #6 was seen on dialysis. She recommended a stat hemoglobin and possible transfusion at the emergency department today. Review of the hospital discharge summary dated 3/9/25 identified Patient #6 received a blood transfusion of one (1) unit of red blood cells. Interview with the CN on 3/11/25 at 2:00 PM identified Patient #6 had treatment on 2/27/24 but there was no order for a hemoglobin draw and a hemoglobin was not drawn. Review of the mircera protocol identified the target value for hemoglobin is 11.”

“PA-ASSESS RENAL BONE DISEASE CFR(s): 494.80(a)(5) The patient’s comprehensive assessment must include, but is not limited to, the following: (5) Evaluation of factors associated with renal bone disease. 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 nutrition (Patient #4), the facility failed draw a weekly calcium level in accordance with physician orders. The findings include the following: Patient #4 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for four (4) hours with a right internal jugular central venous catheter (CVC), dialysate of 2 K 2.5 Ca and an estimated dry weight (EDW) of 94 kg. The care plan dated 11/21/24 identified Patient #4’s uncorrected calcium (total amount of calcium in the blood) was outside of the range of 8 - 10.2. with interventions that included to monitor calcium trends and consult with the physician as needed. Review of Patient #4’s labs dated 11/21/24 identified a calcium level of 7.7 (goal 8 to 10.2). Review of Patient #4’s labs dated 12/10/24 identified a calcium level of 12.3. A dietician’s note dated 12/12/24 identified Patient #4’s labs dated 12/10/24 were reviewed with the charge nurse, physician and patient. Patient #4’s calcium increased from 7.7 to 12.3. The patient will have weekly calcium and phosphorous labs drawn in the month of December. A physician’s note dated 12/17/24 identified that the calcium was up to 12 so Clairol and calcium were stopped. Repeat calcium levels today (12/17/24). Review of Patient #4’s labs identified there was no physician’s order for calcium on 12/17/24, therefore was not drawn on 12/17/24. Review of Patient #4’s labs dated 12/26/24 identified a calcium level of 9.6. Interview with the Dietician on 3/12/25 at 9:01 AM identified she does not put in physician orders for lab draws. She identified it would have been the responsibility of the charge nurse to put in the orders for the weekly calcium draws beginning on 12/12/24.”

“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: 47491 Based on clinical record review, interview, and review of facility documentation and policy for one (1) of three (3) patients reviewed for vaccinations, the facility failed to ensure a patient was cleared for tuberculosis prior to admission to the facility and in accordance with facility policy. The finding included: Patient #5 with an admission date of 12/14/24 had diagnoses that included end stage renal disease. A physician’s order dated 3/12/25 directed hemodialysis treatments three (3) times weekly for four (4) hours with a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, a dialysate flow rate (DFR) of 800, using a left upper arm arteriovenous fistula (AVF). Review of Patient #5’s medical chart identified chest x-rays dated 9/16/23 were used to clear the resident of tuberculosis infection for admission to the facility, however, the x-ray used was eighty-nine (89) days past the one year limit the facility deemed acceptable for admission. Interview with the Clinical Manager on 3/12/25 at 2:00 PM identified the facility’s standard of practice was for the patient’s x-ray to be performed within one (1) year of admission to the facility to be accepted. The Clinical Manager further identified a chest x-ray older than one (1) year of the admission date should not be used and that another chest x-ray, Quantiferon blood test, or Tuberculosis Skin Test (TST) would need to be performed prior to admission to rule out tuberculosis (TB). The facility was unable to provide a policy regarding tuberculosis testing, however did provide a document specifying TB results within thirty (30) days or chest x-ray within one (1) year was required for admission to the facility.”