Usrc Branford Dialysis

“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 observation and review of clinical policy, the facility failed to disinfect a dialysis station in accordance with facility policy. The findings included: Observation on 5/17/24 at 10:22 AM identified RN #1 failed to clean the outer sides of the dialysis chair arms, the tubing extending from the front of the dialysis machine, the tubing attached to the dialysate connectors, the blood pressure cuff basket, and the back counter. Review of the Disinfection and Cleaning of Dialysis Machine Equipment policy directs to clean all external surfaces of the dialysis machine to include top, sides, front and back, blood pressure cuffs and basket, dialysate connectors and lines; hand sanitizer and holder; intravenous pole, items hanging on the pole, attached computer monitors and keyboard/mouse.”

“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 and facility policy for one (1) of five (5) patients reviewed for vaccination status (Patient #4), the facility failed to monitor hepatitis B surface antigen levels for a Hepatitis susceptible patient. The findings included: Patient # 4 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous fistula dialysis access. Review of Patient #4’s lab work dated 3/12/24 identified a negative hepatitis B surface antigen level and a hepatitis B antibody level of less than 4 (which indicated the patient was susceptible to the hepatitis B virus). Review of Patient #4’s April 2024 lab work and interview with the Clinical Nurse Manager on 5/20/24 at 1:05 PM failed to identify a hepatitis B surface antigen level was drawn at all during the month of April. The Clinical Nurse Manager further indicated the hepatitis B surface antigen was to be tested monthly until the patient became immune or was non-susceptible. Review of the Hepatitis B Testing, Vaccination, and Seroconversion policy directed to obtain hepatitis B surface antigen levels monthly for hepatitis B susceptible patients, which included patients with hepatitis B antibody levels of less than 10.”

“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 observations during the inital tour identified the facility failed to ensure a sanitaryand homelike environment. The findings include: On 05/21/24 at 9:30 AM while accompanied by the facility Bio Med Technician and the Facility Administrator (FA) the surveyor observed holes in the wall on the treatment floor where a glove dispenser had been removed.”

“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 review of facility documentation the facility failed to maintain a building that was constructed and maintained to ensure the safety of the patients, the staff and the public. The findings include the following: a. The facility failed to provide documentation to indicate that there was a fuel analysis completed on the emergency generator’s fuel supply within the past year as required by Section 8.3.8 of the 2010 edition of NFPA 110. b. The facility failed to provide documentation to indicate that there was a level 2 (Major PM) completed within the past year as required by NFPA 70 “National Electrical Code” and Section 8.3 of NFPA 110 “Standard for Emergency and Standby Power Systems” and Section 6.4.4.1.1.3 of the 2012 Edition of NFPA 99 “Health Care Facility’s.” c. The facility failed to provide documentation to indicate that there was a load bank test completed within the past year as required by Section 8.4.3.2 of NFPA 110, “Standard for Emergency and Standby Power Systems d. The facility failed to provide documentation to indicate that there was a sensitivity test completed within the past two years as required by Section 14.4.5.3.2 of NFPA 72 and section 9.6.1.3 of the 2012 edition of the “Life Safety Code” standard.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of three (3) hemodialysis patients reviewed for prescription, (Patient #6), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: Patient #6’s diagnoses included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a dialysate flow rate (DFR) of 700. Review of Patient #6’s treatment flowsheets identified the following: 1. On 4/19/24 Patient #6’s Dialysis Flow Rate (DFR) during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. 2. On 4/24/24 Patient #6’s DFR during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. 3. On 5/3/24 Patient #6’s DFR during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. 4. On 5/10/24 Patient #6’s DFR during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. 5. On 5/13/24 Patient #6’s DFR during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. 6. On 5/15/24 Patient #6’s DFR during treatment was administered at 600 with no rationale as to why the prescribed DFR of 700 was not met. Interview and record review with Facility Administrator #3 on 5/20/24 at 1:14 PM identified that Patient #6’s DFR was increased in February. Patient #6’s Kt/V was 1.24 in February and the physician could have increased the DFR to get better Kt/V result for Patient #6. Review of the intradialytic monitoring of patient policy directed every thirty minutes, the access and visualization of the face must be observed and the delivery of the dialysis prescription. It further directed to modify the treatment plan based on the patient’s response, which must be documented by the charge nurse.”

“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 review of clinical records and facility policy for two (2) of six (6) residents reviewed for intradylialitic blood pressures (Patient #4 and Patient #5), the facility failed to administer standing order blood pressure medication when the patient’s systolic blood pressures reached greater than 180 millimeters of mercury (mm/Hg). The findings included: 1. Patient #4 had end stage renal disease, required hemodialysis treatment three times weekly, and had a left upper arm arteriovenous fistula dialysis access. Review of a hemodialysis flow sheet dated 4/24/24 identified Patient #4 had an elevated systolic blood pressures of greater than 180 for one and one half hours during treatment. 2. Patient #5 had end stage renal disease, required hemodialysis treatment three times weekly, and had a left upper arm arteriovenous fistula dialysis access. Review of a hemodialysis flow sheet dated 1/8/24 identified Patient #5 had elevated systolic blood pressures of greater than 180 for one and one half hours during treatment. Interview with the Charge Nurse on 5/17/24 at 2:10 PM identified there is a facility protocol for all patients to administer Clonidine 0.1 mg to patients with sustained systolic blood pressures of greater than 180 for a minimum of one hour. The Charge Nurse further indicated it was the nurse’s decision to offer Clonidine and may withhold a dose if the patient had forgotten to take their blood pressure medication prior to dialysis treatment and informed they would take it following treatment. Further review of the hemodialysis flowsheets failed to indicate if this discussion occurred between the nurse and patient or if Patient #4 and Patient #5 had missed their blood pressure medications on the dates stated above. Review of Hemodialysis Standing Orders policy identified the administration of Clonidine 0.1 mg by mouth as needed for systolic blood pressure of greater than 180.”

“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: 47491 Based on review of clinical records and policy for one (2) of two (2) patients reviewed for anemia (Patient #5), the facility failed to prescribe iron supplementation per protocol for a patient who is anemic. The findings included: Patient #5 had end stage renal disease, required hemodialysis three times weekly, and had a left upper arm arteriovenous fistula dialysis access. Review of Patient #5’s lab results dated 12/18/23 to 1/10/24 indicated hemoglobin levels of 6.1 grams per deciliter (g/dl) to 9.1. g/dl (goal for dialysis patients is 10 g/dl) Review of Patient #5’s lab results dated 12/18/24 identified a ferritin level (iron store) of 199 and an iron saturation level of 18%. Review of physician’s orders dated 12/18/23 to directed to administer 20,000 units of epogen (a medication utilized to stimulate red blood cell production) three times weekly, however, failed to indicate an order for venofer (iron supplementation). Interview with the Regional Nurse Manager on 5/20/24 at 12:50 PM identified Resident #5, a transient, was never ordered venofer upon his/her return to the facility from 12/18/23 to 1/10/24, that it was the anemia manager’s responsibility to review ferritin and iron saturation levels to determine venofer doses and frequency, and was unable to state why this didn’t occur. The Regional Nurse Manager further identified it was policy to follow the iron protocol, especially when a patient was prescribed epogen. Review of the Iron Protocol and Administration policy directed to administer a bolus dose of venofer (100 mg of venofer per treatment for ten treatments) for ferritin levels less than 200 and iron saturation levels less than 20%.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 44675 Based on clinical record review, interview and review of facility policy for one (1) of three (3) Patients , (Patient #1), reviewed for care plans, the facility failed to initiate and complete an unstable care plan following an extended hospitalization in accordance with facility policy. The finding included: Patient #1 was admitted to the facility with diagnoses that included end stage renal disease. Patient #1’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours, with 2.0 K 2.5 Ca dialysate and an estimated dry weight (EDW) of 42 kg. Review of Patient #1’s annual care plan dated 10/25/23 identified Patient #1 was stable. Review of the hospital discharge summary dated 3/23/24 identified Patient #1 was admitted to the hospital on 3/7/24 with the primary diagnosis of abdominal pain secondary to diverticulitis, right sided hernia and anemia secondary to hemorrhage and was discharged on 3/23/24 (17 days). Review of Patient #1’s medical records identified an unstable care plan was not initiated and completed following Patient #1’s hospitalization greater than 15 days. Interview and record review with FA #3 on 5/17/24 at 12:19 PM identified Patient #1 did not have an unstable care plan completed after Patient #1’s hospitalization and should have been triggered by the dietician who is responsible for triggering care plans. Interview with the Dietician on 5/20/24 at 12:07 PM identified she is responsible for the scheduling of care plans. She identified she must have missed triggering Patient #1’s care plan after his/her extended hospitalization. She further identified a care plan should have been triggered for a hospitalization greater than 15 days. Review of the comprehensive interdisciplinary patient assessment/plan of care policy, in part, identified unstable patients are defined by the governing body to include extended hospitalizations; hospitalization longer than 15 days. The policy directed unstable patient care plans are to be completed monthly.”

“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 observations, interviews and policy review, the facility failed to discard of expired medications, and based on review of clinical records and facility policy for one (1) of six (6) sampled patients (Patient #2) reviewed dialysis treatments, the facility failed to follow physician’s treatment orders and address abnormal findings with the licensed nurse. The findings included: 1. a. Observation on 5/17/24 at 9:10 AM identified Nine boxes of Lidocaine 2.5% and Prilocaine 2.5% Cream. Six boxes had an expiration date of 10/23 , an expiration date of 12/23 on one box, and the 3 other boxes expiration dates of February and April of 2024. b. Two (2) milliter vials of sodium chloride with an expiration date of 6/23. c. Three (3) intravenous administration sets with an expiration dates of 9/22 and 12/4/23. Interview with the Charge Nurse on 5/17/24 at 9:50 AM identified the facility should discard of expired medications once the expiration date had been reached, the medication room was rarely utilized as medications were kept on the floor in locked cabinets and inventory of medications in the medication room was missed. Review of the Disposal of Medications policy directed staff would ensure proper disposal of all expired and prescription medications. 2. Patient #2 was admitted to the facility with diagnoses that included end stage renal disease. Patient #2’s physician orders included hemodialysis treatment three times a week for three hours(3) and forty five (45) minutes, 2.0 K 2.5 Ca dialysate, and blood flow rate of 400. Review of Patient #6’s hemodialysis flowsheets identified the following: a. On 5/6/24 Patient #2’s pre-treatment blood pressure sitting was 188/100 and standing 188/118. Treatment was started at 2:51 PM by a Certified Clinical Hemodialysis Technician (CCHT) and the nursing assessment was conducted at 3:14 PM. The flowsheet failed to identify if the nurse was notified prior to treatment initiation of Patient #2’s elevated blood pressures. Patient #2’s post treatment blood pressure sitting was 218/107 and standing 237/114. The post treatment assessment failed to identify what interventions were put into place and if the physician was notified of Patient #2’s elevated blood pressures. Review of Patient #2’s progress notes failed to identify a progress note of Patient #2’s elevated blood pressures and interventions, if any. b. On 5/15/24 Patient #2’s pre-treatment blood pressure sitting was 185/110 and standing 174/104. Treatment was started at 12:18 PM by a CCHT and the nursing assessment was conducted at 3:59 PM by the Charge Nurse (CN). The flowsheet failed to identify if the nurse was notified prior to treatment initiation of Patient #2’s elevated blood pressures. Interview with the CN on 5/20/24 at 1:00 PM identified her documentation of Patient #2’s assessment on 5/15/24 was late and the assessment was completed within the hour of treatment initiation, but not prior to treatment initiation. Review of the pre-treatment assessment of patient policy identified any data outside of the acceptable facility/patient parameters will be reported to the charge nurse prior to treatment initiation. It further directed to compare the data to previous findings and notify the physician of any significant changes or problems. Review of the reportable parameters to CN policy directed pre treatment report to the CN blood pressure systolic greater than 180. It directed the nurse must complete an assessment before treatment if the blood pressure systolic is greater than 180. Post treatment report to the CN blood pressure systolic greater than 180.”