Herald Square Dialysis LLC

“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: 44675 Based on observation, clinical record review, interview, and review of facility policy, the facility failed to clean and disinfect the hemodialysis station after hemodialysis treatment per facility policy. The finding included: Observation conducted on 6/11/24 at 10:47 AM identified Staff Person #1 was cleaning and disinfecting hemodialysis station #9 after a patient treatment. Staff Person #1 failed to clean and disinfect the sharps container attached to the right side of the hemodialysis machine. Staff Person #1 failed to place the hemodialysis chair supine during cleaning and disinfection of the hemodialysis chair. Review of the cleaning and disinfection of equipment, supplies and treatment area policy directed all routinely touched reusable equipment and surfaces in each patient’s treatment area must be disinfected after each patient’s treatment. This includes, but is not limited to the dialysis machine and chair. Dialysis chairs will be reclined, and all areas inspected and disinfected where blood could accumulate and not be readily noticed.”

“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 a documentation review on 06/10/24 at 11:00 AM, 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: 1. During a documentation review, the surveyor was not provided with documentation from the Bio Medical Technician or the Facility Administrator (FA). The following are violations: a. 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. b. The facility failed to provide documentation to indicate that the fire department connections had been hydrostatically tested as required by table 5.1.1.2 of NFPA 25,” Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems”; i.e., there are records in sprinkler inspection reports of the fire department connection being hydrostatically tested. c. The facility failed to provide documentation to indicate that the fire dampers have been inspected in accordance with NFPA 90A,” Standard for the Installation of Air Conditioning and Ventilation Systems”, as required by the 2012 Edition of the “Life Safety Code”. d. The facility did not ensure that the generator was installed and maintained in accordance with NFPA 70 “National Electrical Code” and Section 8.3 of NFPA 110 “Standard for Emergency and Standby Power Systems” of the 2012 Edition of the NFPA 99 “Health Care Facility’s” as required by section 6.4.4.1.1.3. i.e., The facility failed to produce paperwork to indicate that a level 2 service was conducted within the past 12 months.”

“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 three (3) hemodialysis patients reviewed for blood fluid balance, (Patient #7), the facility failed to address an abnormal blood pressures post hemodialysis treatment. The findings include the following: 1. Patient #7 had diagnoses that included end stage renal disease. Patient #7’s physician’s orders included hemodialysis treatment three (3) times a week for three (3) hours and fifteen (15) minutes with a left upper arteriovenous graft (AVG), 2.0 K 2.5 Ca dialysate, 300 blood flow rate (BFR), 800 dialysate flow rate (DFR) and an Estimated Dry Weight (EDW) of 74.5 kilograms. Review of the annual plan of care dated 4/30/24 identified Patient #7 was stable. Patient #7’s blood pressure care plan identified the desired parameters for systolic blood pressure were below 160 and above 110 post dialysis. Review of Patient #7’s hemodialysis flowsheets identified the following: 1. On 5/20/24 Patient #7’s post treatment blood pressure sitting was 181/113 and standing was 194/114. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 2. On 5/22/24 Patient #7’s post treatment blood pressure sitting was 166/109 and standing was 188/118. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 3. On 5/27/24 Patient #7’s post treatment blood pressure sitting was 161/115 and standing was 197/123. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 4. On 5/31/24 Patient #7’s post treatment blood pressure sitting was 199/83 and standing was 179/113. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 5. On 6/3/24 Patient #7’s post treatment blood pressure sitting was 183/120 and standing was 156/101. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 6. On 6/5/24 Patient #7’s post treatment sitting blood pressure was 187/106. There was no documented standing blood pressure. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). 7. On 6/10/24 Patient #7’s post treatment blood pressure sitting was 198/124 and standing was 186/108. The nursing assessment failed to identify if the physician was notified of Patient #7’s abnormal post treatment blood pressure and interventions (if any). Interview with MD #1 on 6/12/24 at 12:44 PM identified Patient #7 has a history of not being compliant with prescribed treatments including missing treatments and shortening treatments. He identified he would want to know if a patient’s blood pressure is elevated post treatment. He identified interventions that could be utilized for Patient #7 would be encouraging the patient to complete the full treatment, reschedule missed treatments and try to get fluid volume off as Patient #7’s blood pressures decrease with removal of fluid. Review of the charge nurse notification protocol identified to report to the charge nurse post treatment blood pressure systolic >160 and/or diastolic >100. It further directed to always report any complaints or unusual signs and symptoms to the nurse and document that the nurse was notified. Review of the patient assessment pre and post dialysis policy directed that the nurse responsible for the patient will be immediately notified whenever the patient’s vital signs are not within normal limits for that patient or reach any alert values.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. 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 access assessment (Patient #4), the facility failed to assess and document for signs and symptoms of infection and patency of a patient’s revised access per facility policy. The findings include the following: 1. Patient #4 was admitted to the facility with diagnoses that included end stage renal disease. Patient #4’s physician orders included hemodialysis treatment three (3) times a week for four(4) hours, 3.0 K 2.5 Ca dialysate, 400 blood flow rate (BFR), 500 dialysate flow rate (DFR) and an estimated dry weight (EDW) of 97.2 kg. Patient #4 had an arteriovenous fistula (AVF) placed 1/1/15. Nursing note dated 5/6/24 at 3:49 PM identified Patient #4 had recurrent bleeding from a non-healing wound on the AVF and the physician was notified. A referral was sent to the access center and Patient #4 was scheduled for an access revision on 5/6/24. Review of Patient #4’s access list identified a right internal jugular Central Venous Catheter (CVC) was placed on 5/7/24. Review of Patient #4’s hemodialysis treatment sheets dated 5/10/24, 5/13/24, 5/15/24, 5/17/24, 5/20/24, 5/22/24, 5/24/24 and 5/27/24 identified Patient #4’s CVC was being utilized for hemodialysis treatments. Patient #4’s AVF was listed on the flowsheets however, was not assessed for patency including checking for bruit and thrill and for signs and symptoms of infection. The nursing assessments failed to identify Patient #4’s AVF was assessed for patency. Review of the nursing notes from 5/10/24 - 5/17/24 failed to identify Patient #4’s AVF was assessed for patency (positive thrill and bruit present) and signs/symptoms of infection. Interview with the Charge Nurse on 6/12/24 at 12:45 PM identified when a patient has two accesses, they are listed on the flowsheet and the AVF needs to be checked in order for the AVF assessment to be generated (where you would document thrill and bruit). She identified it was a newer teammate who had worked with Patient #4 between 5/10/24 - 5/27/24 and did not check Patient #4’s AVF box to document patency. Review of the patient assessment: pre and post dialysis directed pre and post dialysis assessment will include, but not be limited to assessment of the access; patency, signs of infection and access care provided.”

“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 observation, interview and review of facility policy for eight (8) of sixteen (16) Patients (Patient #2, #8, #9, #10, #11, #12, #13 and #14) the facility failed to ensure pre-drawn medications were appropriately labeled in accordance with facility policy, and for two (2) of two (2) Patients, (Patient #14 and #15), the facility failed to document administration and outcome of oxygen therapy. The finding included: 1. During the flash tour of the facility medication room on 6/10/24 at 9:30 AM the following medications dated 6/10/24 were drawn for second shift patients and failed to reflect initials of the staff member who drew the medications and the time drawn: a. Patient #2’s 1000 units of heparin bolus and lidocaine b. Patient #8’s 2 mg loperamide and 0.5 mcg calcitriol c. Patient #9’s 1000 units of heparin bolus d. Patient #10’s 2000 units of heparin bolus e. Patient #11’s 1000 units of heparin bolus f. Patient #12’s 1000 units of heparin bolus g. Patient #13’s 6000 units of heparin bolus h. Patient #14’s 10000 units of heparin bolus Review of the medication: handling, administration, storage and disposal policy directed any medication drawn up before the time it is to be administered shall be labeled with the date/time the medication was drawn up and the initials of the nurse who drew up the medication. 2. a. Patient #14 had diagnoses that included end stage renal disease. Patient #14’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes with a right internal jugular central venous catheter (CVC), 2.0 K 2.0 Ca dialysate, 350 blood flow rate (BFR), 500 dialysate flow rate (DFR) and an estimated dry weight (EDW) of 86.5 kilograms (kg). Observation conducted on 6/11/24 at 12:00 PM of Station #14 Machine #6 identified Patient #14 receiving hemodialysis treatment with 2 liters of oxygen via nasal cannula. Review of Patient #14’s physician standing/initial orders dated 2/28/24 directed to administer oxygen 2 liters per minute via nasal cannula as needed for shortness of breath, hypotension and/or chest pain, and to notify the physician. Review of Patient #14’s hemodialysis flowsheet dated 6/11/24 identified Patient #14’s pre treatment assessment was performed at 11:00 AM and identified Patient #14 was not short of breath and failed to identify why Patient #14 was administered oxygen. Review of the medications given during dialysis failed to identify and order for oxygen and that oxygen was administered, the amount, the reason and outcome. The post assessment was performed at 2:15 PM and identified Patient #14 was not short of breath. The pre and post nursing assessment’s failed to identify why Patient #14 was administered oxygen, the outcome and if the physician was notified per standing orders. b. Patient #15 had diagnoses that included end stage renal disease. Patient #14’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours with a left upper arm arteriovenous fistula (AVF), 2.0 K 2.5 Ca dialysate, 300 blood flow rate (BFR), 500 dialysate flow rate (DFR) and an estimated dry weight (EDW) of 91 kg. Observation conducted on 6/11/24 at 12:04 PM of Station #4 Machine #16 identified Patient #15 receiving hemodialysis treatment with two (2) liters of oxygen via nasal cannula. Review of Patient #15’s physician standing/initial orders dated 1/10/23 directed to administer oxygen two (2) liters per minute via nasal cannula as needed for shortness of breath, hypotension and/or chest pain and to notify the physician. Review of Patient #15’s hemodialysis flowsheet dated 6/11/24 identified Patient #15’s pre treatment assessment was performed at 10:25 AM and identified Patient #15 was short of breath and failed to identify why Patient #15 was administered oxygen. Review of the medications given during dialysis failed to identify and order for oxygen and that oxygen was administered, the amount, the reason and outcome. The post assessment was performed at 1:30 PM and identified Patient #15 was not short of breath. The pre and post nursing assessment’s failed to identify why Patient #15 was administered oxygen, the outcome and if the physician was notified per standing orders. Interview with the Clinical Manager on 6/12/24 at 11:00 PM identified oxygen is a medication, therefore needs a physician order, documentation of administration and outcome. She identified an in-service was initiated on 6/12/24 to educate staff that all medications, including oxygen, must be administered only with a physician’s order and justified as to why the medication is being administered, if a patient requires continuous oxygen, there must be a separate physician order to administer oxygen each treatment and justification for continuous oxygen, if oxygen is administered as an as needed order, if must only be given for the reason identified on the order (i.e. shortness of breath) and if the issue persists the physician must be notified, if the nurse completes the pre-treatment assessment and the patient does not complain of shortness of breath the as needed order for oxygen should not be administered and if the patient no longer requires oxygen, the physician must be notified for further evaluation. Although requested, the Clinical manager identified the facility does not have an oxygen policy and procedure. Review of the charge nurse notification protocol identified to report to the charge nurse pre, intra and post treatment complaints of shortness of breathe/dyspnea.”