Fkc Fox Run

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 22676 Based on observation, interview, and policy review, the facility failed to ensure that they kept items within the dialysis station dedicated to only one station for one of three survey days. This deficient practice had the potential to cause cross contamination resulting in increased infections for all 76 patients receiving in-center hemodialysis at the facility. Findings include: During an observation of the treatment floor on 10/02/24 at 11:45 AM, Charge Nurse 4 disposed of sharps and syringes used during the connection of a patient’s Central Venous Catheter (CVC) at station 2 in a sharps container that was mounted on the dialysis machine in station one. Patient (P) 1 was seated at station 1 and P1’s blood tubing was draped over the sharps container, which had the potential for cross contamination of the dialysis machine. During an interview on 10/02/24 at 11:45 AM, Clinic Manager 2 confirmed the above findings. He/She stated that they mounted the sharps containers only on every other dialysis machine. Review of the facility’s policy titled, “Cleaning and disinfecting the Dialysis Station” dated 09/05/24 indicated, “To prevent cross-contamination between patients, it is important that the previous patient completely vacate the station ...””

“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: 22676 Based on observation, interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure that the wall boxes (dispensing outlets) at 16 of 16 dialysis (Station 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) stations were clean and free of a build-up of a dark yellow substance. This deficient practice had the potential to cause bacteria to grow in the wall boxes and could potentially affect the 76 patients receiving in-center hemodialysis at the facility. Findings include: An observation of all wall boxes on 10/02/24 at 11:45 AM, revealed at Stations: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 a dark yellow sediment build-up on the bottom of the wall boxes. During an interview on 10/02/24 at 11:45 AM, Clinic Manager 2 confirmed the above findings. He/she stated the staff were supposed to clean the wall boxes daily. Review of the facility’s policy titled, “Cleaning and Disinfection of the Dialysis Station” dated 09/05/23 indicated, “Dialysis wall boxes and the area/wall around the wall box must be routinely cleaned at the end of each treatment day or immediately if splattered with blood. All surfaces shall be surface disinfected with 1:100 bleach solution. Special attention should be given, to removing build-up and/or cleaning splatter and spray of concentrate solution. If concentrate leaks are noted at the wall box, staff should notify biomedical services for repair.” Review of the “CDC Dialysis Safety” located at www.cdc.gov titled, “Wall boxes and Drains” dated October 25, 2019 indicated, “All box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). Cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during patient care activities ...More than one disinfectant wipe or application may be needed to ensure all wall box surfaces are visibly wet with disinfectant to achieve contact time specified by the manufacturer.””

“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: 22676 Based on record review, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for three of seven sampled in-center dialysis patients (Patient (P)2, P3, and P6). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 76 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P2’s electronic medical record (EMR) revealed a prescribed Blood Flow Rate (BFR) of 350 milliliters per minute (ml/min). Review of one of six “Post Treatment” flowsheets from 08/27/24 through 09/23/24 in the EMR indicated the following: a. On 09/23/24 from 2:16 PM until 6:05 PM, the BFR was documented at 400 ml/min. There was no documented rationale for the change to the prescribed BFR. 2. Review of P3’s EMR revealed a prescribed BFR of 450 ml/min and a Dialysate Flow Rate (DFR) of 2.0 which would be 800ml/min (the maximum rate the Fresenius Dialysis machine will deliver). Review of one of six “Post Treatment” flowsheets from 08/27/24 through 09/18/24 in the EMR indicated the following: a. On 09/18/24 from 12:39 PM until 10:50 AM, the DFR was documented at 700 ml/min. There was no documented rationale for the change to the prescribed DFR. 3. Review of P6’s EMR revealed a prescribed BFR of 300 ml/min. Review of six “Post Treatment” flowsheets from 08/28/24 through 09/17/24 in the EMR indicated the following: a. On 09/17/24 from 6:46 AM until 10:30 AM, the BFR was documented at 450 ml/min. There was no documented rationale for the change to the prescribed BFR. During an interview on 10/02/24 at 10:00 AM, Clinic Manager 2 confirmed the above findings, and that staff did not follow the physician’s order for dialysis treatment. Review of the facility’s policy titled, “Patient Assessment and Monitoring” dated 05/01/23 revealed, “Check dialysate flow rate setting is correct, and the correct prescribed flow is being delivered ...””