Fkc Main Street

“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: 47821 Based on observation, policy review, and staff interview, it was determined that the facility failed to ensure 1 of 8 (Employee #1) patient care employees performed proper hand hygiene during observations of hemodialysis care. Findings include: Review of facility policy “Hand Hygiene” dated 11/6/2023 revealed, “...Hands will be decontaminated...after contact with other objects within the patient station or treatment space...” Review of facility policy “Termination of Treatment Using an Arteriovenous Fistula or Graft and Optiflux Single Use Ebeam Dialyzer” dated 2/7/2022 revealed, “...Termination: Disconnecting the Patient...Disconnect the blood lines from the needle lines...discard the extracorporeal circuit...discard the gloves and perform hand hygiene...” Review of facility policy “Post Treatment Fistula Needle Removal” dated 7/1/2024 revealed, “...Follow the steps...to remove...needles...Replace under pad under the access arm...The person removing the needles will perform hand hygiene and don clean gloves...” A. During an observation of the cleaning and disinfection of Dialysis Station #1 on 8/1/2024 between 9:35 and 9:50 AM, Employee #1 was observed completing the following tasks: - removed all bloodlines and disposable equipment and discarded in biohazardous waste - emptied the prime waste bucket in the dirty sink - replaced the prime waste bucket on the dialysis machine - proceeded to wet wipe the dialysis machine Employee #1 failed to remove gloves, perform hand hygiene, and don clean gloves after discarding bloodlines and emptying prime waste bucket before proceeding to wipe the dialysis machine. This finding was confirmed with Employee #1 on 8/1/2024 at 9:41 AM. B. During an observation of the discontinuation of dialysis for Patient #10 on 8/1/2024 between 9:45 and 10:20 AM, Employee #1 was observed completing the following tasks: - completed hand hygiene and donned gloves - reinfused extracorporeal circuit - removed gloves, performed hand hygiene, donned gloves - stood patient to obtain blood pressure, entered data in the electronic medical record, and assisted the patient to sit in the chair - disconnected bloodlines from needle lines - removed tape from first needle site, removed first needle, and discarded first needle - removed gloves, performed hand hygiene, and donned gloves - removed tape from second needle site, removed second needle, and discarded second needle - removed gloves, performed hand hygiene, and donned gloves Employee #1 failed to remove gloves and perform hand hygiene after disconnecting the bloodlines from the needle lines and before removing the first needle. This finding was confirmed with Employee #1 on 8/1/2024 at 10:20 AM.”

“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: 48349 Based on policy review, facility tour, and interview with staff, it was determined that the agency failed to maintain a safe and sanitary environment for 22 of 22 patients at the dialysis facility on 8/1/2024. Findings include: Review of facility policy “Storage of Supplies” dated 04/05/2021 revealed, “...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged...All liquid supplies must be stored separate from dry supplies to minimize damage from accidental breakage or spills...Supplies must be rotated First In-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date...” During a flash tour of the facility on 8/1/2024, between 8:25 and 9:25 AM, the following was observed in the room labeled “Janitor Closet”: - 4 rolls of paper towels were stored touching bottles of hand sanitizer, an empty gallon bottle of bleach, and Envirox Sanitizer (liquid cleaning agent). - 1 box of toilet seat covers was stored directly next to Envirox Sanitizer (liquid cleaning agent) - Expired items including: 1 bottle of Envirox Mineral Shock (32oz bottle) lot # 107060-22B, Mfg 3-3-22, use by 3-24 1 bottle of Envirox Critical Care Disinfectant (32oz bottle) lot # 130647-22B, Mfg 8-27-20, use by 8-22 During an interview on 8/1/2024 between 8:25 and 9:25 AM with Employee #4, the above findings were confirmed.”

“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: 48349 Based on document review, observation, and interview with staff, it was determined that the facility failed to maintain a safe and functional environment by not maintaining the building. Findings include: Review of facility job description “Facility Administrator” dated 8/11/2022 revealed, “...Principal Duties and Responsibilities...Responsible for the administration of the daily business operations of the dialysis clinics including...maintenance of the physical plant and center equipment...”. During a flash tour of the facility on 8/1/2024 between 8:25 and 9:25 AM, the following was observed: -The rear supply room doors were not sealed. Both doors had an approximate 1-inch gap from the base of the doors to the ground. During an interview on 8/1/2024 at 8:50 AM with Employee #4, the above finding was confirmed.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 47821 Based on medical record review, policy review, and staff interview, it was determined the Facility failed to ensure the dialysis prescription was followed as ordered for 2 of 10 patients (Patients #5 and #12) in the medical record review sample. Findings include: Review of facility policy “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...Follow the steps below for monitoring...machine parameters during treatment...Check dialysis flow rate [DFR] setting is correct, and the prescribed flow is being delivered...” Review of facility policy “Nursing Supervision and Delegation” dated 11/06/2023 revealed, “...The registered nurse must...review patient treatment prescription...to verify correct settings, and if dialysis prescription is being followed...” Patient #5 A review of medical records revealed a hemodialysis prescription dated 6/8/2024 ordered a DFR of manual 500 mL/min (milliliters per minute). The patient’s dialysis treatments ran with a DFR of 800 mL/min on 7/16/2024, 7/19/2024, and 7/30/2024. There was no evidence in the medical record of the rationale for why the DFR was not running at the prescribed flow rate. During an interview on 8/2/2024 at 11:55 AM, Employee #3 confirmed Patient #5’s dialysis treatments on 7/16/2024, 7/19/2024, and 7/30/2024, did not run with the prescribed DFR. Patient #12 A review of medical records revealed an order for a DFR of manual 600 mL/min for the patient’s 7/26/2024 hemodialysis treatment. The dialysis treatment ran with a DRF of 800 mL/min between 3:30 and 6:33 PM during 6 treatment monitoring checks. There was no evidence in the medical record of the rationale for why the DFR was not running at the prescribed flow rate. These findings were confirmed with Employee #3 on 8/5/2024 at 11:40 AM.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47821 Based on medical record review, policy review, and staff interview it was determined that for 2 of 10 patients (Patients # 1 and #12) in the medical record review sample, the Facility staff failed to provide management of volume status as evidenced by not addressing high patient blood pressures and low patient heart rates during treatment. Findings include: A review of the facility policy “Patient Assessment and Monitoring “ dated 5/01/2023 revealed, “...During treatment...Obtain blood pressure and pulse rate every 30 minutes or more as needed...Report to the nurse...Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury] ...Report to the nurse patients whose heart rates have dropped below 60...” A review of the facility policy “Hypertension” dated 9/07/2021 revealed, “...Staff will recognize, report and immediately address systolic blood pressures greater than 180 mm/Hg...The RN [registered nurse] will assess the patient and determine if further interventions are needed...” A review of the facility job description “Charge Nurse” dated 4/08/2019 revealed, “...Assess patient needs...and communicate concerns to rounding physician...Continuously monitor patient’s condition with regards to problems and potential complications...Administer medications to patients per physician’s orders...” A review of the facility policy “Nursing Supervision and Delegation” dated 11/06/2023 revealed, “...Prior to discharge, the RN must review the treatment record to...Confirm patient is stable for discharge...The record must be reviewed for...Slow...heart rate...high blood pressures...Heart rate <60...addressed by the registered nurse with documentation present...Blood pressures...greater than 180 systolic addressed by the registered nurse with documentation present...” Medical record review revealed: A. Patient #1 Patient’s “Treatment Sheet” dated 7/15/2024 documented the following heart rates less than 60: 7:49 AM: 55 8:19 AM: 55 8:47 AM: 56 9:18 AM: 58 11:50 AM: 59 Patient’s “Treatment Sheet” dated 7/17/2024 documented the following heart rates less than 60: 7:35 AM: 54 8:08 AM: 56 8:32 AM: 54 9:01 AM: 59 9:31 AM: 59 9:55 AM: 58 10:55 AM: 56 11:21 AM: 58 11:39 AM: 59 Patient’s “Treatment Sheet” dated 7/19/2024 documented the following heart rates less than 60: 7:32 AM: 56 8:06 AM: 57 8:30 AM: 55 9:12 AM: 58 10:09 AM: 59 Patient’s “Treatment Sheet” dated 7/22/2024 documented the following heart rates less than 60: 7:33 AM: 59 8:10 AM: 58 8:32 AM: 58 9:01 AM: 58 9:31 AM: 53 10:08 AM: 59 No evidence in the medical record that the patient’s heart rates of less than 60 on the above dates and times were reported to the registered nurse or charge nurse. No evidence in the medical record of RN addressing or assessing low heart rate. These findings were confirmed by Employee #3 during an interview on 8/5/2024 between 11:30 and 11:45 AM. B. Patient #12 Physician orders dated 6/29/2024 included an order for Clonidine hydrochloride 0.1 milligram orally as needed during dialysis for systolic BP (blood pressure) greater than 180 for hypertension. Patient’s “Treatment Sheet” dated 7/15/2024 documented the following systolic BPs greater than 180: 4:00 PM: 194/96 6:23 PM: 190/95 6:56 PM: 185/99 Patient’s “Treatment Sheet” dated 7/17/2024 documented the following systolic BPs greater than 180: 3:59 PM: 181/89 6:35 PM: 181/80 7:01 PM: 185/82 7:07 PM: 195/85 Patient’s “Treatment Sheet” dated 7/20/2024 documented the following systolic BPs greater than 180: 11:50 AM: 195/100 2:29 PM: 197/98 2:52 PM: 188/92 3:22 PM: 195/93 Patient’s “Treatment Sheet” dated 7/24/2024 documented the following systolic BPs greater than 180: 4:00 PM: 186/99 Patient’s “Treatment Sheet” dated 7/26/2024 documented the following systolic BPs greater than 180: 6:06 PM: 181/88 Patient’s “Treatment Sheet” dated 7/29/2024 documented the following systolic BPs greater than 180: 4:48 PM: 181/94 5:35 PM: 182/91 6:35 PM: 188/93 7:01 PM: 192/85 Patient’s “Treatment Sheet” dated 7/31/2024 documented the following systolic BPs greater than 180: 5:02 PM: 181/90 No evidence in the medical record that the RN/Charge Nurse was made aware of the systolic BPs greater than 180. No evidence that the patient received the ordered medication needed for elevated blood pressure on the above dates and times. No evidence of notification by the registered nurse or charge nurse to the patient’s physician. These findings were confirmed by Employee #3 during an interview on 8/5/2024 between 11:30 and 11:45 AM.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 44819 Based on staff interviews and review of facility policies, patient safety event log, and Quality Assessment and Performance Improvement (QAPI) meeting minutes, the facility failed to conduct a thorough review for 15 of 15 incidents of incorrect needle use during hemodialysis treatments through their QAPI process between 12/2023 to 6/2024. The Facility failed to develop a written action plan or complete ongoing monitoring to measure staff improvement in using the prescribed needle size for hemodialysis treatments putting 53 of 53 current patients at risk for inadequate dialysis treatments. Findings include: A review of the Facility’s policy “Quality Assessment and Performance Improvement Program” dated 5/2/2022 revealed, “...The QAPI is designed and implemented to...comprehensively monitor, evaluate, and improve the quality and safety of patient care and services by identifying opportunities and resolving identified problems...” A review of the Facility’s policy “Patient Safety Event Reporting and Documentation” dated 2/6/2023 revealed, “...A successful review of patient events performed by the QAPI Committee during QAPI will...Develop appropriate action plan after the identified Root Cause that will include...Monitoring progress and effectiveness of the action plan ...” A review of the “Patient Safety Event” logs revealed the Facility had 15 documented incidents of “incorrect needles [access needles] used” between November 2023 and June 2024; 2 in November 2023, 4 in December 2023, 2 in January 2024, 0 in February 2024, 1 in March 2024, 5 in April 2024, 1 in May 2024, and 0 in June 2024. A review of the QAPI minutes revealed “Patient Safety” was on the agenda as a monthly topic for the April 2024 to July 2024 meetings. A review of the Facility document “Update Event: Incorrect Needle Used (HD) [hemodialysis]” dated 3/7/2024 revealed incident information for Employee #12 using 17g (gauge) needles instead of the prescribed 16g needles to access Patient #13’s arteriovenous (AV) graft. During an interview on 8/5/24 between 9:08 and 10:15 AM during the QAPI review, with Employees #1, #3, #10, and #13 present, the following was revealed: - When asked what the facility is doing to prevent further incidents of not using the prescribed needle size to initiate hemodialysis treatments, Employee #1 stated an action plan was developed which entailed reeducating involved staff to select the prescribed needle size for hemodialysis treatments, and providing staff education in daily huddles to instruct all new staff members to get a second person to check the needles being used before initiating hemodialysis treatments. When requested, Employee #1 was not able to provide written documentation of the action plan. - Employee #1 acknowledged that the facility is not monitoring staff for the selection of the prescribed needle size before the initiation of hemodialysis treatments. QAPI meeting notes from the 4/24/2024 meeting (review of March 2024 data) revealed, “There was a discussion with the staff to talk about the placement of correct needle size after errors that was [sic] made earlier this month staff [sic] was re-educated on the importance of the correct needle size.” There was no evidence of a discussion of monitoring to determine the effectiveness of the staff education. QAPI meeting notes from the 5/22/2024 meeting (review of April 2024 data) revealed, “There was an action plan opened for incorrect needles being used and staff was told to make sure all new staff members get a second person to check the needles being used on the patient.” There was no evidence of a discussion of monitoring to determine the effectiveness of the staff education. During an interview on 8/5/2024 between 12:10 and 12:25 PM, Employee #1 confirmed there was no written action plan or ongoing monitoring to measure staff improvement in using the prescribed needle size to initiate hemodialysis treatments.”