Bma - Boynton Beach

“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: 22517 Based on observation, administrative record review and staff interview, the clinical staff failed to implement infection control practices to minimize the risk of infection and cross contamination. This is evidenced by the facility failure to ensure staff utilized proper hand hygiene, along with glove changes, during initiation, termination and throughout the treatment. This is also evidenced by the patient’s failure to perform hygiene after holding their access site and staff failure to encourage patients to perform hand hygiene prior to leaving the treatment floor. The findings included: The facility’s policy regarding Hand Hygiene, published 11/06/2023 documented that Hands will be “ Decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water: Before and after direct contact with patients Entering and leaving the treatment area Before performing any invasive procedure such as vascular access cannulation or administration of parental medications Immediately after removing gloves After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled After contact with inanimate objects near the patient When moving from contaminated body site to a clean body site of the same patient After contact with the dialysis wall box, concentrate, drain or water lines After contact with other objects within the patient station or treatment space Hand Hygiene: Patients Patients should perform hand hygiene if able, prior to and after each dialysis treatment.” 1) An observation was made of the Patient Care Technician, Staff B, on 10/16/24 at 10:15 AM at Station 10. The staff had just completed taping the access site for the patient at Station 10. Staff B walked the patient to the scale. Staff B removed her gloves and did not perform hand hygiene. She then walked over to the box of clean gloves and obtained another pair of gloves and donned the gloves and returned to Station 10 and began cleaning at the dialysis station. An interview with Staff B was conducted on 10/16/24 at approximately 4:10 PM. The surveyor reviewed with the Technician the above observation. 2) An observation was made of Staff A, Licensed Practical Nurse, at Station 4 beginning on 10/16/24 at 11:01 AM. Staff A was observed inputting information into the dialysis machine with his gloved hands. The staff did not change his gloves and he began to clean the patient access for the patient at Station 4, Patient # 5. The staff then cannulated the patient’s access with the same gloves. Later at 11:15 AM, Staff A was observed to remove his gloves and he did not perform hand hygiene. The staff obtained gloves from the box of gloves and went to Station 2, donned one glove and input information into the dialysis machine. The staff then removed the one glove and walked over to Station 3, donned another one glove and in put information into the dialysis machine at Station 3. The staff did not perform hand hygiene in between glove changes or from going from one patient station to another. An interview with Staff A, was conducted on 10/16/24 at approximately 4:15 PM. The surveyor reviewed with Staff B the above observation. 3) An observation was conducted of the patient who was actively receiving dialysis at Station 7. The Patient Care Technician, Staff C, removed the needles from the access site of the patient’s right thigh on 10/16/24 at 10:19 AM. At 10:35 AM, the patient removed her glove, which she was holding her access site and did not perform hand hygiene. Staff B then walked the patient to the scale, weighed the patient and took the patient’s temperature. The patient exited the treatment floor without performing hand hygiene and the staff did not encourage the patient to perform hand hygiene after removing her gloves or prior to leaving the treatment floor. An interview with Staff C was conducted on 10/16/24 at approximately 4:20 PM. The surveyor reviewed with Staff C the above observation. 29151 4) Observation of discontinuation of treatment at Station #1 was conducted on 10/16/24 starting at 7:57 AM. Staff A, a Licensed Nurse was observed reinfusing the blood, then disconnected the blood lines and with the same gloves proceeded to remove the access needle. Staff A failed to perform hand hygiene after disconnecting the bloodlines and prior to removing the needle. In addition, the patient was observed donning a glove and holding the access site to achieve hemostasis and at approximately 8:20 AM, the patient left the treatment area, without performing hand hygiene or reminder by staff to perform hand hygiene. 5) Observation of discontinuation of treatment at Station #3 was conducted on 10/16/24 starting at 8:26 AM. Staff A, a Licensed Nurse was observed donning clean gloves, touching the computer screen, then removed the tape from the access site, disconnected the blood lines, changed gloves and proceeded to remove the access needle. Staff A failed to perform hand hygiene in between glove changes. 6) Observation of initiation of treatment at Station #3 was conducted on 10/16/24 at approximately 9:25 AM. Staff A, a Licensed Nurse was observed touching the machine screen inputting data, changed gloves, opened the clean supplies and then proceeded to insert the access needle. Staff A failed to perform hand hygiene in between glove changes. 7) Observation of discontinuation of treatment at Station #4 was conducted on 10/16/24 starting at 9:45 AM. Staff A, a Licensed Nurse was observed donning clean gloves, reinfused the blood, touched the machine computer screen, then disconnected the blood lines, removed the tape from the access site, removed the first access needle and applied a clamp. Staff A failed to perform hand hygiene after disconnecting the blood lines and prior to removing the access needle. Interview with Staff A conducted on 10/16/24 starting at 12:55 PM confirmed the lack of hand hygiene, and explained they got started late this morning and there was a bit of a rush, everyone came in at the same time.”

“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: 29151 Based on observation and interview, it was determined, the clinical staff failed to ensure infection control guidelines were implemented to minimize the risk of cross contamination as evidenced by failure to evacuate the station prior to machine disinfection and failure to disinfect all items at the station. The failure affected stations #11, #4 and #10. The findings included: 1) Observation of care on 10/16/24 at 8:28 AM revealed Staff B, a Patient Care Technician, at station #11, disinfecting the machine and setting up for the next patient. The staff was observed turning the machine opposite to the patient, who was still sitting in the dialysis chair holding the access site. The patient was observed leaving the station and the staff proceeded to disinfect the chair and did not disinfect the machine again prior to initiating the next patient. Interview with Staff B conducted on 10/16/24 at 1:05 PM revealed the facility keeps changing the rules and was not aware that disinfecting the dialysis machine while the patient remains at the station is no longer acceptable. 2) Observation of care conducted on 10/16/24 at 10:10 AM revealed Staff A, a Licensed Nurse, disinfecting station #4. The staff failed to open both sides of the dialysis chair, failed to fully recline the chair, and failed to disinfect the laminated signs hanging from the pole at the station. Interview conducted on 10/16/24 at 12:54 PM with Staff A confirmed the findings. 22517 3) An observation of the care being provided at Station 10 was conducted on 10/16/24 at 10:00 AM. The patient had been receiving dialysis and was noted to be holding one access site in his left arm. The Patient Care Technician, Staff B, began cleaning the dialysis machine which was also located on the left of the dialysis station at 11:01 AM, while the patient was still holding his access site. An interview was conducted with Staff B on 10/16/24 at approximately 4:10 PM. The surveyor reviewed with Staff B the above observation. She stated she thought she could clean the machine while the patient was still at the dialysis station as long as she turned the machine. The surveyor explained that cleaning and disinfection procedures during patient changeover are particularly prone to error and contribute to risk of cross-contamination, thus no patient should be at the station during this time.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 29151 Based on observation, policy review, and interview, it was determined, the clinical staff failed to ensure catheter care was performed following aseptic technique. This failure affected 2 of 2 patients observed for catheter care at Station #1 and #4. The findings included: The facility policy titled “Changing the Catheter Dressing Procedure” documents catheter related infections are one of the leading causes of hospitalization and death. Strict infection control practices and adherence to the catheter dressing change procedure is essential to prevent serious complications. Steps: Place underpad under catheter limb, performed hand hygiene, inspect and remove old dressing, discard and remove gloves, perform hand hygiene, donned clean gloves, using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds. Using aseptic technique, apply the catheter dressing over the dry exit site, being careful not to touch the patient side of the dressing with gloved hands or to any surface. Remove backing of adhesive dressing or apply tape to edges of gauze dressing.” 1) An observation of catheter care for the patient at station #1 and Staff A, a Licensed Nurse, was conducted on 10/16/24 at 8:38 AM. Staff A donned clean gloves and cleansed the exit site with an alcohol swab, moving from the inner towards the outer area with a up and down motion and then used the same swab to go over the same area, this time outer to inner. During the provision of catheter care, the staff had to pull the patient’s clothing out of the way on multiple occasions to disinfect the area and apply the dressing to the site. Staff A failed to utilize aseptic technique when disinfecting the exit site. 2) An observation of catheter care with the patient at station #4 and Staff A, a License Nurse, was conducted on 10/16/24 at 10:25 AM. Staff A donned clean gloves and assisted the patient who was using a walker, took his temperature, gave the patient a mask and escorted the patient to the station. Staff A proceeded to remove gloves, don clean gloves, removed the dirty dressing to the catheter limbs. It was noted the patient did not have a dressing to the exit site. Staff A then proceeded to cleanse the site and applied clean dressing. Staff A failed to perform hand hygiene after changing gloves and after removing the dirty dressing from the catheter limbs and prior to exit site disinfection. Interview conducted on 10/16/24 at 12:54 PM with Staff A confirmed the disinfection of the exit site should be done from the inner to the outer area, and not to go over the area again with the same swab and acknowledged the lack of hand hygiene prior to disinfecting the exit site.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 22517 Based on administrative record review and staff interview, the facility staff failed to consistently follow the established policy and procedures regarding mixing acid for 2 of 2 months reviewed. This is evidenced by the staff failure to ensure that each mixed batch of acid is reviewed and verified by two staff. The findings included: The facility’s policy regarding Acid Concentrate Mixing and Handling Dry Acid Dissolution Unit, published 09/05/2023 documented regarding Batch Records, “Each batch record must be reviewed and verified as complete by two qualified staff members at the end of batch preparation.” Review of the facility’s Granuflo Mixing Log for August and September revealed that the facility mixed 5 batches of Acid/Granuflo during August and September. The facility failed to ensure that two staff reviewed and verified the mixed acid batch on 4 of 5 batches mixed as follows: 1) On 09/11/24, the staff who completed the log and the staff who signed as the reviewer had the same employer ID number, indicating it was the same staff. The log also documents “Reviewer’s employee ID number ***Must be different than person who mixed the batch*** [Reviewer] 2) On 08/07/24, the staff who completed the log and the staff who signed as the reviewer had the same employer ID number, indicating it was the same staff. 3) On 08/19/24, the staff who completed the log and the staff who signed as the reviewer had the same employer ID number, indicating it was the same staff. 4) On 08/26/24, the staff who completed the log and the staff who signed as the reviewer had the same employer ID number, indicating it was the same staff. An interview was conducted on 10/16/24 at approximately 12:30 PM with the Area Technical Operation Manager (ATOM). The surveyor reviewed with the ATOM the documentation on the Granuflo Mixing Log. He confirmed that two different staff are required to mix and verify the mixed batch of Granuflo, which did not occur on the mixed batches documented for August and September.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 22517 Based on observation. administrative record review, and staff interview, the facility staff, Staff C, failed to provide evidence of adequate knowledge of Chlorine breakthrough procedure, during the chlorine testing observation. The findings included: An observation of the chlorine testing was conducted on 10/16/24 beginning at 11:00 AM with the Patient Care Technician (PCT), Staff C. An interview was conducted with Staff C, who reported that she transferred to the facility 5 weeks ago and she primarily opens, which means she is the staff primarily responsible for performing the chlorine testing when the facility opens and provides dialysis care to the incoming patients. The surveyor questioned her regarding the procedures for chlorine testing and proceeded to ask the staff about the maximal allowable limits for total chlorine limits and the procedure when the results from the primary carbon tank exceeds the maximal allowable limit. She reported that if the test results are at this green, pointing to the results charts. The green had the limit of 0.1 mg/L At this point, the surveyor asked Staff C about her actions regarding further testing. The staff was unable to relay the procedure for performing further testing. She was unable to relay the necessity of testing after the secondary tank and the frequency of additional testing if the results of the total chlorine test at the secondary carbon tank did not exceed the maximal allowable limit, nor was she able to state the appropriate site to perform the secondary testing. The Area Technical Operation Manager (ATOM), then joined the interview, who informed the staff of the correct procedure for chlorine testing and referred her to the facility’s policy. He then informed the staff of the appropriate testing site, because she pointed to the testing site on the RO, which is used to test at the initial testing in the morning to verify if there was chlorine breakthrough at the RO. He further explained the timing of the chlorine testing during a chlorine breakthrough. The facility’s policy and procedure regarding Carbon Filtration Chlorine Breakthrough Action Plan for Central Water System, published 05/02/22 documented, “The following procedure must be performed in the event total chlorine levels at or above the level of 0.10 ppm, are detected exiting the Worker carbon filter or Worker bank of carbon filters. The following action included: 1. If treatments has not started, do not begin patient treatments! If treatments are in progress, immediately place all machines in bypass by lifting the shunt door. 2. Notify the nurse in charge 3. Immediately test water exiting the polisher bank of carbon filters and purified water distribution system. Report test results to nurse in charge. (This verifies if the breakthrough has occurred on the polisher carbon filter or if chlorine is present in the purified water distribution system) 4. Nurse in charge will promptly notify the MD (Medical Director), CM/PM, DP/AM, Biomedical Technician, and ATOM of the breakthrough. If: Results of either the polisher carbon filter or polisher bank of carbon filters or the purified water distribution system are greater than 0.1 ppm total chlorine. Then: Keep dialysis machine in bypass. All patient treatment must be discontinued at once. Do not return patient’s blood. If: Results of both the polisher carbon filter (or polisher bank of carbon filters) and the purified water distribution system are less than 0.10 ppm total chlorine. Then: Obtain Medical Director approval to remove dialysis machine from bypass and resume treatments. Increase Total Chlorine testing to a minimum of every 2 hours. Document results from post polisher carbon filters or polisher bank of carbon filters on the TCL-2 log in the electronic documentation system or approved paper TCL-2 log.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 29151 Based on observation, policy review and staff interview, the facility failed to ensure all supplies were maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by the failure of the staff to ensure supplies were not readily available for use beyond the manufacturer’s documented expiration date. The findings included: Facility policy titled “Expiration Dates Sterile Supplies” dated 07/04/12, documents “sterile items will be checked before use to ensure that they have not expired. appropriately dispose of sterile items that have reached the expiration date.” 1) Observation of the treatment floor and laboratory area conducted on 10/15/24 at 10:15 AM revealed the following: 100 BD blood collection tube containers expired on 09/30/24. 96 BD blood collection tube containers expired on 08/31/24. 67 BD gel and lithium Heparin vacutainer expired on 08/31/24. Interview with the Clinic Manager conducted on 10/15/24 at 10:30 AM confirmed the items were expired. 22517 2) An observation was conducted on 10/15/24 at 10:10 AM revealed a solution station containing multiple bottles of solutions clearly dated 08/29. Further observation of the solutions revealed the following: a. A bottle of Conductivity Standard Solution 100mS/cm. Noted on the bottle, “Discard 30 days after opening.” b. A bottle of Conductivity Standard Solution 50 mS/cm. Noted on the bottle, “Discard 30 days after opening.” c. A bottle of Conductivity Standard Solution 14.0 mS/cm. Noted on the bottle, “Discard 30 days after opening.” Another observation was conducted on 10/16/24 beginning at approximately 10:00 AM revealed the same bottles previously observed on yesterday, were now marked over with the date of 09/29. An interview with the Patient Care Technician, Staff C, was conducted on 10/16/24 at approximately 4:20 PM. The surveyor reviewed the above observation. Staff C stated she was the staff who wrote the 09/29 date over the previous date of 08/29. She stated she was informed that the solutions were good for 30 days. 3) An observation the storage Room on 10/15/24 at approximately 10:40 AM revealed a bottle of Standard Solution, 14.0 mS/cm 7.0 pH with a manufacturer’s expiration date of 08/28/24. An interview was conducted with the Biomedical Technician on 10/16/24 at 10:45 AM. The surveyor showed the BMT the expired bottle of conductivity solution.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 22517 Based on clinical and administrative record review and interview, the interdisciplinary team failed to complete an initial comprehensive assessment for all new patients within 30 calendar days for 1 of 4 sampled patients (Patient # 1). This is evidenced by staff failure to complete the assessment for a patient who transferred to the facility with a change in modality. The findings included: The facility’s policy regarding Comprehensive Interdisciplinary Assessment and Plan of Care, published 07/03/23, documented regarding “CIA and POC for Patients New to Dialysis. An initial comprehensive interdisciplinary a (CIA) and plan of care (POC) must be conducted on all patients new to dialysis with the later of 30 calendar days or 13 outpatient hemodialysis sessions within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. Patients changing modality are classified as new patient and must have comprehensive interdisciplinary assessment and plan of care completed with the same frequency as patients new to dialysis.” Review of the clinical record for Patient # 1 on 10/15/24 revealed that the patient transferred to the facility on 08/23/24 after a brief hospitalization for complication with her peritoneal dialysis catheter and the patient was prescribed to receive in-center hemodialysis. Further review of the clinical record revealed a 11/22/23 CIA and POC from another facility outlining the patient peritoneal dialysis treatment. The facility did not have a comprehensive interdisciplinary assessment addressing the patient’s current modality of in-center hemodialysis. Based on the patient’s admission date, the patient’s CIA was to be completed by 09/22/24. An interview was conducted on 10/17/24 at approximately at 12:30 PM with the Clinical Manager and the Acting Director of Operations. She confirmed that they missed completing the CIA and POC. They didn’t recognize that the patient was a change of modality, so they did not do it.”

“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: 22517 Based on observations, clinical and administrative record review and staff interview, the facility failed to ensure patients were monitored during treatment every thirty minutes. This failure affected 4 of 4 sampled patients reviewed (Patient # 1 , # 2, # 3, and # 4). The facility also failed to ensure the appropriate time monitoring and administration of anticoagulation medication for a random observation for Patient # 5. The facility staff also failed to complete a thorough nursing assessment. The findings included: 1) Review of the facility’s policy regarding Heparinization, Published 08/30/2020, documented, “A heparin bolus administration at initiation does not need to be flushed by normal saline to clear the needle or catheter line. Attach heparin syringe to catheter port or access needle line. Gently push and pull the syringe plunger back and forth a 3 or more times to infuse ordered heparin. Following infusion, prior to treatment initiation, wait 3-5 minute to allow systemic anticoagulation to occur.” An observation of the patient at Station # 4, Patient # 5, whose dialysis treatment was being initiated. The Licensed Practical Nurse, Staff A, administered the patient’s bolus dose of Heparin on 10/16/24 at 11:10 AM. The staff initiated the patient’s treatment at 11:12 AM, approximately 2 minutes later (noted blood flowing through the blood lines). An interview was conducted on 10/16/24 at 4:15 PM with Staff A regarding initiating the treatment after the administration of the heparin. He stated you are supposed to wait 3- 5 minutes but he confirmed he did not wait the required amount of time before initiating the treatment, “I waited about a minute”. 2) Review of the clinical record for Patient # 1 on 10/15/24, treatment flow sheets for the Patient #1 dated 09/18/24 to 10/11/24, revealed that the staff failed to provide evidence the patient was monitored as per policy on 3 of 11 treatment flow sheets as follows: a. The treatment flow sheet failed to document monitoring of vital signs, blood flow rate, dialysate flow rate, venous and arterial pressures and access visualization from 12:09 PM until 1:38 AM on 10/11/24, for 1 hour and 29 minutes. b. On 10/04/24, the staff failed to document monitoring for 51 minutes. c. On 09/23/24, the staff failed to document monitoring for 53 minutes, 5:11 PM to 6:04 PM 3) Review of the clinical record for Patient # 4 on 10/17/24, treatment flow sheets for Patient # 4 dated 09/18/24 and 10/14/24, failed to provide evidence the patient was monitored as per policy for 2 of 11 treatment flow sheets. The records failed to document monitoring of vital signs, blood flow rate, dialysate flow rate, venous and arterial pressures and access visualization from as follows: a. The treatment flow sheet on 10/04/24, the staff failed to provide evidence of monitoring the patient for 1 hour and 2 minutes, 12:04 PM to 1:05 PM. b. On 09/27/24, the staff failed to document monitoring for 54 minutes, from 1:09 PM to 2:03 PM. An interview was conducted with the Clinical Manager and the Acting Director of Operations on 10/17/24 at approximately 12:30 PM. The surveyor reviewed the discrepancies identified on the treatment flow sheets. They confirmed the discrepancies identified and were unable to offer an explanation as to why there was no evidence of the patients being monitoring every 30 minutes. Review of the facility’s policy regarding Patient Assessment and Monitoring, published 05/01/2023, documented, “During Treatment, Obtain blood pressure and pulse every 30 minutes or more as needed but not to exceed 45 minutes or per regulations. 4) An observation of the patient at Station # 4, Patient # 5, whose dialysis treatment was being initiated. The Registered Nurse approached the patient on 10/16/24 at 11:13 AM. The nurse palpitated the patient’s legs and then began asking the patient questions. The nurse’s stethoscope remained around her neck while assessing and speaking with the patient. The nurse then began to input information into the dialysis machine. After completing inputting the information, the nurse left the station. The stethoscope remained around the nurse’s neck and she did not auscultate the patient’s lungs or heart. An interview was conducted on 10/16/24 at approximately 4:15 PM with the Registered Nurse. The surveyor reviewed with her the above observation. The facility’s policy regarding Patient Assessment and Monitoring, published 05/01/2023 documented “ The Registered Nurse will assess/re-asses any findings addressed pre or during treatment as needed. During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters as needed: Data Collected above, Assess patient for symptoms, Lungs sounds (as indicated by patient’s condition) Auscultate lungs sounds for Sound: Clear Decreased breast sounds Rales (crackles) Rhonchi Wheezing Location: Right Left Bilateral Heart sounds (As indicated by patient condition) Listen for: Rate Rhythm” 29151 5) Clinical record review conducted on 10/16/24 revealed Patient #3 was admitted to the facility on 07/19/24 for dialysis treatment. Treatment record dated 10/24/24 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 9:32 AM and the next monitoring was documented at 10:31 AM. Treatment record dated 09/23/24 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 9:05 AM and the next monitoring was documented at 10:05 AM. Interview conducted with the Clinic Manager on 10/17/24 starting at 9:23 AM confirmed Patient #3 was not monitored per protocol.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 29151 Based on record review and interview, it was determined, the clinical staff failed to ensure dialysis prescriptions were followed for 4 of 4 sampled patients (Patient #1, #2, #3 and #4). The failure included deviation of the prescribed Blood Flow Rate (BFR), Dialysate Flow Rate (DFR) and lack of documentation for the clinical rationale for not following the dialysis treatment prescription. The findings included: 1) Clinical record review conducted on 10/15/24 revealed Patient #2 has physician’s orders for dialysis treatment dated 09/16/24 for BFR of 400 and DFR of 500. Treatment Records dated 09/20/24, 09/25/24 and 10/14/24 indicate the patient did not receive the prescribed BFR during most of the treatment. The treatment records do not provide an explanation for the deviation from the dialysis prescription. Treatment record dated 10/07/24 indicate the patient did not receive the prescribed DFR. The treatment records do not provide an explanation for the deviation from the dialysis prescription. 2) Clinical record review conducted on 10/15/24 revealed Patient #3 has physician’s orders for dialysis treatment dated 08/01/24 for DFR of 800. Treatment Records dated 09/30/24 and 10/14/24 indicate the patient did not receive the prescribed DFR during most of the treatment. The treatment records do not provide an explanation for the deviation from the dialysis prescription. Interview with the Clinic Manager conducted on 10/17/24 at 9:20 AM, revealed after review of the treatment records for Patients #2 and #3, the manager confirmed the prescription was not followed and there is no documentation to validate the reason for the changes. 22517 3) Review of the clinical record for Patient # 1 revealed that the physician prescribed for the patient to receive dialysis three times a week for 3 hours, Blood Flood Rate (BFR) of 350 and a Dialysate Flow Rate (DFR) of 800. The treatment records from 09/18/24 to 10/11/24 revealed that the staff failed to follow the physician order for the prescribed BFR and /or DFR on 4 of 11 treatment flow sheets and did not provide an why they were unable to follow the physician order as follows: a. On 10/11/24, the staff documented a BFR of 300 from 12:09 PM to 2:19 PM, over 2 hours of a 3 hour treatment. b. On 10/02/24 the patient’s treatment began at 4:02 PM, the staff documented a BFR of 300 beginning at 4:34 PM and maintained this BFR throughout the treatment. c. On 09/30/24 the patient’s treatment began at 3:55 PM, the staff documented a BFR of 300 beginning at 4:33 PM and maintained this BFR throughout the treatment. d. On 09/18/24 the patient’s treatment began at 4:06 PM, the staff documented a BFR/DFR of 300/500. The staff continued to document a DFR of 500 at 4:36 PM to 5:01 PM. 4) Review of the clinical record for Patient # 4 revealed the physician prescribed for the patient to receive dialysis three times a week for 3 hours and 30 minutes, BFR of 450 and DFR of 800. The treatment sheets from 09/16/24 to 10/14/24 revealed the staff failed to followed the physician order for the prescribed BFR/DFR on 4 of 11 treatments as follows: a. On 10/14/24, the staff documented a DFR OF 500 at 1:34 AM for 2 1/2 hours of the 3:30 minutes treatment. b. On 10/11/24 the staff documented a BFR of 400. c. On 09/30/24 the staff documented a DFR of 500 beginning at 12:05 PM . d. On 09/18/24 the staff documented a DFR of 500 for 2.5 hours. An interview was conducted with the Clinical Manager and the Acting Director of Operations on 10/17/24 at approximately 12:30 PM. The surveyor reviewed the discrepancies identified on the treatment flow sheets. They confirmed the discrepancies identified. The facility’s policy regarding Patient Assessment and Monitoring, published 05/01/2023 documented regarding “Machine Parameters and Extracorporeal Circuit, Check machine settings and measurements: Check prescribed blood flow rate is being achieved or reason is documented in medical record if unable to meet prescribed blood flow rate. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.””

“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: 29151 Based on observation, policy review, and interview, it was determined, the clinical staff failed to ensure vascular access care was provided while utilizing aseptic technique to minimize risk of infection. The findings included: Facility policy titled “Access Assessment and Cannulation” dated 05/06/24, documents “Disinfect cannulation site as follows using any of the disinfectants below: 70% isopropyl alcohol, povidone Iodine Pad or 2% Chlorhexidine and 70% alcohol. Perform skin antisepsis on one site at the time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection.” Observation of care conducted on 10/16/24 at approximately 9:20 AM revealed Staff C, a Patient Care Technician, initiating dialysis treatment at station #6. The staff donned clean gloves, disinfected the access site, then palpated the area and inserted the first needle. Staff C proceeded by disinfecting the second site, then again, palpated the area and inserted the second needle. Staff C failed to cleanse the access sites after palpating and prior to needle insertion. Interview with Staff C conducted on 10/16/24 at 2:43 PM confirmed the staff palpated the site and failed to disinfect it before inserting the needles, stating the patient is very difficult and she wants her to palpate it before she sticks her.”