Rcg - Sacred Heart - Adult Dialysis

“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: 50783 Based on observation, policy review, and interview, the facility failed to ensure infection control practices including hand hygiene and removal of gloves between each patient or station while providing care. The findings include: On 8/19/25 Patient care technician (PCT) M was observed leaving the dialysis treatment station with gloves on, walked to the nurses’ desk 1, opened a drawer to search for supplies and, when unable to locate the needed, PCT M proceeded to nurses’ desk 2 with the same gloves on, opened a drawer, searched for the needed supply, obtained the supply, walked back to the dialysis treatment station and checked patient monitors with the same gloves on. After approximately 5 minutes, PCT M was observed with the same gloves on, walking from the dialysis treatment station to nurses’ desk 1. PCT M spoke with a nurse sitting at the desk for approximately 5-7 minutes, then walked back to the dialysis treatment station without removing gloves or performing hand hygiene. On 8/19/25 at 11:45 am, the clinic manager said in an interview that staff know anytime they leave their station and in between each patient they are to remove their gloves and perform hand hygiene. A review of facility policy reference number 47663, published 11/6/2023, titled “personal protective equipment” included instructions for hand hygiene and glove use as: “staff must remove gloves and wash hands after patient care, exposure to blood and body fluids, and touching any surfaces within the patient station. Always perform hand hygiene after glove removal. Avoid touching surfaces with gloved hands that will be touched with ungloved hands.””

“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: 39374 50783 Based on record review, policy review, and interview, the facility failed to ensure immediate follow up actions were taken in response to observed signs of central venous catheter site infection for 1 of 9 patients sampled for record review (#3). The findings include: A review of the treatment record for Patient #3 dated 8/9/2025 included documentation of a note at 12:42pm that the patient care technician noted the catheter dressing change site has green matter around it, reported to RN (registered nurse). Further review of documentation from 8/9/2025 at 16:45 pm documented “CVC (central venous catheter) site cleaned per P&P (policy and procedures) and sterile dressing placed. No s/s (signs/symptoms) of infection noted. Lumens flushed with NS (normal saline) and no resistance noted.” On 8/21/2025 at 1:20pm, the clinic manager said in an interview she remembered there was a follow up culture of the CVC site. The clinic manager looked up the electronic health record for Patient #3 and verified a culture was swabbed on 8/12/2025, three days after the observation was documented in the treatment record on 8/9/2025. The clinic manager was unable to verify if the specimen had been sent out to the laboratory or cultured. There were no results of a laboratory test related to the culture of the CVC site in the record and no additional documentation noted in the record. Review of facility policy 45265, titled “supervision and delegation,” dated 11/6/2023, under the section “reporting of patient care findings to the team nurse in charge” reveals “the staff member who collects information pre, post, and during treatment will document their findings. Any observed changes or abnormal findings in the patient’s condition or vascular access, changes reported by the patient must be reported to the registered nurse who will assess the patient. Registered nurses who are not the nurse in charge must report abnormal findings and interventions to the nurse in charge.””

“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: 50783 Based on record review, policy review, and interview, the facility failed to ensure patients’ blood pressures were monitored at least every 45 minutes during dialysis treatment for 2 of 9 patients sampled for record review (#1 and #5). The findings included: Policy titled “Patient Assessment and Monitoring” reference number 45284, version 4, published 5/01/2023 included instructions that included “obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” A record review for Patient #5 showed that during the treatment on 8/5/2025 on three separate occurrences, the blood pressure monitoring exceeded the standard and policy of monitoring blood pressure no more than 45 minutes apart. On 8/5/2025, a blood pressure reading was recorded at 11:05am and the next recorded blood pressure reading was documented at 12:10pm, one hour and five minutes later. The next blood pressure reading was on 8/5/2025 was documented 56 minutes later, at 1:04pm, and another gap in blood pressure monitoring lasting one hour and 25 minutes was noted between 1:37pm and 3:02pm. During the treatment on 8/12/2025 a blood pressure reading was recorded at 12:10pm and the next recorded blood pressure reading was documented at 1:34pm, one hour and 24 minutes later. A record review for Patient #1 showed that during the treatment on 8/6/2025 there was no documented blood pressure monitoring between 1:31pm and 2:25pm, a period of 54 minutes. The treatment record for Patient #1 on 8/13/2025 included a gap in blood pressure monitoring lasting 59 minutes between 1:03pm and 2:02pm. During an interview on 8/21/2025 at 10:30am, the clinical manager said, “”The machine is set up to automatically check blood pressures every 30 minutes, and sometimes when staff pulls over the data, it does not always pull over the blood pressure for the patient; but the dialysis tech and nurse know to enter the blood pressures manually and that they should have caught the missing information.””

“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: 39374 Based on record review, policy review, and interviews, the facility failed to maintain the prescribed blood flow rate (BFR) during dialysis treatment for 1 of 9 patients sampled for record review (#6). The findings include: A record review of Patient #6 treatment records for 8/6/2025 - 8/16/2025 identified two dates (8/6/2025 and 8/9/2025) when the prescribed blood flow rate (BFR) of 400 (milliliters per minute) was not achieved and there was no documentation to explain the reason for deviating from the prescribed BFR. The treatment record for 8/6/2025 documented initiation of treatment at 12:12pm with a BFR at 450, decreased to 350 at 12:37pm and remained at 350 until the end of treatment at 3:05pm. The treatment record for 8/9/2025 documented initiation of treatment at 6:32am at a BFR of 400. The BFR was decreased to 350 at 7:07am and remained at 350 until treatment ended at 10:01pm. A nurses’ note post-treatment documented “patient left treatment 1.7 kg (kilograms) over EDW (estimated dry weight). Review of a policy titled “Patient Assessment and Monitoring” with reference number 45284, version 4, published 5/01/2023 identified instructions that included “check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow rate.” In an interview on 8/21/2025 at 10:06am, the clinic manager said the expectation is there would be a note explaining the reason why the prescribed BFR was not followed. She explained that common reasons for decreasing the BFR are for elevated blood pressures or pain at the access site that cannot be relieved with manual position adjustments. She confirmed there was no other acceptable reason for not following the BFR and reiterated the expectation is a documented note explaining why the prescription was not followed. On 8/21/2025 at 1:20pm a follow up interview took place with the director of operations and the clinic manager regarding the blood flow rates recorded in the treatment records of Patient #6 and they verified that there was not a justification for the BFRs to deviate from the prescribed blood flow rate.”