Usrc Boynton Beach 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: 29151 Based on observation and staff interview, it was determined, the facility failed to ensure staff utilized proper hand hygiene, along with glove changes, while removing bloodlines and prior to removing needles during 3 of 3 observations affecting stations #15, #7 and #5. According to the CDC, handwashing is the most important measure to prevent contaminant transmission. The findings included: 1) Observation of care conducted on 02/07/24 at approximately 9:41 AM revealed Staff C, a Patient Care Technician, discontinuing dialysis treatment at Station #15. Staff C donned clean gloves touched the computer screen, then disconnected the blood lines and proceeded to remove the first needle from the patient’s arms. Staff C failed to perform hand hygiene after disconnecting the blood lines and prior to removing the access needle from the patient’s fistula. Interview with Staff C conducted on 02/09/24 at 8:40 AM confirmed hand hygiene and gloves should be changed after handling blood lines and before removing access needles. 2) Observation of care conducted on 02/07/24 at approximately 9:55 AM revealed Staff D, a Patient Care Technician, discontinuing dialysis treatment at Station #7. Staff D donned clean gloves disconnected the blood lines and proceeded to remove the first needle from the patient’s arms. Staff D failed to perform hand hygiene after disconnecting the blood lines and prior to removing the access needle from the patient’s fistula. Interview with Staff D conducted on 02/09/24 at 8:35 AM confirmed the observation. 3) Observation of care conducted on 02/07/24 at approximately 10:15 AM revealed Staff B, a Patient Care Technician, discontinuing dialysis treatment at Station #5. Staff B donned clean gloves, squeezed the saline bag, repositioned the chair to a sitting position, then disconnected the blood lines and proceeded to remove the first needle from the patient’s arms. Staff B failed to perform hand hygiene after disconnecting the blood lines and prior to removing the access needle from the patient’s fistula. Interview with Staff B conducted on 02/09/24 at 8:30 AM confirmed the observation.”

“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: 22517 Based on observation and interview, it was determined, the clinical staff failed to follow standard infection control precautions as evidenced by the staff failure to disinfect the Phoenix meter after use for 2 of 3 observations. The findings included: 1) Observation of the initiation of treatment for the Patient at Station 5 on 02/07/24 beginning at 11:06 AM with the Patient Care Technician, Staff B, revealed that the staff brought a specimen cup and the Phoenix meter to the station. She used both the specimen cup and the Phoenix meter at the station. Additionally, Patient # 8 was also seated at the station. Upon uses both the specimen cup and the Phoenix meter, Staff B, then discarded the additional liquid left in the specimen cup into the sink marked clean sink and placed both the specimen cup and the Phoenix meter on the counter. The staff did not rinse or clean the Phoenix meter after bringing the item to the dialysis station. An interview was conducted on 02/09/24 beginning at approximately 10:45 AM with Staff B. She confirmed the above observation, she did not clean the items brought to the station. 2) Observation of the initiation of treatment for the Patient at Station 13 was conducted on 02/07/24 at 11:29 AM with the Patient Care Technician, Staff C, revealed that the staff brought the phoenix meter to the station. The staff used the Phoenix meter and then took the meter and stored the meter on the counter. The staff did not clean the Phoenix meter after taking the meter to the dialysis station. An interview was conducted on 02/09/24 beginning at 10:30 AM with Staff C. She confirmed the above observation,she did not clean the meter after using it at the dialysis station.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 22517 Based on administrative record review and staff interview, the facility failed to ensure staff completed the annual regulatory training regarding infection control. This is evidenced by the 2 of 7 staff reviewed failed to have evidence of current infection control training. (Registered Dietician, Social Worker) Training and education in infection control rationales and practices appropriate to the responsibilities and task assignments of the staff member at risk for occupational exposure to blood must be provided initially on employment and periodically, as determined by facility policy, but at least annually. OSHA mandates dialysis staff receive bloodborne pathogen training annually and CDC recommends infection control training initially on employment and annually. The findings included: 1) Review of the personnel file on 02/09/24 revealed that the Licensed Clinical Social Worker did not have evidence of current Infection Control training. The last training was completed on 01/07/23. An interview was conducted on 02/09/24 at 12:01 PM with the Regional Consultant, who stated she would reach out to the lead Social Worker regarding the staff’s training. The Regional Consultant later reported that the SW had not completed the Infection Control training for 2024. 2) Review of the personnel file for the Dietitian revealed that the Regional Dietitian had not completed Infection Control training for 2024. The last training was documented as 01/23. An interview was conducted on 02/09/24 at 12:00 PM with the Regional Consultant, who stated she would follow-up and get back with the surveyor. She later reported that the Dietitian has not completed training for 2024.”

“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 interview, it was determined, the facility failed to follow protocols for the use of the conductivity meter during 3 of 3 observations of care. The findings included: 1) Observation of care conducted on 02/07/24 at approximate 9:57 AM revealed Staff B, a Patient Care Technician, preparing Station #3, the staff took the pHoenix meter to the station to check the water conductivity. After use, Staff B placed the meter back on the counter. The staff failed to rinse the meter after use with RO (Reverse Osmosis) quality water. Interview with Staff B conducted on 02/09/24 at 8:30 AM confirmed the observation and stated she was not aware the meter had to be rinsed after each use. 2) Observation of care conducted on 02/07/24 at approximate 11 AM revealed Staff D, a Patient Care Technician, preparing Station #1, the staff took the pHoenix meter to the station to check the water conductivity. After use, Staff D placed the meter back on the counter. The staff failed to rinse the meter after use with RO (Reverse Osmosis) quality water. Interview with Staff D conducted on 02/09/24 at 8:35 AM confirmed the observation and stated he was not aware the meter had to be rinsed after each use. 22517 3) Observation of the initiation of treatment for the Patient at Station 5 on 02/07/24 beginning at 11:06 AM with the Patient Care Technician, Staff B, revealed that the staff brought a specimen cup and the phoenix meter to the station. She used both the specimen cup and the phoenix meter at the station. Additionally, Patient # 8 was also seated at the station. Upon uses both the specimen cup and the phoenix meter, Staff B, then discarded the additional liquid left in the specimen cup into the sink marked clean sink and placed both the specimen cup and the phoenix meter on the counter. The staff did not rinse the phoenix meter after using the it to the meter dialysis station. Facility policy titled “Verification of Final Dialysate-Conductivity and pH, dated 10/2023 documents: “To provide guidelines on properly verifying dialysate conductivity and pH prior to each patient treatment and whenever a different composition of acid concentrate is used. Collect dialysate sample .....Rinse the cell and syringe interior thoroughly with RO water after each use. An interview was conducted on 02/09/24 beginning at approximately 10:45 AM with Staff B. She confirmed the above observation and that she did not rinse the items brought to the station.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 29151 Based on record review and staff interview, it was determined, the clinical staff failed to ensure the comprehensive assessment included the patient’s immunization history, indicating whether the patients were offered or have received the standard immunizations (pneumococcal and influenza). The failure affected 1 of 1, newly admitted in-center sampled patient (Patient #2). The findings included: Clinical record review conducted on 02/08/24 revealed Patient #2 was admitted to the facility on 12/21/23. The Comprehensive Interdisciplinary Patient Assessment, nursing assessment and vaccinations history did not document information regarding the patient’s history addressing the influenza and pneumonia vaccines. Additional review of the electronic record for immunizations did not contain information regarding the patient’s being offered or refusing the immunizations. Interview conducted on 02/09/24 at 11:20 AM with the Facility Administrator (FA) revealed after review of the electronic record there is no evidence to determine if Patient #2 was offered, refuse or previously received the influenza and pneumonia vaccines.”

“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: 29151 Based on clinical record review and staff interview, it was determined, the clinical staff failed to identify, report and address persistent elevated blood pressures for 1 of 4 in-center sampled patients (Patient #1). The facility also failed to ensure the appropriate time monitoring and administration of anticoagulation medication for three random observation for Patient # 7, # 8 and # 9. The facility also failed to stop Heparinization 1 hour before the end of treatment for 1 of 4 in-center sampled patients (Patient # 4). The findings included: 1) Clinical record review conducted on 02/08/24 revealed Patient #1 had multiple treatments indicating the patient’s blood pressure was elevated and there is no evidence the nurse implemented interventions to manage the blood pressure readings. Physician’s standing orders date 08/22/23 documents Hypertension, give Clonidine 0.1 mg for systolic blood pressure greater than 180 and notify physician if post sitting systolic blood pressure is greater than 180. Treatment record dated 12/30/23 documents blood pressures as 196/94, 183/76, 188/84, 200/95, 197/87, 199/90, 193/90, 192/89, 184/74, 191/89 and 195/85 on discharge. The record failed to provide evidence that the technician reported elevated blood pressures. There is no evidence of education provided to the patient or interventions to manage the elevated blood pressures or evidence the physician was made aware of the elevated readings. Treatment record dated 12/28/23 documents blood pressures as 196/91 and 184/81 on discharge. The record failed to provide evidence that the technician reported elevated blood pressures. There is no evidence of education provided to the patient or interventions to manage the elevated blood pressures or evidence the physician was made aware of the elevated readings. Treatment record dated 12/26/23 documents blood pressures as 184/75, 186/79, 194/78, 193/72, 200/77 and 187/73 on discharge. The record failed to provide evidence of education provided to the patient or interventions to manage the elevated blood pressures or evidence the physician was made aware of the elevated readings. Treatment record dated 12/23/23 documents blood pressures as 193/90, upon discharge and 188/76, 181/78 during treatment. The record failed to provide evidence that the technician reported elevated blood pressures. There is no evidence of education provided to the patient or interventions to manage the elevated blood pressures or evidence the physician was made aware of the elevated readings. Interview with the Facility Administrator conducted on 02/09/24 at approximately 11 AM confirmed the treatment records provided no documentation as to the interventions or education provided to Patient #1 regarding her persistent elevated blood pressure. 2) Clinical record review conducted on 02/08/24 revealed Patient #4 has physician’s orders for Heparin maintenance dose of 3000 units dated 08/16/23 via AV(arterial-venous) Graft. Treatment Records dated 02/02/24 indicates the patient received Heparin 1500 units, not the prescribed dose. Treatment records dated 01/29/24, 01/26/24, 01/22/24, 01/17/24, 01/12/24 and 01/10/24 documents the Heparin infusion was not stopped an hour prior to the conclusion of the treatments, as specified in the facility policy. Interview with Facility Administrator on 02/09/24 at 1:09 PM confirmed the timing was off and explained the medication pumps are programmed based on the prescribed duration and it accounts for the required hour prior to termination of the treatment. Facility policy titled “Heparinization/Heparin Free Protocol dated 02/203 documents “Heparin administration, maintenance dose, administer using the heparin infusion line and pump. Discontinue one hour prior to treatment completion for fistulas and grafts. 22517 3) Review of the facility policy entitled Initiation of Dialysis Treatment, Policy # C-TI-0010, effective 01/2020, documented “If heparin is not on hold or not contraindicated, administer heparin bolus as ordered by physician. a. Systemic heparin should be given at least 3-5 minutes before treatment initiation via IV push.” An observation of the initiation of treatment for the patient at Station 12, Patient #7 conducted on 02/07/24 beginning at 11:01 AM. The nurse came and administered the loading dose of Heparin at 11:02 AM and the Patient Care Technician, Staff C, immediately began the treatment at 11:03 AM, less than one minute later (noted blood flowing through the blood lines). 4) An observation of the initiation of treatment for the patient at Station 13, Patient #9 was conducted on 02/07/24 beginning at 11:29 AM. The nurse came and administered the loading dose of Heparin at 11:34 AM and the Patient Care Technician, Staff C, began the treatment at 11:36 AM, two minutes later. An interview was conducted on 02/09/24 at 10:30 AM with Staff C regarding initiating the treatment after the administration of the heparin. She stated she is to wait 1 minute. The surveyor informed her of policy, you must wait 3 to 5 minutes. She further confirmed she did not wait the required amount of time before initiating the treatment. 4) An observation of the initiation of treatment for the patient at Station 5, Patient # 8 conducted on 02/07/24 beginning at 11:06 AM. The nurse came and administered the loading dose of Heparin at 11:10 AM and the Patient Care Technician, Staff B, began the treatment at 11:12 AM, two minutes later. An interview was conducted on 02/09/24 at 10:45 AM with Staff B regarding initiating the treatment after the administration of the heparin. She stated that you must wait 3 to 5 minutes. She further confirmed she did not wait the required amount of time before initiating the treatment.”

“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, policy review and interview, it was determined, the clinical staff failed to ensure dialysis prescriptions were followed for 1 of 4 sampled in-center patients (Patient #3). This failure included deviation of the prescribed Blood Flow Rate (BFR) and failure to document the reason for the deviation of treatment. The findings included: 1) Clinical record review conducted on 02/08/24 revealed Patient #3 has physician’s orders for dialysis treatment dated 01/19/24 for Blood Flow Rate of 400 and Dialysate Flow Rate of 800. Treatment Records dated 02/05/24, 01/31/24, 01/12/24 and 01/10/24 indicates the patient did not receive the prescribed blood flow rate. The record does not provide an explanation for the deviation from the prescription. Interview with the Clinical Manager conducted on 02/09/24 at 10:57 AM confirmed the staff failed to follow the prescription and did not document the reason for the changes. 3) Clinical record review conducted on 02/08/24 revealed Patient #2 has physician’s orders for Vancomycin one gram dated 01/04/24. In addition, Patient #2 has orders for Venofer, iron therapy dated 01/08/24. The clinical record indicates the physician instructed to hold the iron while the patient is receiving antibiotic therapy. Treatment Records dated 01/20/24, 01/25/24 and 02/01/24 indicates the patient received both the Venofer and Vancomycin, despite the physician’s instructions to hold the iron (Venofer). Interview with The Facility Administrator conducted on 02/09/24 at 11:15 AM confirmed the iron should have been held and the nurse should have placed the medication on hold to avoid the error.”

“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 using aseptic technique during 2 of 3 observations of initiation of treatment (Stations #3 and #5). The findings included: Observation of care conducted on 02/07/24 at approximately 10:02 AM revealed Staff B, a Patient Care Technician, initiating dialysis treatment at Station #3. Staff B don clean gloves performed the skin disinfection and proceeded to insert the first needle. Staff B then proceeded to insert the second needle without disinfecting the access site. Observation of care conducted on 02/07/24 at approximately 10:29 AM revealed Staff B, a Patient Care Technician, initiating dialysis treatment at Station #6. Staff B performed the same technique, failing to disinfect the second access site. Interview with Staff B conducted on 02/09/24 at 8:30 AM confirmed the observation above and confirmed she does not have to disinfect each access site. Facility policy titled “Assessment and cannulation for AV (Arterial-Venous) Fistula Graft and Patient Self Cannulation, dated 10/2023 documents: “Access preparation, Locate and palpate the needle cannulation sites prior to skin disinfection; remove gloves, perform hand hygiene and donned clean gloves; Disinfect EACH access site separately with one of the following options: alcohol prep pad, povidone iodine and Exsept cleanser.””

“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: 22517 Based on observation, staff interview and administrative record review, the Facility Nursing Staff failed to perform the necessary pre treatment nursing assessments for 3 of 3 random observations for Patients (#7, # 8 and # 9). The findings included: 1) An observation of the initiation of treatment for the patient at Station 12, Patient #7 conducted on 02/07/24 beginning at 11:01 AM. The nurse came and administered the loading dose of Heparin at 11:02 AM , input information into the dialysis machine and then left. The nurse did not perform an pre-treatment nursing assessment. The nurse had a stethoscope around her neck that she did not remove or clean, during observation from 11:00 AM to 12:00 PM. 2) An observation of the initiation of treatment for the patient at Station 13, Patient #9 was conducted on 02/07/24 beginning at 11:29 AM. The nurse came and administered the loading dose of Heparin at 11:34 AM and input information into the dialysis machine and then left. The nurse did not perform an pre-treatment nursing assessment. 3) An observation of the initiation of treatment for the patient at Station 5, Patient # 8 conducted on 02/07/24 beginning at 11:06 AM. The nurse came and administered the loading dose of Heparin at 11:10 AM. The nurse came and administered the loading dose of Heparin at 11:34 AM and input information into the dialysis machine and then left. The nurse did not perform a pre-treatment nursing assessment. An interview was conducted on 02/09/24 at 10:35 AM with the Registered Nurse, Staff A, regarding her failure to perform the pre-treatment nursing assessment. She stated she normally does the assessment prior to the treatment starting, especially on the first shift but she apparently got busy on the second shift and did not perform the assessment. The surveyor informed her she observed her from 11:00 AM to 12:00 and she never removed or cleaned the stethoscope from around her neck.”