Dci East Gainesville

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 49777 Based on record review and interview, the facility failed to engage in collaboration planning for an integrated emergency preparedness response. Findings On 6/6/24 at 9:10 AM, Review of the facility Emergency Preparedness Plan does not provide for a collaboration process with local and state emergency staff. During an interview on On 6/6/24 at 9:18 AM, with Area Operations Director, stated an email was sent to the county emergency preparedness planner and he will revise the plan to include the collaboration process.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 49777 Based on record review and interview, the facility failed to include names and contact numbers for Federal, State and local emergency preparedness staff in their Emergency Preparedness Plan. Findings Review of the facility Emergency Preparedness Plan on 6/6/24 at 9:10 AM, does not provide names and contact information for Federal, State, and local emergency preparedness staff. During an interview on 6/6/24 at 9:18 AM, with Area Operations Director, stated he will revise the plan to include the names and contact information.”

“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: 15234 Based on observation, interview and record review the facility failed to ensure 10 of 12 patients, Patient #2, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, and Patient #16, and 1 staff member (Staff A) observed followed acceptable infection control practices to include hand washing upon entering the dialysis treatment floor, after discontinuation of dialysis treatment prior to leaving the dialysis treatment room and hand sanitation after removal of gloves during patient care. Findings include: Observations of patients not washing their hands upon entering the treatment floor and at the completion of treatment before leaving the treatment area included: On 6/3/2024 at 10:17 AM, Patient#8 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #8 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:22 AM, Patient#9 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #9 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:26 AM, Patient#10 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #10 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:45 AM, Patient#11 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #11 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:45 AM, Patient#2 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #2 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:46 AM, Patient#12 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #12 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:50 AM, Patient#13 was observed entering the facility and proceeding to the dialysis chair with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #13 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 11:08 AM, Patient#15 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #15 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 11:09 AM, Patient#16 was observed entering the facility and proceeding to the dialysis chair with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #16 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 11:16 AM, Patient#14 was observed leaving the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #14 to wash or sanitize his hands before leaving the facility. On 6/3/2024 at 10:19 AM, Staff A, Certified Clinical Hemodialysis Technician, was observed discontinuing Patient #2’s central venous catheter treatment. At 10:19 AM, Staff A doffed his gloves, used hand sanitizer to sanitize his hands, patted his hands dry on his gown and donned new gloves. At 10:35 AM, Staff A again A doffed his gloves, used hand sanitizer to sanitize his hands, patted his hands dry on his gown and donned new gloves. During and interview on 6/4/2024 beginning at 1:28 PM, the Clinical Manager confirmed patients should sanitize their hands upon entering and before leaving the treatment area in accordance with facility infection control practices. She confirmed staff should either rub their hands together until dry or allow their hands to air dry after using hand sanitizer. Review of the facility policy titled “Infection Control in Dialysis,” last reviewed 2/26/2024, showed the policy read “Preventing transmission among chronic hemodialysis patients of bloodborne viruses and pathogenic bacteria from both recognized and unrecognized sources of infection requires implementation of a comprehensive infection control program. The components of such a program include infection control practices specifically designed for the hemodialysis setting, including serologic testing and immunization, surveillance, and training and education.” The policy specified “Hand hygiene: includes either washing hands with soap and water or using a waterless, alcohol-based antiseptic hand rub with 60-90% alcohol content” and “hand hygiene will be performed: after touching blood, body fluids, secretions, excretions, and potentially contaminated items before and after direct patient contact before invasive procedures such as vascular access cannulation or administration of parenteral medications immediately after gloves are removed after contact with inanimate objects; i.e. [for example] medical equipment or environmental surfaces at the patient station before entering and upon exiting the patient treatment area when moving from a contaminated body site to a clean body site of the same patient before and after palpitating catheter insertion sites before and after accessing or dressing an intravascular catheter.” The policy continued “A “clean” sink will be available for patients to wash their access site prior to treatment and their hands following treatment” and “Even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surfaces of gloves during glove removal. The CDC [Center for Disease Control] recommends that hand washing incorporate rubbing hands together “vigorously” for 20 seconds, and that the use of alcohol-based rubs incorporate covering all surfaces of the hands and fingers, until hands are dry.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49777 Based on observation, record review and interview the facility failed to follow the guidance and recommendations for the safe and proper use of multiple-dose medication vials when preparing heparin syringes for patient use. Findings: Observed on 6/3/24 at 10:52 AM, observed the nurse manager removing a needle attached to a syringe that had been left in the heparin multi-use vial in the medication room. The nurse manager discarded the syringe and needle and a new needle attached to a new syringe was used to draw heparin from the multi-use heparin vial without using an approved antiseptic agent. The nurse manager obtained a new vial and did use alcohol to clean the rubber stopper before she drew up the second heparin dose in a second syringe. The vial was dated and timed. Record review of the facility policy titled “Use of Multiple Dose Vials”, published June 14, 2021, showed the policy read “Staff preparing medications should clean the rubber stopper of the multi-use vial with 70% isopropyl alcohol, ethyl alcohol, iodophor or other approved antiseptic swab, and allow to dry before entering the vial. The injection port should also be swabbed before using the port to administer a medication.” During interview on 6/3/24 at 10:53 AM, with nurse manager, she stated that she was interrupted with notification of a critical value while drawing heparin dose from multi-dose vial and left the needle in the vial in the medication room.”

“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: 15234 Based on record review and interview the facility failed to ensure interventions to address hypertension were documented as implemented per facility protocol for 1 patient, Patient #5, of 5 patients reviewed for blood pressure management. Findings include: Review of Patient #5’s physician’s order, start date 6/16/2023, showed Resident #5 was ordered to be administered Clonidine hydrochloric acid 0.1 milligram every hemodialysis treatment as needed. Review of Resident #5’s treatment record, dated 5/24/2024, showed Resident #5’s blood pressure readings were recorded as 193/111 at 11:25 AM and as 199/105 at 11:30 AM on 5/24/2024. Review of Resident #5’s treatment record notes, dated 5/24/2024, showed the note read “MED [Medication] CLONIDINE HCL [hydrochloric acid] Reason Not Given: Parameter Not Met.” Review of Resident #5’s treatment record, dated 5/31/2024, showed Resident #5’s blood pressure readings were recorded as 192/108 at 11:21 AM and as 191/106 at 11:31 AM on 5/31/2024. Review of Resident #5’s treatment record notes, dated 5/31/2024, read “MED [Medication] CLONIDINE HCL [hydrochloric acid] Reason Not Given: Parameter Not Met.” During interview on 6/4/2024 beginning at 11:42 AM, the Clinical Manager stated Patient #5’s blood pressure readings in excess of 190/100 were within parameters for administration of Clonidine. She stated that the facility parameters for administration of Clonidine were patient blood pressure readings in excess of 190/100. Review of a facility protocol document, undated, showed the protocol specified blood pressure intra [intradialytic] “for hypertension, after one hour of UF [ultrafiltration] and two doses of Clonidine.” Review of the facility policy titled “Administration of Oral Clonidine,” date issued 1/25/2023, showed the policy read “6. If B/P [Blood Pressure] is above 190/100, please give 0.1 clonidine po [by mouth] per diem.””

“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: 49777 Based on record review and interview the facility failed to follow the prescribed to follow the prescribed dialysate flow rate (DFR) for 1 patient, Patient #3, of 5 in center hemodialysis patients reviewed. Findings Include: Record review of Patient #3’s dialysis treatment orders, in effect 3/22/2024, revealed Patient #3 was prescribed a dialysate flow rate of 800. Record review of patient #3’s dialysis treatment record, dated 5/24/2024, revealed Patient #3’s dialysate flow rate was set at 600 six times during his dialysis treatment on 5/24/2024. Record review of patient #3’s dialysis treatment record for 5/24/2024 failed to reveal documentation that justified or explained why Patient #3’s dialysate flow rate had deviated from his prescribed blood flow rate. Record review of patient #3’s dialysis treatment record, dated 5/27/2024, revealed Patient #3’s dialysate flow rate was set at 600 seven times during his dialysis treatment on 5/27/2024. Record review of patient #3’s dialysis treatment record for 5/27/2024 failed to reveal documentation that justified or explained why Patient #3’s dialysate flow rate had deviated from his prescribed blood flow rate. Record review of patient #3’s dialysis treatment record, dated 5/29/2024, revealed Patient #3’s dialysate flow rate was set at 600 six times during his dialysis treatment on 5/29/2024. Record review of patient #3’s dialysis treatment record for 5/29/2024 failed to reveal documentation that justified or explained why Patient #3’s dialysate flow rate had deviated from his prescribed blood flow rate. During an interview on 6/5/24 beginning at 1:05 PM, Nurse Manager confirmed the dialysate flow rate for Patient #3 was set at 600 during treatments on 5/24/20204, 5/27/24 and and 5/29/2024. The nurse manager stated, “A change from the patient’s dialysate flow rate should always be justified with documentation in the clinical record.””