Usrc Dalton 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: 03383 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) Recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that seven of 22 patients (P) (P#11, P#19, P#22, P#23, P#24, P25, and P#26) observed who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal and prior to leaving the facility. This deficient practice had the potential for cross contamination and increased risk of infection and could affect 107 in-center patients who were dialyzing at this facility. Findings include: An observation in the patient treatment area on 9/4/24 between 8:42 a.m. and 10:50 a.m. revealed the following: - P#11, who was seated at Station (S) 1 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#11 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#19, who was seated at S21 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#19 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#22, who was seated at S5 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#22 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#23, who was seated at S18 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#23 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#24, who was seated at S22 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#24 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#25, who was seated at S7 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#25 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#26, who was seated at S19 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#26 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. According to CDC recommendations, 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 surface of gloves during glove removal. The Facility Administrator was informed about the above findings on 9/6/24 at 5:05 p.m.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 03383 Based on observation and staff interviews, it was determined that the facility failed to ensure that eight of 22 patients (P) (P#15, P#16, P#17, P#18, P#19, P#20, P#21, and P#8) observed, had their vascular access sites (dialysis needle insertion sites) uncovered/visible to the staff throughout dialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exsanguination (severe loss of blood). The facility in-center hemodialysis census was 107. Findings include: An observation in the patient treatment area on 9/4/24 between 8:42 a.m. and 10:50 a.m. revealed the following: - P#15 [seated at Station (S) 3], P#16 (S4), P#17 (S13), P#18 (S17), P#19 (S21), and P#20 (seated at S24) had their vascular access sites covered and were not visible during their dialysis treatment. A review of the Flowsheets dated 9/4/24 for each patient listed above showed “access visualized” between 8:42 a.m. and 10:50 a.m. when their access sites were observed by this surveyor to had been covered with a blanket. An observation in the patient treatment area on 9/5/24 between 1:46 p.m. and 2:30 p.m. revealed the following: - P#21 (seated at S12) and P#8 (seated at S19) had their vascular access sites covered and were not visible during their treatment. During an interview on 9/5/24 at 2:30 p.m., LPN HH confirmed the above findings and stated “I’m sorry”, talked to P#8 and P#21 and removed blanket from access sites of both patients. The Facility Administrator was informed of the above findings on 9/5/24 at approximately 2:45 p.m. and during the exit conference on 9/6/24 at 5:15 p.m.”

“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: 03383 Based on a review of the facility’s Fiscal Year 2024 Quarterly Dialysis Facility Report (DFR: A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), a review of facility records, and staff interview, it was determined that the interdisciplinary team (IDT) failed to make changes to plans of action to improve and sustain the facility’s anemia (when the body doesn’t have enough healthy red blood cells or hemoglobin to carry oxygen to the body’s tissues) management for peritoneal dialysis (PD) patients for three of three months (May 2024 - July 2024) of Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 33 home dialysis patients (29 PD and four home hemodialysis patients) who were under the care of this facility. Anemia could lead to a variety of symptoms such as fatigue, shortness of breath, dizziness, headaches, and heart problems. Findings include: A review of the QAPI meeting minutes from May - July 2024, revealed that the facility was above the US (United States) threshold in anemia. In comparison, a review of the facility’s last quarter QAPI meeting minutes from May 2024 - July 2024, revealed the following outcomes that were greater than the US threshold. Anemia - (Hemoglobin less than 10.0 g/dL) - for PD patients at this facility was 24.1% in May 2024; 48.4% in June 2024; and 48.3 % in July 2024, when compared to US at 23% nationally. The facility’s QAPI meeting minutes from May 2024 - July 2024 revealed documentary evidence that the IDT conducted a comprehensive review of the above outcomes; however, no changes were made to the action plans to ensure and sustain improvement. The Facility Administrator confirmed the above findings on 9/5/24 at approximately 3:30 p.m., and stated that the IDT will work toward improvement of anemia outcomes.”

“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: 03383 Based on a review of medical records, staff interviews, and review of policies and procedures, it was determined that the medical director failed to ensure that two of four Registered Nurses (RN) (RN AA and RN BB] and one of one Licensed Vocational Nurse (LVN) (LVN AA) who cared for three of three patients (P) (P#3, P#7, and P#8) sampled who experienced elevated blood pressure (BP) readings before, during, and after dialysis treatment, adhered to policies and procedures relative to elevated BP. This deficient practice could negatively affect the health and safety of P#3, P#7, and P#8. Persistently high BP could cause heart disease and stroke. The facility census was 107. Findings include: A review of treatment flowsheets from 7/2/24 to 9/2/24 showed the following: P#3: On 8/27/24: - P#3’s dialysis treatment was initiated by RN AA at 1:36 p.m. P#3’s BP was 174/100 mmHg (millimeters of mercury). There was a lack of documented evidence that P#3’s BP was taken for one hour and 55 minutes. At 3:31 p.m., P#3’s BP was 165/110 mmHg [diastolic BP (bottom number) increased from 100 to 110] and P#3 complained of cramping. At 3:33 p.m., P#3’s BP was 104/75 mmHg. - The flowsheet dated 8/27/24 was reviewed with the Facility Administrator (FA) and Clinical Specialist (CS) on 9/6/24 at 1:48 p.m. The FA and CS had no explanation for why vitals were not taken or documented from 1:36 pm to 3:33 p.m. On 9/2/24: - The initiation of P#3’s dialysis treatment began at 3:35 p.m. with a BP reading of 161/94 mmHg. There was a lack of documented evidence that P#3’s BP was taken for one hour and 55 minutes. BP was not taken again until 5:30 p.m. P#3’s EDW (Estimated Dry Weight) was 95 kg (kilogram). - 8/21/24: Pre weight: 103.3 / Post weight: 99.9 kg - 8/23/24: Pre weight: 102.9 / Post weight: 99.7 kg - 8/26/24: Pre weight: 104.6 / Post weight: 104.4 kg - 8/27/24: Pre weight: 104.2 / Post weight: 101.3 kg - 8/28/24: Pre weight: 100.9 / Post weight: 98 kg - 9/02/24: Pre weight: 103.3 / Post weight: 101 kg There was a lack of documentary evidence that the nurse notified the physician about dry weights with variance > (greater than) or < (less than) 1kg from EDW per policy. During an interview on 9/6/24 at 2:09 p.m., the FA stated that EDW adjustments were made on 7/23/24 - 87.9 kg; 8/10/24 - 93.6 kg.; and 8/21/24 - 95 kg. FA stated EDW can only be increased by 1 kg per week. A review of P#3’s Standing Orders dated 6/5/24 showed the following: - Hypertension: Clonidine 0.1 mg (milligram) PO (by mouth) x 1 prn (as needed) SBP (Systolic BP) > 180. Repeat BP q (every) 15 min (minutes) for 1 hour after giving medication. Notify MD if post sitting systolic BP >180 mmHg. - Vital signs pre and post dialysis - TPR, (standing and sitting) BP and pulse q 30 min and prn during treatment. - Record pre and post treatment weights (if variance > or < 1kg from EDW notify MD (Physician). P#7: On 7/2/24: - P#7’s pre-dialysis standing BP was 160/86 mmHg and 156/96 mmHg sitting at 6:13 a.m. P#7’s dialysis treatment began at 11:34 a.m. with a BP reading of 141/50 mmHg. The next BP taken was at 6:31 a.m. and it was 171/101 mmHg; at 7:01 p.m., BP was 159/96 mmHg; 155/102 mmHg at 7:31 a.m.; 141/115 mmHg at 8:01 a.m.; 160/94 mmHg at 8:14 a.m.; 164/97 mmHg at 8:31 a.m., 157/116 mmHg at 9:01 a.m.; 174/100 mmHg at 9:31 a.m.; 147/101 at 9:45 a.m., 171/103 at 10:01 a.m.; and the treatment ended at 10:18 a.m. The last BP was 170/108 mmHg at 10:32 a.m. PCT documented “Informed RN/NP patient’s bp is hypertensive (sic). Bp meds rx to be prescribed (sic)”. BP was not rechecked prior to patient leaving the facility. There was a lack of documented interventions for elevated BP readings. - Similar findings occurred on 7/16/24, 7/18/24, and on 7/25/24. On 8/1/24: - P#7’s dialysis treatment began at 9:24 a.m. with a BP reading of 165/91 mmHg. The next BP taken at 9:32 a.m. was 160/108 mmHg; 169/101 mmHg at 10:01 a.m.; 162/100 mmHg at 10:30 a.m.; 181/111 mmHg at 11:01 a.m.; 147/113 mmHg at 11:03 a.m.; 169/96 mmHg at 11:05 a.m.; and 176/103 at 11:08 a.m., when treatment ended. The last BP reading was 192/106 mmHg sitting and 176/106 mmHg at 11:23 a.m. The flowsheet did not show that BP was rechecked prior to patient leaving the facility. There was a lack of any interventions that addressed elevated BP readings during and after dialysis treatment. RN BB did not administer Clonidine per standing orders nor notified the physician of P#7’s elevated BP readings. The FA and CS confirmed the above findings on 9/6/24 at 2:15 p.m. The FA stated the nurse should have rechecked the BP and notified the physician about the elevated BP. A review of P#7’s Standing Orders dated 4/1/24 showed the following: Hypertension: Clonidine 0.1 mg PO x 1 prn SBP > 180. Repeat BP q 15min for 1 hour after giving medication. Notify MD if post sitting systolic BP>180 mmHg. P#8: On 8/24/24: - P#8’s pre-dialysis standing BP was 202/108 mmHg and 190/101 mmHg sitting. P#8’s dialysis treatment began at 11:34 a.m. with a BP reading of 188/81 mmHg. The next BP taken at 12:01 p.m. was 197/96 mmHg; 186/98 mmHg at 12:31 p.m.; 194/98 mmHg at 1:01 p.m.; 200/99 mmHg at 1:31 p.m. and P#8 received Clonidine 0.1 mg at 1:34 p.m. At 2:01 p.m., BP was 187/90 mmHg; 175/86 mmHg at 2:31 p.m.; 169/81 mmHg at 3:01 p.m.; 173/81 mmHg at 3:31 p.m.; and 189/125 mmHg at 3:34 p.m. at the end of treatment. BP readings were not taken every 15 minutes for one hour per standing orders. A review of the flowsheet with the FA and CS on 9/6/24 at 1:58 p.m. revealed nurses wait for an hour to see if the BP will go down; but had no reason why BP was not rechecked or taken every 15 minutes for one hour after Clonidine was administered per standing orders. On 8/27/24: - P#8’s pre-dialysis standing BP was 227/110 mmHg and 218/98 mmHg sitting. P#8’s dialysis treatment began at 11:39 a.m. with a BP reading of 201/87 mmHg. - The next BP taken at 12:01 p.m. was 187/80 mmHg; 208/99 mmHg at 3:58 p.m., post treatment; and was 205/86 mmHg at 4:00 p.m. There was a lack of documentary evidence that BP was rechecked prior to patient leaving the facility. There was a lack of documented interventions done after the last BP reading of 205/86 mmHg. - A review of the flowsheet with the FA and CS on 9/6/24 at 2:51 p.m., confirmed the above findings. FA stated the nurse should have rechecked the BP and should have notified the physician about the elevated BP readings. A review of P#8’s Standing Orders dated 4/18/24 showed the following: Hypertension: Clonidine 0.1 mg PO x 1 prn SBP > 180. Repeat BP q 15min for 1 hour after giving medication. Notify MD if post sitting systolic BP >180 mmHg. A review of policy titled, “Intradialytic Monitoring of Patient” dated 7/2024 revealed the following: Vital signs: - Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters, refer to C-FORMS-0081 Reportable Parameters to CN. A review of policy titled, “Reportable Parameters to CN” CT/CCHT/LPN with revision date of 1/2020 showed the following: - Pre-dialysis B/P: Systolic > 200 or < 100; Diastolic > 100 - Intra-dialysis: Systolic > 180 or < 90 Diastolic > 100 - Post-dialysis: Systolic > 180 or < 90 Diastolic > 100”