Dci - Dialysis Clinic, Inc. - Blakely

“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 Centers for Disease Control and Prevention (CDC) recommendations, staff interviews, and review of facility policy and procedure, it was determined that the Infection Control Committee failed to ensure that six of six patients [seated at Stations (S) 1, 9, 12, 13, 14, and 15] 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 negatively affect the health and safety of 48 patients who were dialyzing at this facility. Findings were: During observation in the Patient Treatment Room on 1/10/24 between 9:24 a.m. and 10:48 a.m., the following was observed: - The patients who were seated at S1, S9, S12, S13, S14, and S15 held pressure to their dialysis access sites and left the facility without performing hand hygiene. - Patients who were seated at S1, S9, S12, S13, S14, and S15 were not reminded by the staff to wash their hands nor were 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 Nurse Manager and Assistant Director of Operations were informed about the above observations on 1/11/24 at 10:30 a.m. This surveyor requested hand hygiene policy which was provided on 1/11/24 at 10:35 a.m. A review of Procedure No. 304 titled, “Use of Gloves Including Hand Hygiene” dated 01/16/19 stated: Gloves must be provided to patients and visitors if these individuals assist with procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment ... Hand hygiene will be performed immediately after gloves are removed.”

“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: 03383 Based on a review of patient records and staff interview, it was determined that the Interdisciplinary Team (IDT) failed to develop and implement a plan of care to manage the blood pressure (BP) of one of one patient (P#3) sampled, who experienced extremely high blood pressure (BP) readings before, during, and after dialysis treatment. The facility census was 48. Findings were: A review of Physician’s Hemodialysis Standing Orders that was signed by the physician on 3/16/23, showed the following: Clonidine 0.1 mg p.o. (by mouth) x 1 for systolic (upper number) BP > 180 and diastolic (bottom number) BP > 105 the last 60 minutes of the treatment. Recheck BP in 30 minutes and one hour. Notify physician if patient is symptomatic or no response to medication. If pulse is less than 60, call physician before administering Clonidine. A review of P#3’s treatment flowsheets showed the following: P#3’s Treatment Plan: Duration: 4 hours, EDW (Estimated Dry Weight): 138.5 kg (kilogram), BFR (Blood Flow Rate): 550, DFR (Dialysate Flow Rate): 600. On 12/31/23: - P#3’s pre dialysis BP sitting was 208/108 and 203/115 standing. His pulse rate was 92. - P#3’s elevated BP was not related to excessive fluid as P#3’s pre dialysis weight was 138.5 kg, which is only 0.3 kg over his EDW. - The initiation of P#3’s dialysis treatment began at 9:01 a.m. P#3’s BP at 9:02 a.m. was 222/116. - P#3’s BP was 209/117 at 9:32 a.m.; 218/118 at 10:03 a.m.; 209/113 at 10:32 a.m.; 175/108 at 11:01 a.m.; 163/95 at 11:31 a.m.; 171/92 at 12:01 p.m.; 168/100 at 12:31 p.m.; 185/102 at 1:01 p.m.; and 201/111 at 1:04 p.m. There was a lack of documented intervention that addressed P#3’s elevated BP readings before, during, and after dialysis treatment. - The treatment record did not show that Patient Care Technician (PCT BB) who was assigned to care for P#3, notified either one of the Registered Nurses (RN GG or RN JJ) about P#3’s elevated BP readings. - The treatment record did not show that RN GG or RN JJ notified the physician or administered standing order for Clonidine 0.1 mg as ordered. - P#3’s post dialysis BP was extremely elevated at 201/111. - P#3’s post weight was 137.7 kg which was 0.8 kg below his EDW. - There was a lack of documented intervention that addressed P#3’s elevated post treatment BP and post weight below EDW. During an interview on 1/11/24 at 12:32 p.m., the Nurse Manager and Assistant Director of Operations confirmed the above findings per treatment record and did not produce documentation of any interventions to manage P#3’s volume status. A review of Policy No: (N 1 of 2) E-6 titled, “Patient Assessment Pre - Hemodialysis” last updated October 2010 stated: The physician should be notified before dialysis is initiated on any patient with abnormal findings uncommon for the individual patient including: a. Elevated Blood Pressure ... e. Severe Hypotension (low BP) ... j. Tacycardia (increased heart rate). A review of Policy No: (N 1 of 2) E-7 titled, “Patient Assessments Post Hemodialysis” last updated January 2016 stated: The post assessment must be completed after treatment has ended and documented on the flow sheet. Assessments are completed by licensed staff and all abnormal finding are reported to the charge nurse.”

“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: 03383 Based on a review of medical records, staff interviews, and a review of facility policy, it was determined that the interdisciplinary team (IDT) failed to implement the patients’ plan of care to effectively manage patient outcomes for adequacy of dialysis [effectiveness of dialysis prescriptions to avoid symptoms of uremia (build up of toxins in the blood) - measured by Kt/V], for 2 of 5 sampled in-center hemodialysis patients (P#3 and P#4). The facility census was 48. Findings were: A review of medical records showed the following: P#3: A review of P#3’s Interdisciplinary Care Plan: Stable - Completed (9/11/23) showed “Patient has low Kt/V. Action Steps: Recheck as scheduled. Completion Date: 10/31/23.” A review of P#3’s laboratory results revealed the following: - On 9/6/23, P#3’s Kt/V was 0.99 - On 9/18/23, the Kt/V was 0.86 - On 9/27/23, Kt/V was 1.18 - On 10/2/23, Kt/V was 1.11 - On 10/16/23, Kt/V was 1.21 - On 10/23/23, Kt/V was 1.32 A review of physician orders dated 10/23/23 showed increase BFR to 550 and the duration of dialysis was also increased to four hours. On 11/6/23, P#3’s Kt/V dropped to 0.93. A review of treatment flowsheets from 12/12/23 - 1/8/24 showed the following: P#3’s Treatment Plan: Duration: 4 hours, EDW (Estimated Dry Weight): 138.5 kg (kilogram), BFR (Blood Flow Rate): 550, DFR (Dialysate Flow Rate): 600. On 12/27/23: - P#3’s dialysis treatment started at 2:28 p.m. with a BFR of 550; BFR was decreased to 500 at 3:33 p.m. and remained at 500 until the treatment ended at 6:33 p.m. - There was a lack of documented reason for the decreased BFR. On 12/29/23: - P#3’s dialysis flowsheet showed a BFR of 200 at 1:01 p.m.; was increased to 550 at 1:31 p.m.; and was decreased to 400 at 2:31 p.m. until 5:01 p.m. - There was no documentation found in the treatment sheet that explained why the BFR did not remain at 550 for the entire treatment. On 1/5/24: - P#3’s treatment record showed a BFR of 200 at 5:18 p.m. and was increased to 350 at 5:48 p.m. The BFR was again increased to 500 at 7:18 p.m. until the end of treatment. - There was no documentation found in the treatment sheet that explained why the BFR was not set at 550 for the entire treatment. On 01/08/24: - P#3’s treatment record showed a BFR of 200 at 3:38 p.m.; 350 at 5:48 p.m.; and was increased to 500 at 4:08 p.m. until 6:39 p.m. - There was no documentation found in the treatment sheet that explained why the BFR was not set at 550 for the entire treatment. P#4: P#4’s Treatment Plan: Duration: 4 hours, EDW (Estimated Dry Weight): 73.5 kg (kilogram), BFR (Blood Flow Rate): 500, DFR (Dialysate Flow Rate): 800. - 12/31/23 - P#4’s treatment record showed a BFR of 400 during the entire treatment. - There was a lack of documented reason for the decreased BFR. During an interview on 1/11/24 at 12:32 p.m., the Nurse Manager and Assistant Director of Operations confirmed the above findings per treatment records and did not show documentation of the reasons as to why the BFR was not set per the treatment plans. A review of Policy No: (N 1 of 2) E-16 titled, “Verification of Treatment Plan Prior to Initiation of Dialysis” dated January 2019 stated: The dialysis verification process is initiated after the dialysis machine has passed testing and the machine check has been completed. Verification must be completed with patient in the chair. Two clinical staff are required to verify the treatment plan. The primary staff is responsible for verifying the treatment plan on the machine. Secondary staff will verify treatment plan on the flowsheet ... Both staff will initial and sign the flowsheet - verifying the treatment plan is correct.””