Dci Fayetteville

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 32734 Based on observation, staff interviews, and a review of policies and procedures (P&P), it was determined that the facility failed to ensure that there was a safe environment for all patients as evidenced by failure of four of four staff [Registered Nurse (RN) AA/Charge Nurse (CN), RN BB, Patient Care Technician (PCT) AA and PCT BB] to verify the expiration dates of the Combined Standard Solution pH 7.0/Conductivity 14.0 used for the calibration of Myron L Meter (A device used to measure pH (acidity) and conductivity (measurement of the dialysate’s ability to conduct electricity), to ensure accuracy of testing dialysate (a solution of pure water, electrolytes and salts such as bicarbonate and sodium) for safe patient use, prior to the initiation of dialysis treatments. This failure had the potential to negatively affect the health and safety of 19 patients that dialyze at this facility. Findings were: Cross Reference V250 - Failure of the facility to ensure that the machines’ dialysate pH and conductivity was accurately tested prior to each patient treatment.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 32734 Based on a review of facility records and staff interviews, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 19 in-center hemodialysis patients who were dialyzing at this facility. Findings were: Cross Reference V250 - Failure of the facility to ensure that there was a safe environment for all patients as evidenced by failure of four of four staff [Registered Nurse (RN) AA/Charge Nurse (CN), RN BB, Patient Care Technician (PCT) AA and PCT BB] to verify the expiration dates of the Combined Standard Solution pH 7.0/Conductivity 14.0 used for the calibration of Myron L Meter (A device used to measure pH (acidity) and conductivity (measurement of the dialysate’s ability to conduct electricity), to ensure accuracy of testing dialysate (a solution of pure water, electrolytes and salts such as bicarbonate and sodium) for safe patient use, prior to the initiation of dialysis treatments.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 32734 Based on observation and staff interview, it was determined that the facility failed to ensure that the facility’s emergency equipment and drugs were readily available and not expired. This failure had the potential to negatively impact the health and safety of 19 patients who dialyzed at this facility. Findings were: Observation of the emergency crash cart on 6/5/24 at 10:34 a.m., revealed that two of three sets of Philips adult pad cartridges used with the AED (Automatic External Defibrillator) in the event of a cardiac arrest (heart attack) expired on 4/7/24; and one of two Albuterol inhalers used for respiratory distress expired on 4/7/24. During an interview at 10:45 a.m. on 6/5/24, with Registered Nurse (RN) AA, who was the Charge Nurse, she stated “I check the crash cart daily and the other nurse (RN BB) checks it monthly. I was unaware of expired meds or supplies”.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 32734 Based on a review of facility records, patients and staff interviews, it was determined that the facility failed to ensure that the patients were oriented and trained on the facility’s Emergency Preparedness Plan (EPP). This failure had the potential to negatively affect the health and safety of 19 patients who dialyzed at this facility. Findings were: Review of the Emergency /Safety Binder and Patient Education Binder from November 2023 - June 2024 revealed a lack of documented evidence that patients nor staff had been educated on the facility’s Emergency Plan. Patients had not been trained on emergency disconnection of treatment procedures and there were no documented Fire Drills. During interviews on 6/5/24 with patients between 1:00 p.m. and 1:30 p.m., the following was revealed: - At 1:00 p.m., Patient (P) #1, who was seated at Station (S) 1 stated “I started at the facility in March 2023, and I have not been taught anything about Emergency Preparedness”. P#1 denied ever being trained how to disconnect from the machine during an emergency or participated in any Fire Drills. - At 1:10 p.m., P#2, who was seated at S4 stated “I’ve been at this facility for nine years and I think they may have talked to me about Emergency Preparedness and how to disconnect myself from the machine, but I just don’t remember”. During an interview with Registered Nurse (RN) BB on 6/5/24 at 1:25 p.m., she presented a patient education binder with laminated printouts of various topics located at the nurse’s station used for educating patients and acknowledged that there was no documented evidence of an actual patient training.”

“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: 32734 Based on observation, staff interviews, and a review of facility policy and procedures and the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA) and one of two Patient Care Technicians (PCT BB) observed, changed gloves when going from a “dirty” area or task to a “clean” area or task. This deficient practice had the potential to negatively affect the 19 in-center hemodialysis patients who dialyzed at this facility. Findings were: During observation in the Patient Treatment Room on 6/5/24 between 10:10 a.m. and 1:30 p.m., the following was observed: - At 10:24 a.m., PCT BB was observed preparing the access of Patient (P) #6, who was seated at Station (S) 3 for cannulation (insertion of dialysis needles). PCT BB pushed P#3’s shirt up to expose the arteriovenous graft (AVG - dialysis access) located mid-sternum (middle of the chest), opened clean supplies, cleaned access, and discarded used/contaminated alcohol pad onto the clean pad/liner with clean supplies, then proceeded to cannulate the AVG without changing gloves between tasks. - At 10:52 a.m., RN AA was observed during initiation of hemodialysis treatment on P#7, who had a central venous catheter (CVC - a flexible tube that was inserted into a vein, and was guided/threaded into a large vein above the right side of the heart called the superior vena cava) at S10. RN AA cleaned the CVC site, withdrew blood from the ports, touched the machine (dirty) and keyboard, and then connected P#7’s bloodlines to the CVC. RN AA failed to change gloves between tasks. During an interview with PCT BB and RN AA at approximately 11:00 a.m., both stated they were unaware of the breaches in infection control practices. A review of Procedure: 301, titled, “Universal Precautions” dated 1/16/19 showed the following: Page 4 33. Gloves will be changed as soon as possible following contamination. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area) could cause the spread of bacteria/infections.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 32734 Based on observation and staff interview, it was determined that the facility failed to ensure that a sufficient number of sinks were readily available in one of one Patient Treatment Room, to facilitate hand washing and to meet the needs of the staff and patients. This facility had 16 in-center hemodialysis (ICHD) stations and 19 ICHD patients who dialyzed at this facility. Findings were: During observation of the Patient Treatment Room on 6/5/24 between 10:00 a.m. and 1:00 p.m., one of two designated “clean” sinks used for handwashing, was not operable. The clean sink located at the back nurse’s station had discarded plastic syringe caps and other small debris; and the foot pedal used to push to supply water did not work. During and interview with the biomed technician at approximately 11:05 a.m., he acknowledged that the sink did not work.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 32734 Based on observation and staff interviews, it was determined that the Infection Control Committee failed to ensure that one of one Nurse Practitioner (NP) observed, wore appropriate personal protective equipment (PPE such as gown), while she interacted with patients during a time of high risk for spurting or spattering of blood, as, for example, during initiation or termination of dialysis. This deficient practice had the potential to negatively affect the health and safety of the NP. Findings were: During observation in the Patient Treatment Room on 6/7/24 from 9:00 a.m. to 10:15 a.m., the following was revealed: - At 9:14 a.m., during shift change, the NP went from patient to patient at Station (S) 5, S6 and S8 and picked up clip boards off the top of each machine, shook hands with a patient while wearing a lab coat which was opened in the front (inappropriate PPE). - At 9:24 a.m., the NP walked over to Patient (P) #8 at S2. NP picked up the clip board off the top of machine while she had a conversation with P#8, during the termination of P#8’s dialysis treatment. The NP left the facility prior to interview. During the exit interview on 6/7/24 at 2:00 p.m., the Area Director and the Senior Director of Operations were notified of the above findings and did not offer any comments.”

“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: 32734 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) guidelines, staff interviews, review of NKF KDOQI (National Kidney Foundation Kidney Disease Outcomes Quality Initiative) Vascular Access Guideline, and a review of facility policy and procedures, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA) observed during initiation and termination of hemodialysis (HD) treatment on two of two patients (P#7 and P#8) observed who had Central Venous Catheter (CVC - a flexible tube that was inserted into a vein, and was guided/threaded into a large vein above the right side of the heart called the superior vena cava), utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of P#7, P#8, and all other patients who had CVC, as their dialysis access. The facility census was 19. Findings were: During observation in the Patient Treatment Room on 6/5/24 and on 6/7/24 between 9:00 a.m. and 1:30 p.m., the following was observed: - On 6/5/24 at 10:52 a.m., RN AA was observed during initiation of hemodialysis treatment on P#7, who had a CVC at Station (S) 10. RN AA cleaned the CVC site, withdrew blood from the ports, touched the machine (dirty) and keyboard, and then connected P#7’s bloodlines to the CVC. RN AA failed to change gloves between tasks. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause the spread of bacteria/infections. - On 6/7/24 at 9:11 a.m., RN AA was observed terminating dialysis treatment on P#8, who had a CVC at S2. P#8 did not wear a face mask during the entire procedure. During an interview on 6/7/24 at 9:30 a.m., the Nurse Practitioner asked RN AA why the patient was not wearing a mask. RN AA stated “he refused to wear a mask”. A review of the NKF KDOQI (National Kidney Foundation Kidney Disease Outcomes Quality Initiative) Vascular Access Guideline stated “Airborne contaminants from both patients and staff are prevented best by the use of surgical masks when the catheter lumens or exit site are exposed”. A review of Procedure: 112 titled “Central Venous Protocol” showed the following: Page 3 under Key Points Wearing a face mask decreases the risk of transmitting microorganisms from the respiratory tract of the staff member or the patient, onto the catheter site itself, as well potentially into the vascular system of the patient.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 32734 Based on observation, a review of policies and procedures (P&P), and staff interviews, it was determined that the facility failed to ensure that four of four Direct Patient Care Staff [Registered Nurse (RN) AA/Charge Nurse (CN), RN BB, Patient Care Technician (PCT) AA and PCT BB], verified the expiration date of the Combined Standard Solution pH 7.0/Conductivity 14.0 used for the calibration of Myron L Meter (A device used to measure pH (acidity) and conductivity (measurement of the dialysate’s ability to conduct electricity), to ensure accuracy of testing dialysate (a solution of pure water, electrolytes and salts such as bicarbonate and sodium) for safe patient use, prior to the initiation of dialysis treatments. This failure had the potential to negatively affect the health and safety of 19 in-center hemodialysis patients who dialyzed at this facility. Findings were: During inspection on 6/5/24 at approximately 10:10 a.m., of the Tri-Station [a metal holder that housed the pH and conductivity solutions and a bottle of Reverse Osmosis (RO) Water used for the calibration of Myron L Meters], the following was revealed: - The Mesa Labs Combined Standard Solution pH 7.0/Conductivity 14.0 had expired on 11/17/23 but was dated as opened by the staff on 3/11/24 and had been used to calibrate the Myron L Meters from 3/11/24 through 6/5/24. A review of an undated procedure titled, “Myron L D6 Meter Disinfection, Calibration, Use and Storage” showed the following: Confirm that the 14.0 mS conductivity and 7.0 pH buffer solutions expiration dates (x2) are not expired. During an interview on 6/5/24 at 11:03 a.m., the Biomed Technician confirmed that the staff was currently using the solution and he was unaware that the solution was expired. He immediately discarded the solution and brought a new bottle from the Supply Room. Both RN AA and RN BB stated they were unaware of the expired solution.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 32734 Based on observation and staff interview, it was determined that the facility failed to ensure that all cabinets were maintained free from damage and defects to ensure safety for all patients and staff. This environmental concern was observed in one of one Patient Treatment Room. This deficient practice had the potential to cause injury to staff and patients who were seated nearby. The facility census was 19. Findings were: During observation in the Patient Treatment Room on 6/5/24 between 10:00 a.m. and 1:00 p.m., the cabinet located at the back nurse’s station that stored bags of normal saline (sterile salt water), had one door broken off the hinges and the second door was missing. During an interview with the Biomed Technician on 6/5/24 at approximately 11:00 a.m., he acknowledged the broken cabinet doors.”

“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: 32734 Based on observation and staff interviews, it was determined that the facility failed to ensure that two of eight patients (P#11 and P#12) observed during dialysis treatment, had their vascular access 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 had 19 patients. Findings were: During observation in the Patient Treatment Room on 6/5/24 between 10:00 a.m. and 1:00 p.m., P#11 who was seated at Station (S) 8 and P#12 who was seated at S12, had their vascular access sites covered with a blanket during dialysis treament. During an interview on 6/5/24 at approximately 10:30 a.m., Registered Nurse (RN) AA and Patient Care Technician (PCT) BB both acknowldeged that the patients’ access sites were covered.”