Usrc Adel

“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 CDC recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that four of seven patients (P#1, P#8, P#11, P#12 ) 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 67 in-center patients who were dialyzing at this facility. Findings were: During observation in the patient treatment area on 02/13/24 between 11:26 a.m. and 12:30 p.m., the following was observed: - P#1, P#8, P#11, and P#12 held pressure to their dialysis access sites and left the facility without performing hand hygiene. - P#1, P#8, P#11, and P#12 were 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 2/15/24 at 1:45 p.m.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 03383 Based on a tour of the facility and staff interview, it was determined that the facility failed to ensure that one of one double doors at the back of the building, was maintained to prevent entry of insects and vermin; and to provide a safe environment for 67 patients who were dialyzing at this facility. Findings were: During a tour of the facility on 02/13/24 at 11:26 a.m., the following was observed: - The back double doors leading to the outside had approximately 1/4 inch - 1/2 inch gap between the double doors and the floor width across the door (12 inches width across the right door) that could allow insects and vermin to enter the building. The Facility Administrator was present during the tour and confirmed the above findings on 02/13/24 at 11:26 a.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 four of ten patients (P#2, P#8, P#9, P#10) observed in the patient treatment area at Stations 2, 7, 9, and 16, 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 census was 67. Findings were: During observation in the Patient Treatment Room on 02/15/23 between 7:00 a.m. and 2:22 p.m., the following was revealed: - P#2, P#8, P#9, and P#10 who were seated at Stations 16, 2, 9, and 7 respectively, had their access sires completely covered by a blanket. PCT LL confirmed the above findings, talked to each patient and removed the blanket from their access sites. The Facility Administrator was informed of the above findings on 02/15/23 at 2:00 p.m.”

“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 three of six sampled patients (P#2, P#5, and P#7). Findings were: A review of treatment flowsheets from 1/30/24 - 2/15/24 showed the following: P#2: P#2’s Dialysis Prescription dated 01/24/24: Duration: 225 minutes (3 hours and 45 minutes), BFR (Blood Flow Rate): 450 mL/min (milliliter per minute), DFR (Dialysate Flow Rate): 1.5 autoflow. On 1/30/24: P#2’s treatment started at 5:01 a.m. and was discontinued at 8:54 a.m. (3 hours 53 minutes). Treatment record showed that BFR was set at 400 mL/min at 5:01 a.m. and was decreased to 375 mL/min at 6:32 a.m. until 8:52 a.m. when treatment was terminated. The record did not show why the BFR was not set to 450 mL/min as ordered. This was confirmed by the Facility Administrator (FA) on 02/15/24 at 8:44 a.m. On 2/8/24: P#2’s treatment started at 4:32 p.m. and was discontinued at 8:19 a.m. (3 hours 47 minutes). -Treatment record showed that BFR was decreased from 450 mL/min to 400 mL/min at 6:32 a.m. until 8:17 a.m. Vitals and machine settings were not checked for over an hour (7:08 a.m. and 8:17 a.m.). - The record did not show why the BFR was decreased to 400 ml/min. On 2/13/24: P#2’s treatment started at 4:41 a.m. and was discontinued at 8:26 a.m. (3 hours 45 minutes). -Treatment record showed that BFR was decreased from 450 mL/min to 400 mL/min at 6:32 a.m. until 8:17 a.m. Vitals and machine settings were not checked for over an hour (7:08 a.m. and 8:17 a.m.). - The record did not show why the BFR was decreased to 400 mL/min. - The FA was informed on 2/14/24 at 8:44 a.m. and confirmed that treatment records lacked reason for not maintaining the BFR at 450 mL/min as ordered. P#5: P#5’s Dialysis Prescription dated 01/04/24: Duration: 180 minutes (3 hours), EDW: 71 kg, BFR: 450 mL/min, DFR: 600 mL/min. On 2/10/24: P#5’s treatment started at 9:09 a.m. and was discontinued at 12:53 p.m. (2 hours 53 minutes) Pre-weight: 72.6 kg. Post weight: 70.6 kg. Treatment record showed that P#5 dialyzed with a DFR of 500 mL/min during the entire treatment. The treatment record did not show why the DFR was not set to 600 mL/min as ordered. P#7: P#7’s Dialysis Prescription dated 01/04/24: Duration: 240 minutes (4 hours), EDW: 62.5 kg, BFR: 450 mL/min, DFR: Autoflow 1.5 x On 2/2/24: - Treatment record showed that BFR was at 200 mL/min at 7:50 a.m., was increased to 350 mL/min at 7:58 a.m. until the end of treatment. - The record did not show why the BFR was not set to run at 450 mL/min, as ordered. On 2/3/24: - P#7’s treatment started at 7:48 a.m. and was discontinued at 10:52 a.m. (3 hours 4 minutes). - Treatment record showed that BFR was at 200 mL/min at 7:50 a.m., was increased to 350 at 7:58 a.m. until the end of treatment. - The record did not show why the BFR was not set to run at 450 mL/min as ordered. - The FA was informed on 2/15/24 at 12:56 p.m. and confirmed treatment records lacked reasons for not setting the BFR to 450 mL/min as ordered. A review of Policy titled, “Intradialytic Monitoring of Patient” dated September 2020 stated: Patient: Direct patient care staff will monitor the following parameters during each dialysis treatment: Delivery System: 3. Blood flow rate 4. Dialysate flow rate”