Fmcna Dialysis Services of Chattahoochee Valley

“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: 50523 Based on observation, staff interview, a review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and a review of facility Policy and Procedures (P & P), it was determined that the Infection Control Committee failed to ensure that two of two Registered Nurses (RN AA and RN BB), who were observed during initiation of hemodialysis (HD) treatment of two of two patients (P), (P#1 and P#2), who had Central Venous Catheters (CVC- a thin flexible tube that is placed into a large vein above the heart), as their primary dialysis access, utilized appropriate infection control techniques to prevent cross contamination. Failure to properly cleanse a CVC exit site using aseptic techniques can introduce bacteria from the skin into the bloodstream and could potentially cause a serious infection known as a central line-associated bloodstream infection (CLABSI). This deficient practice had the potential to negatively affect the health and safety of P#1 and P#2 and the other 30 in-center hemodialysis patients with CVCs, who were under the care of this facility. The facility census was 64. Findings include: During observation in the Patient Treatment Room on 9/15/25 between 10:46 a.m. and 12:01 p.m., the following was revealed: - At station (S) 6, RN BB was observed removing P#2’s old CVC dressing. Then RN BB took a Chlorhexidine (an antiseptic that kills or prevents the growth of bacteria on the skin) Swab and started cleansing the CVC exit site by moving the swab in an up and down motion from the outer area (dirty) towards the inner area (clean), on both the left and right sides of the CVC exit site. This breach in infection control technique had the potential for cross contamination. - RN AA was also observed performing P#1’s CVC dressing change and cleansing of P#1’s CVC exit site at S15. RN AA repeated the same breach in infection control technique, as mentioned above. - During an interview on 9/15/25 at 12:31 p.m., RN AA stated that when cleansing a CVC exit site, the nurse was to start from the middle of the exit site and disinfect outward toward the surrounding skin area. - During an interview on 9/15/25 at 12:40 p.m., RN BB repeated the same statement given by RN AA, indicating that disinfection should begin from the center of the exit site and proceed outward. Both RNs knew the facility’s procedure but were not following it. - According to the CDC, cross contaminating (going from dirty to clean tasks or area), could cause the spread of bacteria/infections. - A review of Policy: 45664 Version 8 titled, “Changing the Catheter Dressing Procedure” with latest revision date of May 2, 2025, stated: Cleaning the Site: 2. 2% Chlorhexidine and 70% alcohol: Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 03383 Based on patient and staff interviews and document review, it was determined that the facility failed to ensure that one of one patient (P#1) grievances was followed up on and resolved per facility policy and procedures. Findings include: During an interview on 2/4/25 at approximately 10:43 a.m., P#1 stated that she was on dialysis 11 years before kidney transplant; transplant lasted eight years and failed 2 months ago, and since returning for dialysis, P#1 experienced chest pain and chest discomfort. P#1 believes the machine is pulling too hard; “I didn’t have chest pain before treatment started.” Stated, “I don’t gain much weight between treatments”. P#1 stated that it takes a day to recover after a dialysis treatment and she has informed techs, the nurse, and the physician about experiencing chest pain and discomfort during treatment, “They haven’t done anything about my concerns. I miss and cut treatments because of chest pains during treatment; I’ve asked them to decrease pull; however, the tech will come along and increase pull. I never had a problem with this (chest discomfort/chest pain) when I was on dialysis before transplant. It must be dialysis causing chest pain.” P#1 stated that she didn’t feel well. A review of “Clinical Notes Report” entered by Patient Care Technician (PCT) BB showed “On 1/9/25 had a conversation with patient regarding her treatment on the floor with staff. Patient is stating that she feels that she is being mistreated and pulled to [sic] hard for her dialysis treatment. I explained to her that the staff is following her order, and she stated that she has chest pain when she gets her dialysis. I have agreed to sit with the patient on 1/14/25 along with her dialysis order and treatment sheet so she can have an understanding of what’s happening during treatment time.” A review of the “Grievance Log” revealed that there was no record of concerns shared by P#1 on 1/9/25. None of the treatment notes dated 1/9/25 to present showed that the patient’s concerns were reported to the nurse. A review of Policy titled, “Patient Grievance” dated 1/2/14 stated the following: All facility staff: - Promptly acknowledging the patient/family member’s concern and reporting any patient grievances to the Nurse in Charge or the Team Leader. - Assisting in assessing and resolving patient grievances as appropriate. Receiving and Responding to Grievances: - Any patient treated at an FMCNA dialysis facility has the right to file a grievance at any time. - Grievances may be filed written or verbally, by the patient or patient’s designated representative. - Any grievance that involves a situation or practice that may place patients or staff members in immediate danger must be resolved immediately. - Timeframes outlined in the procedure for acknowledging, investigating, and addressing grievances shall be followed. During an interview on 2/4/25 at 11:01 a.m., the Clinic Manager (CM) confirmed that a grievance was not filed to address the patient’s concerns. The CM acknowledged concern with not following up on the patient’s grievances and did not offer further explanation as to why it was not done. The grievance policy was not followed.”