Usrc Roswell

“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, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one patient (P#5 ) observed who held pressure to her access sites for hemostasis (stopping of the flow of blood) after dialysis, and two of two Patient Care Technicians (PCT CC and PCT JJ) observed, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal. This deficient practice had the potential for cross contamination and increased risk of infection and could affect 56 in-center hemodialysis patients who were dialyzing at this facility. Findings were: During observation in the patient treatment area on 1/17/24 between 1:00 p.m. and 2:45 p.m., the following was observed: - P#5, who was seated at Station (S) 1 held pressure to dialysis access needle sites and left the facility without performing hand hygiene. - P#5 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - PCT CC was observed performing tasks at S8 with gloved hands, removed gloves and without performing hand hygiene, donned a new pair of gloves and continued taking patient off dialysis at S8. - PCT LL was observed removing gloves and did not perform hand hygiene. 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 1/18/24 at 1:45 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 patients’ treatment records, staff interview, and a review of facility policy, it was determined that the interdisciplinary team (IDT) failed to ensure that three of six in-center hemodialysis patients (P#3, P#6 and P#8) sampled, received their prescribed dialysis blood flow rate (BFR) to achieve and maintain adequate dialysis. Findings were: A review of treatment flowsheets showed the following: P#3: P#3’s Dialysis Prescription: Duration: 120 minutes (3 hours and 30 minutes), EDW (Estimated Dry Weight): 76 kg (kilogram), BFR: 400, DFR: 600. On 11/20/23: - P#3’s treatment started at 11:03 a.m. and was discontinued at 4:51 p.m. - Treatment record showed that BFR was decreased to 300 at 1:04 p.m. until 4:51 p.m. - The record did not show why the BFR was decreased to 300. On 1/02/24: - P#3’s treatment started at 12:28 p.m. and was discontinued at 2:56 p.m. -Treatment record showed that BFR was decreased from 400 to 300 at 12:59 p.m. until 2:56 p.m. - The record did not show why the BFR was decreased to 300. P#6: P#6’s Dialysis Prescription: Duration: 180 minutes (3 hours), EDW: 62.5 kg, BFR: 350, DFR: 600. On 1/15/24: - P#6’s treatment started at 12:09 p.m. and was discontinued at 3:13 p.m. - Treatment record showed that BFR was 200 at 12:09 p.m., was increased to 400 at 12:33 p.m., was decreased to 300 at 1:03 p.m., and remained at 300 until dialysis treatment was discontinued at 3:13 p.m. - The record did not show why the BFR was set to run at 300 instead of 350, as ordered. P#8: P#8’s Dialysis Prescription: Duration: 270 minutes (4 hours and 30 minutes), EDW: 105.5 kg, BFR: 400, DFR: 800. On 1/05/24: - P#8’s treatment started at 6:31 a.m. and was discontinued at 11:17 a.m. - Treatment record showed that the BFR was set at 250 at 6:31 a.m. and remained at this rate for the entire treatment that ended at 11:17 a.m. - There was a lack of documented reasons for not adhering to P#’s treatment plan as ordered. On 1/12/24: - P#8’s treatment started at 6:56 a.m. and was discontinued at 10:22 a.m. - Treatment record showed that the BFR was set at 350 and the DFR was set at 600 at 6:50 a.m. The BFR remained at 350 until 10:00 a.m. when it was increased to 400 until 10:06 a.m. and was decreased to 200 when dialysis was discontinued. - The DFR remained at 600 for the entire treatment. - The record did not show why the BFR was not set to run at 400 for the entire treatment, and why the DFR was set to run at 600 instead of 800 as ordered. On 1/17/24: - P#8’s treatment started at 6:50 a.m. and was discontinued at 11:18 a.m. - Treatment record showed that the BFR was 205 at 6:50 a.m., was increased to 400 at 7:03 a.m., was decreased to 350 at 9:33 a.m. and remained at 350 until 10:33 a.m. The BFR was decreased to 200 when dialysis treatment was discontinued at 11:18 a.m. - There was a lack of documented reasons for not adhering to P#’s treatment plan as ordered. - The Facility Administrator was informed on 1/19/24 at 4:23 p.m. and confirmed the above findings. The 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 Intervention: - Modify the treatment plan based on the patient’s response, which must be documented by the charge nurse. - Notify patient’s physician of any significant change or problem.”