Dialysis Care Center Pleasant Hill

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50523 Based on a review of facility records, staff interviews, and a review of the facility Policy and Procedures (P&P), it was determined that the Medical Director failed to ensure that four of four Registered Nurses (RN AA, RN BB, RN CC and RN DD) adhered to the facility’s P&P relative to obtaining access cultures from one of one sampled patient’s (P#1’s) Central Venous Catheter (CVC - A flexible tube inserted into a vein and threaded into a large vein above the right side of the heart) site, with documented signs and symptoms of infection such as swelling, redness, and drainage. This deficient practice had the potential for infection to go undetected and untreated that could lead to bloodstream infections like sepsis (a dangerous reaction to an infection where the body’s immune system overreacts and starts harming its own organs). The facility census was 59. Findings include: A review of the facility’s “Admission and Discharge” list from August 2025 to November 2025 revealed that P#1 was admitted to the facility on 9/11/25. A review of P#1’s “Treatment Details Report” dated 9/11/25 - 9/19/25 showed the following: - On 9/11/25, P#1’s CVC site appeared swollen with redness and drainage. There was a lack of documented evidence that the physician was notified of these signs and symptoms of infection, to obtain an order for cultures per facility P&P. - On 9/15/25, P#1’s CVC site was noted to be within normal limits with redness. - On 9/17/25, P#1’s CVC site was noted to be bruised. - On 9/19/25, P#1’s CVC site was noted to be bruised. P#1 complained of nausea and received 4 milligrams (mg) of Zofran (medication used to prevent nausea and vomiting). P#1 terminated her treatment by 41 minutes earlier and was discharged home at 12:29 p.m. with a temperature of 97.3 Fahrenheit (F). There was no documentary evidence that P#1 expressed any weakness, vomiting or fever while at the facility. - A review of P#1’s “Hospitalization” records dated 9/3/25 and 9/19/25 revealed the following: On 9/3/25, P#1’s CVC became dislodged, prompting vascular surgery elevation and subsequent placement of a right subclavian tunneled dialysis catheter after unsuccessful attempts at the right internal jugular access. Following catheter placement, P#1 developed a right chest hematoma (collection of blood outside of blood vessels) at the procedural site. The hematoma remained stable without evidence of active bleeding or hemodynamic compromise. On 9/19/25, P#1’s chief complaint was sepsis. P#1 presented with a temperature of 100.3 F, nausea, vomiting and productive cough diagnosed with septic shock (severe form of sepsis where blood pressure drops dangerously low, making it hard for organs to get enough blood). On 9/21/25, P#1’s blood cultures were positive times two for Group B Streptococcus (GBS) (a type of bacteria that can cause bloodstream infections) and positive for Corynebacterium (a group of bacteria) aspirated from a hematoma near P#1’s right subclavian dialysis catheter that was placed on 9/3/25. On 9/23/25, P#1’s right chest catheter was replaced with a left internal jugular. During an interview on 11/17/25 at 1:08 p.m., the Medical Director (MD) stated that P#1 started at the facility on 9/11/25 and presented with a hematoma on the right side of her CVC from a recent insertion. The MD stated that he and the facility had monitored P#1’s access as it was healing. The MD also stated P#1 never complained of pain coming from her access. On 11/17/25 at 3:02 p.m., RN AA stated that on 9/19/25, the side of P#1’s CVC was bruised where the hematoma had been, but not at the insertion site of the CVC. RN AA also stated that P#1 had wanted to end her treatment early due to feeling nauseous, yet she had never vomited while at the facility. - A review of Policy: HDS-IC-L-T-700-007 titled, “ Obtaining Access Cultures” dated January 2016 showed the following: III. Overview: The signs and symptoms of infection include: “ Redness “ Drainage V. Policy: A physician’s order is required to culture drainage from an access site (peritoneal catheter, vascular access catheter) vascular access site (AV fistula, graft) or wound.”