Liberty Dialysis Hawaii - Kona Dialysis

“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: 47783 Based on observations, interviews and policy review, the facility failed to ensure staff consistently adhere to requirements for performing hand hygiene and changing of gloves. This deficient practice placed the patients at risk for potential exposure to infectious pathogens. Findings include: 1) On 02/20/24 at 12:13 PM, observed Patient Care Technician (PCT) 1 initiate treatment for patient in station 18 using his arteriovenous (AV) fistula. Prior to cannulation (insertion of dialysis needles), PCT1 assessed the AV fistula by palpation and disinfected arterial cannulation site with alcohol pads. PCT1 did not change gloves after evaluating access and prior to cannulation. Review of facility policy titled “Access Assessment and Cannulation” stated, “. . . Assessment of Vascular Access . . . Step 2 - wash hands and don PPE: gloves, gown/apron, safety glasses and mask, or full-face shield . . . LOOK . . . LISTEN . . . FEEL . . . Step 9 - Remove gloves and perform hand hygiene. Don new gloves . . . Disinfect cannulation site . . .” On 02/23/24 at 10:15 AM, interview was conducted with the Clinical Manager (CM) and Clinical Coordinator (CC). Both CM and CC confirmed that staff are supposed to change gloves when performing a task moving from dirty to clean. 2) On 02/21/24 at 10:39 AM, observed PCT2 discontinuing treatment for patient in station 18. After PCT2 finished applying the dressing to patient’s access, he removed his gloves, took off his eye protection and placed it on the table by the clean area. PCT2 then donned a new pair of gloves without performing hand hygiene. 3) On 02/21/24 at 11:07 AM, observed PCT3 discontinuing treatment for patient in the isolation room. After returning the patient’s blood, PCT3 changed gloves without performing hand hygiene prior to donning a new pair. PCT2 then disconnected the bloodlines from the AV fistula needles and changed gloves again without performing hand hygiene. 4) On 02/21/24 at 4:29 PM, observed Registered Nurse (RN) 1 administer an intravenous medication to patient in station 18. RN1 was wearing gloves, wiped the medication port of the intravenous line with an alcohol pad, administered the medication and removed her gloves. RN1 donned a new pair of gloves without performing hand hygiene and flushed the intravenous line with normal saline. Review of facility policy titled “Hand Hygiene” stated, “. . . Hands will be. . . Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water . . . Immediately after removing gloves. . .” On 02/22/24 at 03:10 PM, interview was conducted with the CM in her office. CM confirmed that staff are supposed to perform hand hygiene using alcohol-based hand rub or soap and water immediately after removing gloves. 22063 5) On 02/20/24 at 12:45 PM observed RN2 remove his/her gloves, discard the pair in the trash, then took out a new pair from the glove box. The RN did not perform hand hygiene before reaching for a new pair of gloves in the box. RN2 then laid the pair atop the opening of the glove box and performed hand hygiene. RN2 then applied the gloves that were atop the glove box. On 02/22/24 at 04:25 PM interview with the CM confirmed hand hygiene should be done upon removal of gloves and applying a new pair of gloves. 37954 6) On 02/20/24 at 11:20 AM observed PCT7 initiate treatment for patient at station 4. PCT7 touched the chair to recline it, touched patient’s sleeve to push it up and then proceeded to clean the access site. Inquired with PCT7 if she is to change dirty gloves, perform hand hygiene and put on clean gloves prior to cleaning patient’s access site and PCT7 confirmed they “made an error.” 7) On 02/22/24 at 10:05 AM observed PCT8 evaluate access site for patient sitting at station 12. Afterwards PCT7 touched the keyboard, blood filter and went back to the patient without taking off dirty gloves, performing hand hygiene and putting on clean gloves before applying antiseptic to patient’s skin over cannulation site. On 02/22/24 at 3:30 PM interviewed CM who confirmed staff are to change dirty gloves, perform hand hygiene and put on clean gloves before applying antiseptic to a patient’s skin over the cannulation site prior to insertion of dialysis needles. CM confirmed during this time staff are not to touch anything else such as equipment and patient.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 47783 Based on observation and staff interview, the facility failed to ensure the clean areas were protected from potentially infectious pathogens. A staff member was observed placing a used Personal Protective Equipment (PPE) in a designated clean area where clean supplies are kept. This deficient practice has the potential to cross-contaminate clean supplies used for patient treatments. Findings include: On 02/21/24 at 10:39 AM, observed Patient Care Technician (PCT) 2 discontinuing treatment for patient in station 18. After PCT2 finished applying the dressing to patient’s access, he removed his gloves, took off his goggles (PPE used for the eyes) and placed it on the table by the clean area. PCT2 did not wipe the goggles prior to placing it on the table. A dialyzer, dialysis bloodlines, bag of normal saline and rolled up disposable pad were also on the table. On 02/22/24 at 03:10 PM, interview was conducted with the Clinical Manager (CM) and Clinical Coordinator (CC). Both CM and CC confirmed that the tables on the treatment floor are used to place clean supplies. CC said the staff was supposed to wipe the goggles after use and before placing it on the clean supplies table.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 22063 Based on observations, record review, and interviews, the facility did not ensure the cleaning and disinfection of the station and equipment that was potentially contaminated with patients’ blood was done in accordance with the facility’s policy and procedures. This deficient practice has the potential to spread infectious diseases and affect all the patients in the facility. Findings include: 1) On 02/21/24 at 04:15 PM observed Patient Care Technician (PCT)5 disinfecting Station 20. PCT5 opened the left side swing panel of the chair/arm rest, wiped the panel, and closed it. This was repeated to the right panel of the chair. On 02/22/24 at 04:25 PM interview was done with the Clinic Manager (CM) and Director of Operations (DO). Inquired whether the swing arm of the chair needed to be dry before closing it. DO reported that there should be a contact time before closing the swing arm. Staff were agreeable to follow-up and provide the information regarding contact time. The facility provided a policy and procedure titled, Cleaning and Disinfecting the Dialysis Station with a publish date of 09/05/23. The procedure for disinfecting dialysis station after treatment includes, “Step 4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by the manufacturer.” 47783 2) On 02/21/24 at 09:48 AM, observed Patient Care Technician (PCT) 4 clean dialysis machine and chair in station 20. PCT4 used disposable wipes that were soaked in a 1:100 diluted bleach solution. The container for the bleach solution was not covered. On 02/21/24 at 11:01 AM, observed PCT3 clean dialysis machine and chair in station 2. PCT3 used disposable wipes that were soaked in the same uncovered bleach solution container PCT4 used. On 02/21/24 at 11:30 AM, Clinical Coordinator (CC) was at the nurses’ station. Showed CC the uncovered container where PCT3 and PCT4 soaked the disposable wipes used to clean the dialysis machines and chairs. Asked CC if the container was supposed to be open without a cover. CC said the staff are supposed to place the cover back on the container after they soak the disposable wipes. On 02/22/24 at 10:05 AM, interview conducted with the Biomedical Technician (BT) in his office. BT confirmed that the container for the bleach solution is supposed to be covered immediately after the staff soak the disposable wipes to maintain the strength of the concentration required to properly disinfect the equipment and surfaces. Review of facility policy titled “Cleaning and Disinfecting the Dialysis Station” stated, “. . . Bleach solution will be stored in a labeled, covered opaque containers to prevent disintegration of the chemical (sodium hypochlorite) when exposed to sunlight and air. . . “ 37954 3) On 02/22/24 at 09:30 AM observed PCT9 clean dialysis machine and chair in station 12. PCT9 used disposable wipes that were soaked in a 1:100 diluted bleach solution. PCT9 opened the left and right side swing panel of the chair/arm rest, wiped the panels, and closed them prior to air drying. At this time interviewed PCT9 and inquired if the swing panel of the chair/arm rests are supposed to be closed once they are wiped or kept open to dry. PCT9 confirmed she closes it.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 47783 Based on observation, interviews and record review, the facility failed to ensure equipment used in the isolation room were labeled appropriately to identify them to be used only for HBV+ (Hepatitis B Virus Positive) patients. This deficient practice has the potential to expose other patients who are susceptible to HBV (organism that causes a contagious liver infection spread through the exposure to blood and bodily fluids). Findings include: On 02/20/24 at 11:05 AM, observed Patient Care Technician (PCT) 7 caring for a patient in the isolation room. Registered Nurse (RN) 4 said the isolation room is only used to provide hemodialysis treatment to patients identified as HBV+ or HBsAg (hepatitis B surface antigen) positive. RN4 added that the facility currently has two patients requiring hemodialysis treatments in the isolation room. On 02/20/24 at 02:20 PM, inspected isolation room with RN4. Noted that the dialysis machine, chair, IV (intravenous) pump (equipment used to deliver medications through the vein), centrifuge machine (equipment used to process blood specimen), Myron meter (equipment used to measure hydrogen ion levels), IV pole, face shields, stethoscope (equipment used to listen for sounds produced within the body), broom and dust pan were not labeled to identify them to only be used in the isolation room. RN4 confirmed none of the items mentioned were labeled. On 02/20/24 at 02:34 PM, interview conducted with the Clinical Manager (CM) by station 1. Asked CM if the items in the isolation room were supposed to be labeled “for isolation room use only”. CM said “Yes.” and added she will notify the Biomed Technician (MT). On 02/22/24 at 10:05 AM, interview conducted with BT in his office. BT confirmed that all items in the isolation room are supposed to be labeled “Isolation” to alert the staff not to use them outside of the isolation room. Review of the facility policy titled “Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+)” stated, “. . . Separated dedicated supplies and equipment, including blood glucose monitors, must be used to provide care to the HBsAg positive patient . . . All supplies used in the isolation room/area . . . should be labeled “isolation” and not routinely removed. . . “”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47783 Based on record review and staff interview, the facility failed to provide necessary care and services to manage the volume status for three patients (P) sampled for record review. The Patient Care Technician (PCT) failed to notify the Registered Nurse (RN) when the blood pressures (BP) for P5, P12 and P8 were high during their dialysis treatments. This deficient practice placed the three patients at risk of serious health complications related to hypertension (high blood pressure). Findings include: Review of the facility policy titled “Patient Assessment and Monitoring” stated, “. . . Direct patient care staff may collect data such as weight, BP, . . . note any changes or abnormal findings . . . the registered nurse must assess the patient. . .” Also stated under “Blood Pressure”, “. . . Report to the nurse: Systolic (upper reading) blood pressures greater than 180 mm/Hg (millimeters of mercury), Diastolic (lower reading) blood pressure greater than 100 mm/Hg. . .” 1) Review of dialysis treatment records from 02/02/24 to 02/21/24 for P5 conducted. Noted the BP readings on the following dates and times were above the facility stated parameters: 02/02/24 at 02:30 PM - 186/77. 02/05/24 at 12:29 PM - 190/80, 01:30 PM - 188/87, 02:00 PM - 187/72, 02:59 PM - 183/73. 02/07/24 at 12:01 PM - 207/85, 12:30 PM - 230/93, 01:02 PM - 222/98, 01:31 PM - 181/84, 02:04 PM - 181/79, 02:32 PM - 187/86. 02/09/24 at 02:05 PM - 193/67. 02/19/24 at 01:00 PM - 181/74, 02:01 PM - 187/81, 02:31 PM - 191/82, 04:01 PM - 195/85. 02/21/24 at 04:00 PM - 188/79. No documentation was found in the dialysis treatment records that the PCT notified the RN of P5’s elevated BP. 2) Review of dialysis treatment records from 02/05/24 to 02/21/24 for P12 conducted. Noted the BP readings on following dates and time were above the facility stated parameters: 02/05/24 at 10:09 AM - 187/118, 10:23 AM - 206/86, 11:10 AM - 211/101, 11:35 AM - 208/105, 12:00 PM - 196/93, 12:32 PM - 207/92, 01:00 PM - 181/88. 02/07/24 at 09:05 AM - 206/102, 10:46 AM - 186/95, 11:02 AM - 184/120, 11:33 AM - 184/90, 12:11 PM - 185/93, 12:30 PM - 194/94, 01:01 PM - 188/79, 01:39 PM - 181/86. 02/09/24 at 09:44 AM - 203/97, 10:08 AM - 187/112, 11:34 AM - 188/65, 12:32 PM - 194/92. 02/12/24 at 09:31 AM - 100/103, 10:31 AM - 207/97, 11:02 AM - 214/102, 11:36 AM - 203/94, 12:02 PM - 186/84, 13:31 PM - 200/107, 01:10 PM - 208/78, 01:12 PM - 216/96, 01:31 PM - 189/79. 02/21/24 at 09:43 AM - 198/90, 12:07 PM - 199/88, 12:31 PM - 202/86, 01:30 PM - 190/87. No documentation was found in the dialysis treatment records that the PCT notified the RN of R12’s elevated BP. On 02/22/24 at 03:10 PM, interview was conducted with the Clinical Manager (CM) and the Clinical Coordinator (CC) in her office. CM confirmed that the PCTs are supposed to notify the RN if the BP readings for the patients are outside the facility identified parameters and document it in the treatment sheet. The CC also added that the RN is supposed to assess and provide intervention to address the elevated BP. 37954 2) Review of dialysis treatment record from 02/09/24 for P8 conducted. Noted the BP readings on the following dates and times were above the facility stated parameters: 02/09/24 at 02:00 PM - 170/104 02/09/24 at 02:38 PM - 172/101 02/09/24 at 03:01 PM - 176/113 02/09/24 at 03:32 PM - 181/110 02/09/24 at 04:05 PM - 164/103 No documentation was found in the dialysis treatment records that the PCT notified the RN of R8’s elevated BP. On 02/09/24 at 05:12 PM RN4 documented, under nursing evaluation, at end of P8’s dialysis “Pt (patient) tolerated tx (treatment) well with no complaints. Denies dizziness, HA (headache) cramping or other complications post tx (treatment). No pain. No s/s (signs or symptoms) of infection. VS (vital signs) WNL (within normal limits). Pt (patient) over EDW (estimated dry weight). advised pt (patient) to limit fluids. will try to get to edw by end of week. left unit stable.” On 02/22/24 at 03:30 PM interviewed CM in her office. CM confirmed PCTs are supposed to notify the RN if the BP reading is outside of facility identified parameters.”

“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: 47783 Based on record reviews, and interviews, the facility failed to ensure the physician’s prescribed dialysis orders were followed for Patients (P) 13, P10 and P1 were dialyzed according This deficient practice placed the patients at risk for not achieving desired adequacy outcomes of dialysis. Findings include: 1) Review of Electronic Health Record (EHR) and dialysis treatment records from 02/05/24 to 02/21/24 for P13 was conducted. Dialysis treatment orders included: Estimated Dry Weight (EDW) of 127.5 kg (kilograms); frequency of three days a week (Mon/Wed/Fri); treatment time of four and a half hours; BFR (blood flow rate) of 400 ml/min (milliliters per minute) and DFR (dialysate flow rate) of 1.5 times the BFR (600 ml/min). Treatment record for 02/05/24 noted that dialysis treatment was initiated at 07:22 AM and ended at 11:51 AM. BFR documented from 07:22 AM to 09:22 AM was 350 ml/min. No information was found in the treatment record and EHR why the BFR order was not followed. Treatment record for 2/9/24 noted dialysis treatment was initiated at 08:00 am and ended at 12:01 PM. Treatment time was cut short per patient’s request due to transportation issues. BFR documented from 08:02 AM to 08:31 AM was 300 ml/min; from 09:37 AM to 10:38 AM, BFR was 350 ml/min; and from 11:00 AM to 12:01 PM, BFR was 325 ml/min. No information was found in the treatment record and EHR why the BFR order was not followed. 2) Review of EHR and dialysis treatment records from 02/02/24 to 02/21/24 for P10 was conducted. Dialysis treatment orders included: EDW of 61.5 kg; frequency of three times a week (Mon/Wed/Fri); treatment time of four hours; BFR of 400 ml/min and DFR of 1.5 times the BFR (600 ml/min). Treatment record for 02/05/24 noted that dialysis treatment was initiated at 12:48 PM and ended at 04:50 PM. BFR documented at 12:51 PM was 350 ml/min, and from 03:00 PM to 04:45 was 375 ml/min. No reason was noted in the treatment record and EHR why the BFR was not at prescribed. During an interview with the Clinical Manager (CM) and Clinical Coordinator (CC) on 02/23/24 at 10:15 AM, both confirmed that the staff are supposed to document in the treatment records why the prescribed BFR is not achieved during treatment and any actions taken fix the issue. 22063 3) P1 was admitted to the facility on 08/16/22. P1 arrived for treatment on 02/20/24 at 10:52 PM. Interviewed the patient at chairside. P1 reported having high phosphorus and potassium. Second observation at 12:30 PM found patient asleep. The dialyzer was F180NRe, BFR was 350 ml/min and DFR was 700 ml/min. Record review was done on 02/21/24 at 02:00 PM. The treatment orders included: EDW of 87 kg; frequency of three times a week (Tues/Thurs/Sat); treatment time of four hours; BFR of 350 ml/min; and DFR of 700ml/min. Review of the treatment records from 01/30/24 to 02/20/24 was done. The treatment record for 01/30/24 noted in the post dialysis and evaluation section the average BFR was 340 ml/min. The treatment data noted a BFR of 300 ml/min at 10:40 AM and 02:04 PM. There was no documentation of the reason for the delineation of the treatment order. The treatment record for 02/17/24 noted in the post dialysis and evaluation section, the average BFR was 300 ml/min. The treatment data noted a BFR of 300 ml/min at 10:55 AM, 12:31 PM, 01:04 PM, 01:31 PM, 02:02 PM and 02:33 PM. There was no documentation addressing the reason why the precribed BFR was not reached. Review of the chairside notes for 01/30/24 and 02/17/24 did not have documentation to address P1’s BFR. On 02/22/24 an interview and concurrent record review was conducted with the CM. The CM reported the BFR can be affected by the positioning of the needle which would require an adjustment of the needle. CM also reported she is not sure why the needle positioning was not adjusted. The CM confirmed there was no documentation of why the BFR was not attained. Review of facility policy titled “Patient Assessment and Monitoring” stated, “. . . During Treatment . . . Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. . .””

“POC-MANAGE MINERAL METABOLISM CFR(s): 494.90(a)(3) Provide the necessary care to manage mineral metabolism and prevent or treat renal bone disease. This Standard is not met as evidenced by: 22063 Based on observation, record review, and interview with staff, the facility did not ensure the necessary care was provided for Patient (P)16 to manage mineral metabolism. P16 was provided with the medications to take at home, however, there was no observation that the patient took the medications. This deficient practice has the potential to place the patient at risk for the adequate management of bone and mineral metabolism. Findings include: Cross Reference to V726. Accuracy of medical records. On 02/22/24 at 10:10 AM, observed discontinuation of dialysis for P16. P16’s spouse was handed a cup which was placed on P16’s wheelchair. Observed there were three pills in the cup. Registered Nurse (RN)3 was asked to identify these pills. RN3 reported this was Vitamin D and Sensipar which would be taken at home. Record review was done on 02/22/24 at 11:08 AM. Review of treatment sheet for 02/22/24 noted an order for Vitamin D3, oral (0.750 mcg - 0.250 mcg and 0.500 mcg) three times a week and Sensipar, oral (30 mg) three times a week. The medications were documented as “yes” for admin prescribed. There was no documentation that the medications were given to the patient to take at home or that these medications were refused. The physician order for Vitamin D (0.75 mcg/three times a week) was entered on 01/09/24. The order for Sensipar (30 mg oral post dialysis with snack three times a week) was dated on 02/13/24. On 02/22/24 at 01:02 PM interview and concurrent record review was done with Clinical Manager (CM) in her office. CM confirmed the orders for Vitamin D and Sensipar. Review of the treatment record, medications section, CM clarified the documentation of “yes” indicated the medications were administered. CM also clarified that the “C” indicates the medications were given in center. Observation of the patient taking medications home was shared with the CM. CM reported the expectation is for the patients to take their medications while in center at chairside. Further review of the record, CM confirmed the documentation indicated that the medications were actually given to patient.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 22063 Based on observations, record review, and interview with staff members, the facility did not assure patients washed their access site prior to initiation of dialysis and ensure patients were provided with a clean gauze during discontinuation of dialysis. These deficient practices placed patients at risk of infection to their vascular access, resulting in the inability to sustain their vascular access. Findings include: 1) On 02/22/24 at 10:10 AM observed Patient Care Technician (PCT) 6 discontinue Patient (P)16’s dialysis treatment. PCT6 removed the venous line and placed a gauze atop the site. The gauze was observed with blood. The patient continued to put pressure on the site. PCT removed the arterial line and placed a gauze atop the site. P16 put pressure on both sites. The PCT taped the gauze down. There was visible blood on the gauze at the venous site and at the end of the tape toward the forearm. Interviewed PCT6 regarding the visible blood on the gauze and the tape. PCT responded he/she didn’t see the blood on the gauze and/or the tape. Interview was done with the Clinic Manager (CM) and Clinic Coordinator (CC) on 02/22/24 at 04:25 PM. Observation of soiled gauze and tape was shared. Inquired whether there was a need to apply a clean gauze to ensure bleeding stopped or an infection control issue. The CC commented a soiled gauze does not indicate clotting and bleeding stopped. The CM responded it is an infection control issue and the PCT needed to redress the site with a new gauze. 2) On 02/22/24 observed P17 arrive for hemodialysis treatment. Did not observe P17 wash his access site (right forearm) before initiation of treatment. At 10:47 AM interviewed P17 at chairside. Inquired whether he washed his access site prior to treatment. P17 responded he took a shower at home before coming to treatment and washed his hands when he went to the bathroom. Further queried whether the staff asked him if he washed his access site, P17 responded he was not asked. 3) On 02/20/24 observed P15 being assisted to the treatment area by PCT7. P15 was in a wheelchair. Observed the PCT did not stop at the sink located at the entrance to the treatment area so P15 or PCT could assist in washing the access site. P15 was placed in front of the assigned station. Subsequently, P15 was transferred via Hoyer lift by two staff members. 4) On 02/20/24 at 12:35 PM observed P14 arrive to the treatment area. P14 was dressed in a long-sleeved flannel overshirt. P14 placed his bag down at the station then went to the bathroom. At 12:50 PM, P14 emerged from the restroom and went to his station. P14 did not stop at the sink to wash his access site. Also, observed P14’s shirt sleeves were not rolled up. P14 sat in his chair and the PCT rolled up the sleeve of his left arm (access site). A review of the policy and procedures provided by the facility, titled Access Assessment and Cannulation with publish date of 07/05/22 was reviewed. Review of the steps to assess the vascular access included, “Step 1. Prior to treatment, ask patient to wash access area with soap per hand hygiene procedure. Wash access (per above) if patients unable to clean their access”. 47783 5) On 02/21/24 at 09:20 AM, observed PCT4 discontinue dialysis treatment for patient in station 20. PCT4 placed a rolled-up gauze over the venous needle insertion site before removing the needle, placed a folded gauze pad over the rolled-up gauze, secured it with three pieces of paper tape and applied a clamp over it. PCT4 then secured the clamp over the site with another piece of tape and proceeded to remove the arterial needle. At 09:29 AM, PCT4 removed the clamp from the venous site and observed some blood on both the folded and rolled-up gauze applied to the venous needle insertion site. PCT4 changes the folded gauze but not the rolled-up gauze that was under it and secured it with paper tape. The patient was then assisted to her wheelchair and brought to the weighing scale. Review of facility policy titled “Post Treatment Fistula Needle Removal” stated, “. . . Once hemostasis is achieved: Remove the gauze. . . Place Band-Aid, adhesive dressing or gauze dressing secured with clean tape. . .” During an interview with the CM on 02/23/24 at 10:15 AM, CM confirmed that the staff are supposed to change the blood soiled dressing on the needle insertion sites once it has stopped bleeding. 37954 6) On 02/22/24 observed P19 get weighed prior to treatment and arrive to treatment area, station 12. Did not observe P19 wash his access site (left forearm) before initiation of treatment. At 10:05 AM interviewed P19 at chairside. Inquired whether staff asked him to wash his access site prior to treatment. P19 stated staff did not ask him to wash his access site, stated he has never been asked to wash his access site prior to initiation of treatment. 7) On 02/22/24 at 10:15 AM interviewed R20 at station 4 after initiation of treatment. Inquired whether staff asked her to wash her access site prior to treatment. P20 stated she does not wash her arm with soap and water at the dialysis center. Inquired why and she stated the water is too cold, that she uses a wet paper towel to wipe her arm instead. On 02/22/24 at 03:30 PM interviewed Clinic Manager (CM) and inquired if staff are expected to ask patients to wash their access site (arm) prior to initiation of treatment and she confirmed this.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47783 Based on record review and interview with staff members, the facility did not assure medical records were accurate. Post dialysis evaluations were not accurately documented in the treatment records for patients (P) 12 and P8, and documentation of the administration of in-center medications did not accurately note the patient did not take prescribed medications at the center. This deficient practice has the potential provide to inaccurate and/or incomplete information of the patient’s condition during the dialysis treatment and inaccurately reflect the patient’s adherence to treatment. Findings include: Cross reference to V543 (POC-Manage volume status) Patient Care Technician did not notify Registered Nurse when blood pressure readings were out of range. 1) Review of dialysis treatment records from 02/05/24 to 02/21/24 for P12 conducted. Noted prescribed treatment time was not completed on 02/05/24. Further review of the treatment record revealed that P12’s treatment was interrupted twice to use the restroom due to complaints of having “GI (gastrointestinal) upset.” P12’s Blood Pressure (BP) readings were also elevated during the treatment with readings as high as 211/101. Documented in the “Post-Dialysis Vitals and Evaluation” section under “New Complaint or Observations Which Developed During Dialysis:” stated, “No new findings”. Treatment record on 02/07/24 stated, “No new findings” and “VSS (vital signs stable)” in the post dialysis evaluation section. BP readings were as high as 206/102. Treatment record on 02/12/24 stated, “No new findings” and “VS WNL (vital signs within normal limits)” in the post dialysis evaluation section. BP readings were as high as 214/102. Treatment record on 02/21/24 stated, “No new findings” and “VS WNL (vital signs within normal limits)” in the post dialysis evaluation and nursing evaluation sections. BP readings were as high as 204/93. During an interview with the CM on 02/23/24 at 10:15 AM, CM confirmed that the staff documentation in the post dialysis evaluations were not reflective of the patient’s BP readings. 22063 2) Cross reference to V546. The treatment record for Patient (P)15 indicated medications (Vitamin D and Sensipar) were administered at the center. Registered Nurse (RN)3 was observed to give P15 and her spouse the medications in a cup to take home and did not ensure the medications were taken. The medical record indicated the medications were administered, however, RN3 did not observe P15 actually take the medications. 37954 Cross reference to V543 (POC-Manage volume status) Patient Care Technician did not notify Registered Nurse when blood pressure readings were out of range. 3) Review of dialysis treatment record from 02/09/24 for P8 conducted. P8’s Blood Pressure (BP) readings were elevated during the treatment with readings as high as 181/110. No documentation was found in the dialysis treatment records that the PCT notified the RN of R8’s elevated BP. On 02/09/24 at 05:12 PM RN4 documented, under nursing evaluation, at end of P8’s dialysis “Pt (patient) tolerated tx (treatment) well with no complaints. Denies dizziness, HA (headache) cramping or other complications post tx (treatment). No pain. No s/s (signs or symptoms) of infection. VS (vital signs) WNL (within normal limits). Pt (patient) over EDW (estimated dry weight). advised pt (patient) to limit fluids. will try to get to edw by end of week. left unit stable.” 02/09/24 at 02:00 PM - 170/104 02/09/24 at 02:38 PM - 172/101 02/09/24 at 03:01 PM - 176/113 02/09/24 at 03:32 PM - 181/110 02/09/24 at 04:05 PM - 164/103 On 02/22/24 at 03:30 PM interviewed CM in her office. CM confirmed PCTs are supposed to notify the RN if the BP reading is outside of facility identified parameters. CM confirmed high blood pressures are not within normal limits and the nurse should not have documented this.”