Liberty Dialysis Hawaii - Waipahu 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: 51870 Based on observations, interviews with staff, and review of the facility’s policy, the facility failed to ensure gloves were changed and hand hygiene performed for two out of four patients (Patient (P)16 and P17) that were observed for initiation of dialysis. This deficient practice puts patients at risk for access infection. Findings include: 1) On 08/19/25 at 10:45 AM, observed Patient Care Technician (PCT)15 initiating dialysis treatment for P16. After PCT15 assessed P16’s fistula access site and prior to cannulating (insertion of needles), PCT15 did not change gloves and perform any hand hygiene. Concurrent interview with PCT15 confirmed that he should have don new gloves and sanitize his hands prior to inserting needles to P15’s fistula access to prevent infection. 2) On 08/19/25 at 11:15, observed PCT18 not changing gloves and performing any hand hygiene prior to cannulating P17’s fistula access. Concurrent interview with PCT18 confirmed that she should have don new gloves and perform hand hygiene prior to cannulation to prevent infection On 08/21/25 at 10:00 AM, interview with Clinical Manager (CM) confirmed that staff should be changing gloves and performing hand hygiene after assessing access and prior to cannulating patient’s access to prevent infection. On 08/20/25 at 01:30 PM, review of the facility’s “Access Assessment and Cannulation” policy, dated 05/05/2025, in the “Assessment of Vascular Access” section, it noted, “. . . 9. Remove gloves and perform hand hygiene. Don new gloves . . . After assessing the access, staff must perform hand hygiene and don new gloves. With the new gloves, staff may perform the full cannulation procedure . . .””

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 51870 Based on observation, interviews, and record review, the facility failed to ensure Central Venous Catheter (CVC) exit site care was performed aseptically for one of three patients (Patient (P)18) observed. As a result of this deficient practice, P18 was placed at risk for potential CVC related infection. Findings include: On 08/19/25 at 01:00 PM, observed Registered Nurse (RN)3 provide CVC exit site care for P18. RN3 cleaned the CVC exit site using an antiseptic swabstick going from the center of the exit site to two inches out, then back to the center of the exit site. Thie motion was repeated three more times before RN3 covered the CVC exit site after the area was dry. On 08/19/25 at 01:15 PM, interview with RN18 confirmed that he should have cleaned the exit site going from the center of the exit site and outward in a circular motion. RN18 noted that this is important to prevent CVC infection. On 08/20/25 at 12:40 PM, interview with Clinic Manager (CM) confirmed that the CVC care should be cleaned using a circular motion from inner to outer regardless of what antiseptic is used. Review of the facility policy “Changing the Catheter Dressing Procedure,” stated, “. . . 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 . . .””

“PE-COMFORTABLE TEMPERATURE CFR(s): 494.60(c)(2) The dialysis facility must: (i) Maintain a comfortable temperature within the facility; and (ii) Make reasonable accommodations for the patients who are not comfortable at this temperature. This Standard is not met as evidenced by: 47783 Based on observations and interviews, the facility failed to maintain a comfortable temperature within the facility for two of the three survey days. This deficient practice could present an uncomfortable environment for the patients during dialysis treatments and possibility to result in patients covering the access site with blankets which may delay the identification of life-threatening complications such as excessive bleeding. Findings include: On 08/19/25 at 08:55 AM, observed 11 patients getting their dialysis treatments in the third pod of the facility. Nine of the 11 patients were bundled up in heavy blankets. Observed the two thermostats by the hallway were reading 66 degrees Fahrenheit (F). On 08/20/25 at 08:52 AM, observed Registered Nurse (RN)7 and Patient Care Technician (PCT)25 in the third pod wearing thick jackets as they were talking to a patient (Patient (P) 19) in station 25. Nine of the 11 patients dialyzing in the pod were covered up with heavy blankets and three were also wearing beanies. The two thermostats by the hallway were reading 66 degrees F. On 08/20/25 at 09:02 AM, asked P19 if the temperature in the treatment area was comfortable for her. P19 said, “It’s too cold in here.” P19 was wearing a thick jacket and a beanie. On 08/20/25 at 09:05 AM, observed P20 dialyzing in station 36. P20 was bundled up in a heavy blanket and was wearing a beanie. Asked P20 if the temperature in the treatment area was too cold for her. P20 said, “It’s always freezing in here.” On 08/20/25 at 09:10 AM, asked PCT25 if they are able to adjust the temperature on the thermostat. PCT25 said it is locked and are not allowed to adjust it. On 08/08/25 at 09:12 AM, Clinical Manager (CM) confirmed the thermostats were set at 66 degrees F and said she will let the biomed staff know so they can adjust it. The facility was not able to provide a policy on providing a comfortable temperature for the dialysis unit.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47783 Based on record reviews and interviews, the facility failed to ensure physician’s prescribed dialysis orders were followed for two of 15 patients (Patient (P)7 and P14) sampled for record review. This deficient practice placed the patients at risk for not achieving or sustaining desired adequacy outcomes of dialysis. Findings include: 1) Review of P7’s dialysis treatment records from 08/06/25 to 08/18/25 was conducted. Dialysis treatment orders included: Estimated Dry Weight (EDW) of 70.6 kg (kilograms), frequency of three days a week, treatment time of three hours and 30 minutes, BFR (blood flow rate) of 400 ml/min (milliliters per minute) and DFR (dialysate flow rate) of 600 ml/min. Treatment record for 08/18/25 noted that dialysis treatment was initiated at 12:50 PM with a BFR of 350 ml/min and ended at 03:39 PM. BFR was maintained at 350 ml/min throughout the dialysis treatment. No information was found in the treatment record and Electronic Health Record (EHR) why the BFR order was not followed. During an interview with Clinical Coordinator (CC)1 in the treatment area conference room on 08/21/25 at 01:07 PM, CC1 acknowledged that there was no documentation why the prescribed BFR for P7 was not followed or if the staff did any interventions. CC1 said the staff are expected to report to the RN if the BFR is not achieved and document it in the treatment record. Review of facility policy titled, “Patient Assessment and Monitoring” stated, “. . . Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow . . .” 51870 2) On 08/20/25 at 01:30 PM, review of P14’s dialysis treatment record on 08/13/25 showed that dialysis was initiated at 15:25 PM. The BFR at 15:33 PM was noted to be at 200 ml/min and continued to be at 200 ml/min for one and a half hours until 17:05 PM, when it was increased to 300 ml/min (the prescribed BFR for P14). The treatment record did not indicate any reason for why the BFR was left at 200 ml/hr. On 08/20/25 at 2:00 PM, interview with Clinical Manager (CM) confirmed that the BFR should have been set to 300 ml/min if there were no indications of any problems at the initiation of dialysis. CM noted that not following the prescribed BFR can affect the patients’ adequacy of dialysis. On 08/20/25 at 2:45 PM, review of the facility’s “Initiation of Treatment Using Arteriovenous Graft of Fistula and Optiflux Single Use Ebeam Dialyzer” policy, published on 05/05/25, in the “Initiation of Treatment” section, it noted, “. . . If no problems are noted, turn the blood flow rate to the rate prescribed by the physician to achieve optimal clearances . . .””

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 47783 Based on record review and staff interviews, facility failed to adjust and implement plan of care (POC) to reflect the patient’s current condition for two of 15 patients (Patient (P)9 and P15) sampled for record review. Revising and providing appropriate interventions and goals on the POC guides staff on how to provide individualized care. This has the potential to affect all patients in the facility not meeting quality outcome goals. Findings Include: 1) On 08/20/25 at 01:00 PM, a review of P9’s Electronic Health Record (EHR) was conducted. P9 is a 36-year-old patient admitted to the facility on 05/08/18 for in-center hemodialysis treatments. Review of recent lab values for Phosphorus revealed the following result: 9.1 mg/dL (milligrams per deciliter) on 06/05/25, 10.4 mg/dL on 07/03/25 and 11.1 mg/dL on 08/07/25. High phosphorus levels, known as hyperphosphatemia, can lead to bone disease, calcification of arteries and organs, and other serious health issues. Latest POC dated 03/05/25 noted goal for Phosphorus was 3.0 to 5.5 mg/dL, however, under “Area of Focus”, it was noted that the plan for “Mineral Metabolism/Bone Disease” as closed. On 08/21/25 at 01:07 PM, a concurrent interview and record review with Clinical Coordinator (CC)1 was conducted in the treatment area conference room. Reviewed Phosphorus level results and current POC with CC1. Asked CC1 if the care plan for “Mineral Metabolism/Bone Disease” should be open. CC1 confirmed that it should be open since the Phosphorus level is above of the stated goal and trending up. 51870 2) On 08/20/25 at 01:00 PM, review of P15’s EHR was done. Noted that on 02/24/2025, P15 had dialysis treatment using a newly inserted left internal jugular central venous catheter (CVC) due to right forearm graft access clotting. Review of P15’s POC under “Area of Focus” section noted “Dialysis Access” as closed on 10/09/24, with a “Goal” of “No Catheter” and a due date of 10/09/25. Interventions were all closed on 10/09/24, with no new interventions noted for 2025 to address current access. On 08/20/25 at 02:00 PM, interview with Clinic Manager (CM) and CC1 confirmed that they did not update P15’s POC to reflect interventions in line with P15’s current CVC access. Both agreed that updating the POC is important as it directs the patients treatment plan and care. Review of the facility’s “Comprehensive Interdisciplinary Assessment and Plan of Care,” published on 07/03/23, it noted, “. . . Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessment . . . Failure to Achieve Plan of Care Outcome states, the Interdisciplinary team must adjust the patient’s Plan of Care and document changes to the POC. Implement the Plan of Care changes to address the identified issues . . .””