Liberty Dialysis Hawaii - Hawaii Kai 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: 51868 Based on observations, interviews and record 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 and staff at risk for potential exposure to infectious pathogens. Findings Include: 1) Observation on 03/12/25 at 10:45 AM, observed Patient Care Technician (PCT) 19 discontinue the dialysis treatment for Patient (P) 5 at Station 17. PCT19 removed his gloves after reinfusing extracorporeal circuit, disconnected bloodlines but failed to perform hand hygiene before donning clean gloves. During an interview with the Clinical Manager (CM) on 03/12/25 at 12:15 PM, CM verified that all staff are required to perform hand hygiene after removing gloves and before donning clean gloves. Review of the facility’s policy titled, “Hand Hygiene,” with a published date of 11/06/2023, Version 8, stated, “. . . Hands will be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ... Immediately after removing gloves. . .” 2) On 03/12/25 at 03:00 PM, observed Registered Nurse (RN) 3 cleaning the CVC exit site for P3 at station 19. RN3 removed old dressing and discarded in the trash bin, and immediately proceeded cleaning area around CVC exit site with antiseptic without changing gloves and performing hand hygiene. RN3 verified, in an interview conducted on 03/12/25 at 03:15 PM at the nurse’s station that he did not change old gloves and perform hand hygiene after discarding old dressing and before cleaning the CVC exit site per policy and procedure. Review of facility policy titled “Central Venous Catheter (CVC) Dressing Change,” published date 05/06/24 stated, “. . . 5. Inspect and remove the old dressing ... 7. Discard dressing and remove gloves. Perform hand hygiene. . .” 37954 3) On 03/14/25 at 11:50 AM, Registered Nurse (RN) 1 was observed at station 18. Patient (P) 9 requested that RN1 look at his upper right arm. RN1 put on clean gloves and removed the dressing that was in place, threw it away and then walked over to the nurse’s station where the clean supplies are kept and picked up a package of sterile gauze. RN1 left the package of sterile gauze at P9’s chair side table and walked back to the clean supplies area at the nurse’s station with the dirty gloves still on and picked up another package of sterile gauze. RN1 walked back to station 18 and dressed P9’s right upper arm. RN1 took off his dirty gloves and performed hand hygiene by using the alcohol-based hand rub. An interview was conducted with RN1 at this time in front of the nurse’s station. Observation was shared with RN1 and asked if he should have done something differently, he stated take off dirty gloves and perform hand hygiene before getting supplies. On 03/14/25 at 12:40 PM interviewed Clinical Manager (CM) in the conference room. Inquired if staff are allowed to use dirty gloves to get clean supplies with and she confirmed staff are not to do this and confirmed they have been trained on this upon orientation and annually with infection control training.”

“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: 47783 Based on observation, staff interviews, record review, the facility failed to ensure that staff thoroughly disinfected all surfaces of the dialysis station after treatment. This deficient practice has the potential to transmit blood borne pathogens and infections, and negatively impact the 59 patients receiving in-center hemodialysis treatments at this facility. Findings Include: On 03/12/25 at 10:51 AM, observed Patient Care Technician (PCT)7 at station 13 clean the dialysis machine and recliner. PCT7 wiped all the external surfaces of the machine but did not wipe the prime bucket. PCT7 then gathered the supplies needed for the next patient and was about to start setting up the machine. Observed the prime bucket on the side of the machine still has clear liquid in it. Asked PCT7 if he was supposed to empty and disinfect the prime bucket between patients. PCT7 replied, “Yes, I should do that before setting up.” On 03/14/25 at 08:28 AM, an interview with the Clinical Manager (CM) was conducted in the conference room. CM confirmed the staff are to wipe the inside and outside surfaces of the prime bucket between patient use and at the end of the day. CM added that this is one of the tasks they observe for when completing the monthly infection control audits. Review of facility policy titled “Cleaning and Disinfecting the Dialysis Station” with a publish date of 09/05/23 stated, “. . . Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment . . .” Review of facility form used for infection control audits titled “Cleaning and Disinfection of the Dialysis Station” presented on 03/14/25 at 09:25 AM was done. The third question on the form stated, “Was the prime waste bucket emptied and disinfected internally and externally and allowed to air dry?””

“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: 51870 Based on observation, interview and record review, the facility failed to ensure staff used aseptic technique to cleanse Patient (P) 2 and P10’s Central Venous Catheter (CVC) site before applying new dressing. As a result of this deficient practice, the two patients were placed at risk for potential CVC related infections. Findings Include: 1) On 03/14/25 at 11:15 AM, observed RN2 providing CVC care for P2. P2’s catheter exit site is located on the right upper chest area. Sutures (from previous insertion site) were noted approximately two inches below to the right of the current catheter exit site. RN2 cleaned the outside perimeter of the catheter exit site with side-to-side motion with antiseptic swabstick. RN2 then proceeded to apply new dressing to catheter exit site. On 03/14/25 at 11:30 AM, concurrent interview with RN2 confirmed that she did not clean the catheter exit care with antiseptic swabstick starting from catheter exit site out. When RN2 was asked why she did not clean the catheter exit site, RN2 replied, “I only cleaned the outer area because there was a suture, and I couldn’t clean around it.” On 03/14/25 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’s CVC dressing change policy and cleaning of the catheter site stated, “. . . 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) . . .” 37954 2) On 03/14/25 at 11:30 AM observed RN1 providing CVC care for P10. RN1 removed the old dressing, discarded dirty gloves, performed hand hygiene using an alcohol-based hand rub and put on new gloves. RN1 proceeded to clean the area around the CVC. RN1 was observed applying the antiseptic to the CVC exit site and moving away from the site, making quick back and forth motions to clean the area. At this time inquired with RN1 what he was doing and he stated patient is itchy and it (moving back and forth) makes it feel better. After RN1 applied the dressing and an interview was conducted near the nurse’s station. Inquired if nurses are to clean CVC from inside to out and RN1 confirmed CVC is to be cleaned from inside to out. On 03/14/25 at 12:40 PM an interview with the CM was done in the conference room. Inquired if nurses are to clean patient’s CVC from inside to out and she confirmed staff are to clean going from the inside out.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 47783 Based on observation, interview and record review, the facility failed to ensure the testing for chlorine/chloramine (disinfectant used in drinking water) in the water was performed correctly per the test strip manufacturer’s directions for use. This deficient practice has the potential for an unidentified chlorine breakthrough to cause harm to all the 59 patients receiving hemodialysis treatment at the facility. Findings Include: On 03/12/25 at 08:15 AM, observed Patient Care Technician (PCT)7 and Registered Nurse (RN)2 perform water testing for total chlorine using the RPC Ultra-Low Total Chlorine Test Strips. PCT7 filled the sample cup with water and place it on flat surface. PCT7 then set the timer to one minute (60 seconds) and opened the test strip. After dipping the strip in the water sample, PCT7 started the timer that counted down from 60 seconds. PCT7 removed the strip from the water sample when the timer alarmed, she turned off the timer and checked the color of the strip with RN2. Observed 12 seconds had passed from the time the strip was removed from the water to the time it was read by looking at the clock on the wall in the water room. Asked PCT7 what was the procedure for checking the chlorine/chloramine. PCT7 said the strip is dipped in the sample water for 60 seconds then read after 20 seconds. On 03/14/25 at 08:28 AM, the Clinical Manager (CM) confirmed during an interview in the conference room that staff are to wait 20 seconds after removing the strip from the water to read the strip. Review of the manufacturer’s direction for use company document titled “RPC Ultra-Low Total Chlorine Procedure” stated, “. . . dip the end with the reagent pad in the sample water and move the strip in a constant gentle motion back and forth for a total of 60 seconds. Remove the strip and shake once briskly to remove excess water. Wait 20 secs [seconds] for the color to develop. . .””

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 51868 Based on observation and interview the facility failed to discard an expired container of RPC E-Z Check Ozone Test Strips and an expired container of Residual Chlorine Reagent Strips with bleach indicator. As a result of this deficiency, there was a risk of increased disinfection residual in the dialysis water system. Findings Include: During flash tour of the water room, concurrent observation and interview was done with Biomed Technician (BMT). On 03/12/25 at 07:58 AM, a container of RPC E-Z Check Ozone Test Strips was observed to have an expiration date of 03/31/2024. Also, a container of Residual Chlorine Reagent Strips with bleach indicator was seen to have an expiration date of 02/2025, found at the nurse’s station. BMT confirmed that the test strips were expired and should have been discarded.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 51868 Based on observation, interview, and record review, the facility failed to maintain a safe environment by storing all clean supplies off the floor and a minimum of 18 inches from the ceiling, during one of three survey days. Failure to store and handle all clean supplies properly had the potential to negatively impact all in-center patients receiving dialysis treatment at this facility. Findings Include: During flash tour of the facility’s storage room on 03/12/25 at 8:06 AM, concurrent observation and interview was done with Biomed Technician (BMT), observed four boxes of clean supplies on the floor and six boxes of clean supplies stored on storage shelves less than 18 inches from the ceiling. BMT said that clean supplies should not be on the floor and should be more than 18 inches from the ceiling. During an interview on 03/12/25 at 10:30 AM, the Area Team Lead (ATL) confirmed clean supplies should be stored off the floor and a minimum of 18 inches from the ceiling. Review of the facility’s policy titled, “Storage of Supplies,” published date 04/05/2021, Version 2, stated, “. . . All clean or sterile supplies, except drums of concentrate, must be stored off the floor and a minimum of 18 inches in a sprinkled facility from the ceiling. . .””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 37954 Based on observations, interview and policy review, the facility failed to keep the vascular access sites (a way to reach the blood for hemodialysis) for two of 23 patients in view of the staff during their hemodialysis treatments. This deficient practice has the potential for accidental needle dislodgement or line separation to go undetected and could result in exsanguination (severe loss of blood). Findings Include: 1) On 03/12/25 at 07:47 AM a flash tour was conducted. During the flash tour observed patient (P) 3 resting at station one with her vascular access site on her right arm that was covered by a chux. Vascular access site and connection lines from hemodialysis machine were not in view. On 03/12/25 at 08:03 AM interviewed Patient Care Technician (PCT) 11. Inquired if she noticed P3’s access site was covered and she stated “She has been told not to cover her access site. ...” On 03/12/25 at 08:05 AM interviewed P3. Inquired who covered her right arm where her access site is and she stated that she covered it because “my hand is cold.” On 03/17/25 at 02:18 PM called and requested from Area Team Lead copy of facility policy for access site to remain uncovered during treatment. Area Team Lead was able to provide the policy. Review of the facility policy titled “Patient Assessment and Monitoring” with a published date of 05/01/23 version 4 states “Purpose The purpose of this policy is to provide guidance to initials of facility direct patient care staff on assessment and monitoring patients before, during and after treatment. ... During Treatment Step 1 ... Access Observe connections are secure and visible ... Ensure access remains uncovered throughout the treatment ... No bleeding or infiltration is noted ...” 51868 2) During flash tour of the facility on 03/12/25 at 07:47 AM, observed a patient dialyzing at Station 17. The patient was reclined in the chair with a blanket covering her from chest to feet. At 08:30 AM Patient Care Technician (PCT) 19 approached the hemodialysis machine to review the information on the screen and typed in information and left the station without checking and uncovering patient’s access site. PCT19 confirmed in an interview on 03/12/25 at 08:35 AM, the patient’s access should remain uncovered throughout the treatment and the above-mentioned patient’s site had been covered with blankets. The Area Team Lead (ATL) confirmed in an interview on 03/12/25 at 09:05 AM, patient’s access site shall be secure and visible at all times. Review of policy titled: “ Patient Monitoring During Patient Treatment” stated, “ . . . all patients must be under visual observation by . . . staff during treatment . . . Observe and document at the initiation of dialysis and at every safety check that all connections are secure and visible . . . Ensure access remains uncovered throughout the treatment . . .””

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 47783 Based on record reviews and interviews, the facility failed to complete timely assessments to evaluate the present health status for four of eight Patients (P) sampled for record review. Pre-treatment assessment was conducted greater than one hour after treatment was initiated for P2, P4, P5 and P8. This deficient practice placed the four patients at risk for preventable medical complications related to their hemodialysis treatments due to possible unidentified adverse health conditions. Findings Include: 1) Review of P2’s treatment sheets from 02/28/25 to 03/12/25 was conducted. Treatment sheet dated 03/03/25 revealed treatment was started by Patient Care Technician (PCT)12 at 06:08 AM. Registered Nurse (RN)1 documented patient evaluation at 07:19 AM, one hour and 11 minutes after treatment was initiated. On 03/05/25, treatment was started by PCT12 at 05:05 AM and RN1 documented patient evaluation at 06:55 AM, one hour and 50 minutes after treatment was initiated. On 03/07/25, treatment was started by PCT12 at 05:08 AM and RN1 documented patient evaluation at 07:13 AM, one hour and 55 minutes after treatment was initiated. No documentation was found in all three treatment sheets that indicated they were “Late Entry”. 2) Review of P4’s treatment sheets from 02/28/25 to 03/12/25 was conducted. Treatment sheet dated 03/03/25 revealed treatment was initiated by PCT7 at 10:30 AM. RN1 documented evaluation at 12:31 PM, two hours and one minute after treatment was started. No documentation was found that stated it was a “Late Entry”. 3) Review of P5’s treatment sheets from 02/28/25 to 03/12/25 was conducted. Treatment sheet dated 03/03/25 revealed treatment was started by PCT11 at 10:14 AM. RN1 documented patient evaluation at 11:27 PM, one hour and 13 minutes after treatment was initiated. No documentation was found that stated it as a “Late Entry”. On 03/14/25 at 08:28 AM, an interview and record review was conducted with the Clinical Manager (CM) in the conference room. CM confirmed the RN did not evaluate and assess the patients within one hour of treatment initiation. CM added sometimes the RN does the assessment and documents later when at the nurse’s station. When this happens, the RN would note it as a “Late Entry”. 51868 4) Review of P8’s treatment sheet dated 02/28/25 revealed the treatment was started at 09:44 AM and the RN signed the assessment at 10:58 AM, one hour and 14 minutes after. Treatment sheet for 03/03/25 revealed the treatment was started at 09:42 AM and the RN signed the assessment at 11:43 AM, two hours and one minute after. The CM confirmed in an interview at the conference room on 03/14/25 at 10:35 AM that RN did not evaluate and assessed P8 within one hour of treatment initiation. Review of facility policy titled “Nursing Supervision and Delegation,” with published date of 11/06/23 stated, “. . . The registered nurse must evaluate each patient preferably within an hour . . . to: Confirm identity; Review the patient’s condition; Review accuracy and completeness of treatment and patient data; Review patient treatment prescription and equipment parameters . . . Talk to the patient to elicit information such as changes in condition, response to treatment, new injuries . . . complaints . . .””

“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: 37954 Based on record review and interview the facility failed to ensure physician’s orders for one of eight patients sampled for record review were followed. The facility did not ensure the blood flow rate ordered for Patient (P) 1 was followed during treatment. Failure to follow the physician’s orders dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatment for P1. Findings Include: On 03/14/25 record review of P1’s hemodialysis (HD) orders revealed the blood flow rate ordered at 400. Review of P1’s treatment sheets from 01/13/25, 01/17/25, 01/22/25 and 02/10/25 revealed staff working with P1, during his dialysis, did not follow the ordered blood flow rate of 400 and did not document why the blood flow rate was less than the physician ordered rate. On 01/13/25 at 16:03 (04:03 PM) Patient Care Technician (PCT)7 documented blood flow rate was 350. At 16:32 (04:32 PM) PCT13 documented blood flow rate was 350. At 17:02 (05:02 PM) PCT7 documented blood flow rate was 350. At 17:33 (05:33 PM) PCT6 documented blood flow rate was 350. Documented average blood flow rate for P1 on 01/13/25 was 350. On 01/17/25 at 16:03 (04:03 PM) PCT7 documented blood flow rate was 350. At 17:20 (05:20 PM) and at 17:33 (05:33 PM) Registered Nurse (RN) 4 documented blood flow rate was 350. At 18:07 (06:07 PM) PCT9 documented blood flow rate was 350. At 18:31 (06:31 PM) RN5 documented blood flow rate was 350. At 19:01 (07:01 PM) PCT9 documented blood flow rate was 350. Documented average blood flow rate for P1 on 01/17/25 was 350. On 01/22/25 at 16:32 (04:32 PM) PCT9 documented blood flow rate was 350. At 17:01 (05:01 PM) PCT9 documented blood flow rate was 300. At 17:31 (05:31 PM) RN5 documented blood flow rate was 300. At 18:03 (06:03 PM) PCT9 documented blood flow rate was 350. Documented average blood flow rate for P1 on 01/22/25 was 320. On 02/10/25 at 16:08 (04:08 PM) RN1 documented blood flow rate was 350. At 16:34 (04:34 PM) PCT13 documented blood flow rate was 350. At 17:03 (05:03 PM) PCT7 documented blood flow rate was 300. At 17:44 (05:44 PM) and 18:10 (06:10 PM) PCT11 documented blood flow rate was 300. At 18:31 (06:31 PM) and 19:03 (07:03 PM) PCT11 documented blood flow rate was 325. Documented average blood flow rate for P1 on 02/10/25 was 320. Review of P1’s treatment sheets revealed P1 only received his prescribed blood flow rate of 400 once during his treatments reviewed, which was documented on 01/22/25 at 16:13 (04:13 PM) by RN5. Review of the treatment sheets did not find any documentation that the PCTs assigned to P1 notified the RNs of the documented low blood flow rates. PCTs and RNs did not document a reason why P1’s blood flow rates were lower than ordered or what was causing this to occur. An interview was conducted with the Clinical Manager (CM) on 03/14/25 at 12:40 PM in the conference room. CM was asked if staff are expected to follow the prescribed flow rate that is prescribed for patient’s dialysis and she confirmed staff are to follow the prescribed flow rate for all patients receiving dialysis. Review of facility policy titled “Patient Assessment and Monitoring” published on 05/01/23 version 4 states “Purpose The purpose of this policy is to provide guidance to initials of facility direct patient care staff on assessment and monitoring patients before, during and after treatment. ... During Treatment Follow the steps below for monitoring patient and machine parameters during treatment: ... Step 3 Machine Parameters and Extracorporeal Circuit Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47783 Based on record review and interview, the facility failed to provide necessary care and services to manage the volume status for one of eight patients (P) sampled for record review. The Patient Care Technician (PCT) failed to notify the Registered Nurse (RN) when the blood pressures (BP) for P4 were high during dialysis treatments. This deficient practice placed the patient 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 “During Treatment . . . Blood Pressure”, “. . . Report to the nurse: Systolic (upper reading) blood pressures greater than 180 mm/Hg (millimeters of mercury) . . . “ Review of P4’s treatment sheets from 02/28/25 to 03/12/25 conducted. BP readings on the following dates and times were above the facility stated parameters: 02/28/25 - 195/79 at 11:01 AM, 191/69 at 11:30 AM and 203/64 at 12:00 PM. 03/05/25 - 190/67 at 10:35 AM 03/10/25 - 207/77 at 11:03 AM, 192/71 at 11:34 AM, 191/75 at 12:31 PM and 189/80 at 13:02 PM. There was no documentation found of PCT notifying the RN of P4’s elevated BP. On 03/14/25 at 08:28 AM, an interview was conducted with the Clinical Manager (CM) in the conference room. CM confirmed the PCTs are to notify the RN if the patient’s BP readings are outside the facility identified parameters so the RN can assess the patients.”

“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: 37954 Based on observations, interviews and record review, the facility failed to aseptically clean the AV (arteriovenous) fistula (surgeon connects an artery to a vein in the arm) site of two Patients (P)7 and P9, prior to cannulation (insertion of needles) and failed to clean P9’s AV fistula with soap and water prior to treatment initiation. As a result of this deficient practice, it puts all patients at risk for potential AV fistula related infections. Findings Include: 1) On 03/12/25 at 09:10 AM, P7 was observed at station three. Patient Care Technician (PCT) 11 was observed at this time for the initiation of treatment. PCT11 had performed hand hygiene, put on clean gloves and retrieved a stethoscope that was hanging hear the nurse’s station. PCT11 was observed cleaning the stethoscope with an alcohol wipe. PCT11 used the same alcohol wipe to clean P7’s AV fistula site. PCT11 then proceeded to insert the needles into P7’s AV fistula. Afterwards an interview was conducted with PCT11 near the nurse’s station. Observation of using the alcohol wipe to clean the stethoscope and then used the same alcohol wipe to clean P7’s AV fistula site. Further observed PCT11 did not take off her dirty gloves, perform hand hygiene and put on clean gloves prior to aseptically cleaning P7’s AV fistula prior to inserting the needles was shared with PCT11. PCT11 nodded her head and stated, “I get it.” 2) On 03/12/25 at 10:21 AM P9 was observed at station four. PCT11 was observed during this time for P9’s access of AV fistula for initiation of treatment. P9 was observed prior to sitting at station four washing his hands with soap and water but did not wash his AV fistula site with soap and water. P9 sat at station four and pulled off two band aids from his AV fistula in front of PCT11. PCT11 did not wash P9’s AV fistula prior to initiating P9’s dialysis. PCT11 performed hand hygiene, put on clean gloves, assessed P9’s AV fistula. PCT11 applied antiseptic to AV fistula and inserted needles into P9’s AV fistula. Afterwards an interview was conducted with PCT11 near the nurse’s station. Observations were shared with PCT11 that she did not cleanse the AV fistula with soap and water, did not take off dirty gloves and do hand hygiene prior to applying antiseptic to skin over P9’s AV fistula. PCT11 did not agree with surveyor and stated she did take off her gloves, perform hand hygiene and put on new gloves before cleaning P9’s AV fistula with a clean alcohol wipe because of prior observation shared with her. On 03/14/25 at 12:40 PM an interview with Clinical Manager (CM) was done in the conference room. Inquired at that time if staff are expected to know when they are to change gloves and perform hand hygiene when initiating dialysis. CM stated staff are expected to take off dirty gloves and perform hand hygiene. Shared observation of staff using an alcohol wipe to clean the stethoscope and then used to cleanse an AV fistula site prior to initiation of HD and inquired if this was okay and CM confirmed this was not okay, staff are to use a clean alcohol wipes. Inquired if staff are to wash a patient’s AV fistula prior to treatment if the patient does not and CM confirmed staff are expected to wash the AV fistula. Review of facility policy titled “Access Assessment and Cannulation” published 05/05/24 stated, “. . . The purpose of this procedure is to provide guidance for assessing patency and placement of needles in an AVFistula or AVGraft to obtain access to the circulatory system for dialysis. ... Assessment of Vascular Access Follow the steps below to assess the vascular access: Step 1 Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient’s access with soap and water. ... 9 Remove gloves and perform hand hygiene. Don new gloves. Note: To clarify glove changes during the cannulation procedure: After assessing the access, staff must perform hand hygiene and don new gloves. With the new gloves, staff may perform the full cannulation procedure including skin disinfection, lidocaine administration (if applicable) and cannulation. If any of the steps in the procedure are interrupted, hand hygiene must be performed and new gloves must be donned. . .””

“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: 51868 Based on observation, interview and record review, the facility failed to ensure all direct patient care staff who treat patients in the facility follow the policy and procedure on receiving and stocking medications. This deficient practice has the potential for the medication to be obtained and used illegally. Findings Include: 1) On 03/12/25 at 01:15 PM, observed two out of six unlocked Patient Care Technician (PCT) heparin lock boxes and one of two registered nurse medication lock boxes on the nurse’s station. During an interview with Registered Nurse (RN) 3 they acknowledged all medication lock boxes are to be locked and secured. The Area Team Lead (ATL) confirmed in an interview on 03/12/25 at 01:30 PM, that all medication lock boxes be locked and secured at all times. Review of facility policy “Receiving and Stocking Medication,” Published date 11/07/22, Version 02, states: “. . . Ensure that all medications are secured in a lockable cabinet or medication refrigerator . . . Ensure that medication cabinet and medication refrigerator are properly locked for security of medications . . .” 37954 2) On 03/14/25 at 11:55 AM observed a PCT heparin lock box that was left unlocked at the nurse’s station, across from station 19. Surveyor opened lid to the unlocked heparin box and observed two vials of heparin that was left in the unlocked lock box. One heparin vial was sealed and the other one was opened and it was half full. During this observation an interview was done with PCT9. Inquired if the heparin lock box is to remain locked when not in use and PCT9 confirmed it is to be locked when not in use and thanked surveyor.”

“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: 37954 Based on observation, interviews, and record reviews, the facility failed to keep accurate medical records for two of eight Patients (P) 3 and P1 sampled for record review. As a result of this practice, residents are at risk for potential medication and treatment errors. Findings Include: 1) On 03/12/25 at 10:10 AM P3 was observed sitting at station one. P3 was observed taking medication by mouth that had been left on her chair side table. During this time Registered Nurse (RN)3, who was assigned to P3, was observed vacuuming on the other side of the room near station 20. P3 was asked what medication she stated calcitriol. On 03/12/25 at 10:40 AM interviewed RN3 and inquired if he left medication for P3 on her chair side table. RN3 stated “P3 was insistent that I leave the medication for her to take”. Inquired if this is something he usually does and RN3 stated “no not normally” and stated “Maybe P3 was insistent with me because I am new.” On 03/13/25 during record review of P3’s documented treatment from 03/12/25 found RN3 had documented P3 was given Vitamin D (calcitriol) 0.750 mcg oral at 09:52 AM. On 03/12/25 at 17:47 (05:47 PM) RN3 documented “Pt refused to take oral medication on time and requested to put it on pt’s side table. RN reinforced compliance but pt strongly insist. Educate pt on the importance of adherence to medication policy. Pt took her meds post tx and witnessed by this RN.” On 03/14/25 at 12:40 PM an interview was done with Clinical Manager (CM) in the conference room. Inquired if nurses are allowed to leave medication with patients at their chair side table and take without the nurse observing the patient take it. CM stated nurses are expected to give and witness the medication is taken by the patient. Review of facility policy titled “Medication Preparation and Administration” published 02/06/23 states “Purpose To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control. ... Documentation The following points must be followed to ensure proper documentation of medication preparation and administration. ... Medications must not be signed off prior to administration.” 51870 2) On 03/13/25 at 10:00 AM, record review of P1’s electronic medical record (EMR), noted Registered Nurse (RN) 1’s progress note entry on 03/10/25 at 13:31 PM documentating, Per [Name of Physician]: START Vancomycin 1000 mg (milligrams) IV (intravenous) x12 doses (last dose 04/04/25). There were no physician’s orders in P1’s EMR and per dialysis treatments on 03/10/25, and 03/12/25, Vancomycin was not administered. Further review of P1’s EMR did not reveal any current infections to warrant antibiotics. On 03/13/25 at 01:30 PM, interviewed Medical Director (MD). When MD was asked if she remembered ordering Vancomycin for P1 yesterday, she responded, “I didn’t order antibiotics for P1, it was for P3. I spoke with RN1 yesterday. If I had ordered it for P1, then I would’ve cancelled it.” On 03/14/25 at 08:50 AM, interviewed RN1 at the nurse’s station and asked RN1 to get into P1’s progress notes. When asked if he documented the Vancomycin order, he replied, “Yes.” When asked if there was a physician’s order for the medication, he replied, “There should be.” RN1 proceeded to check for the physician’s orders in P1’s EMR but could not find it. RN1 then remembered and confirmed that Vancomycin order was for another resident and verbalized, “I charted on the wrong patient, thank you for catching that.” At 09:00 AM, observed RN1 documenting in P1’s progress notes, 03/14 ERROR: The above note was error, intended for another patient. Order was put in for correct patient, but not was documented in wrong patient’s chart. Review of the facility’s policy titled “Medical Record Documentation Standards,” published on 02/05/24, version 4, “... Policy The dialysis facility must monitor and maintain complete, accurate, and accessible records on all patients. ... These records will reflect the condition of the patient from the time of first dialysis treatment until the patient is discharged.””