Usrc Beretania Dialysis

“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 all 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 10/01/24 at 08:28 AM, a flash tour was conducted in the treatment area. The facility has a total of 17 stations with one station enclosed and used to isolate HBV+ or HBsAg (hepatitis B surface antigen) positive patients. Asked Patient Care Technician (PCT)5 if the room was being used. PCT5 said they have one patient that uses the isolation room every Monday, Wednesday and Friday. On 10/01/24 at 11:29 AM, a concurrent observation and interview was conducted with Clinical Specialist (CS)2 in the isolation room. Observed that the reclining chair and sharps container were not labeled to identify them to only be used in the isolation room. CS2 confirmed the two items mentioned were not labeled “Isolation” and should have been labeled like the other supplies and equipment in the isolation room. Review of the facility policy titled, “Use of Isolation for Hepatitis B Antigen positive or Unknown Status Patients” stated, “. . . Separate dedicated supplies and equipment . . . will be labeled “isolation” and not routinely removed from the isolation area/room . . .””

“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 record review and interviews, the facility failed to ensure the water tests for total chlorine or chloramine (disinfectants commonly used in drinking water) were performed every four hours. Exposure of the blood to chlorine and chloramines in the water during hemodialysis (a treatment to remove excess fluid and waste products from the blood) can cause destruction of the red blood cells. This has the potential to affect all 88 in-center patients. Findings include: On 10/02/24 at 12:51 PM, a review of the total chlorine testing logs from 08/01/24 to 09/30/24 was conducted. Noted that the first checks are done between 04:10 AM to 04:40 AM, then approximately every four hours after that. On 09/28/24, the second check was done at 08:25 AM and the third check was done four hours and six minutes later at 12:31 PM. On 10/02/24 at 02:43 PM, a concurrent interview and record review was conducted with the Biomedical Technician (BMT) and Clinical Specialist (CS)1 in the conference room. Asked CS1 how often are the staff supposed to check the water for chlorine and chloramines. CS1 said the staff check it in the morning before they mix bicarbonate and start treatments, and every four hours after that. Showed Total Chlorine Testing log entries for 09/28/24 to CS1 and BMT. Both acknowledged the entry for 09/28/24 at 12:31 PM was beyond four hours. BMT added that sometimes the log entry is late if the tablet used to enter the test results is not able to connect to the network. Asked BMT if there is a way to check if the tablet was not able to connect to the network on 09/28/24. BMT said the staff would note in the comment section of the ELF (Electronic Log Filing) if there were any issues. BMT checked ELF entries for 09/28/24 and was not able to find any notes from the staff for that day. Review of the facility policy titled “Total Chlorine testing” stated, “. . . Total Chlorine Testing will be performed every four (4) hours while patients are being treated . . .””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47783 Based on observation and interview, the facility failed to maintain the integrity of the water purification system when rust was observed on the bracket where the micron filter was attached. Failure to maintain the integrity of the facility’s water purification system parts or components had the potential to negatively impact the water purification process necessary for hemodialysis and the safety of the 88 patients receiving their treatments at this facility. Findings include: On 10/01/24 at 08:41 AM, a flash tour was conducted with the Biomedical Technician (BMT) in the water treatment room. While going through the water system components with the BMT, observed heavy build-up of rust on the bracket holding the five-micron filter (water filter that removes very small particles and sediment) on the wall between the brine tank (part of the water softener that holds the salt) and reverse osmosis (water treatment process that removes contaminants by using pressure to force water through a semipermeable membrane) system. On 10/02/24 at 02:50 PM, a concurrent observation and interview was conducted with the BMT and Clinical Specialist (CS)1 in the water treatment room. Showed the five-micron filter bracket to BMT and CS1, both acknowledged that the top side of the bracket was covered in rust and said there is not supposed to be rust on any components or parts of the water system.”

“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 interview, the facility failed to provide necessary care and services to manage the volume status for two of nine patients (Patient (P)4 and P5) sampled for record review. The Patient Care Technician (PCT) failed to notify the Registered Nurse (RN) when the blood pressures (BP) for P4 was elevated, and there was no intervention provided for P5 when he finished treatment above ordered EDW (Estimated Dry Weight - a patient’s weight when the body does not have any excess fluid). This deficient practice placed the patients at risk of possible health complications related to hypertension (high blood pressure) and hypervolemia (condition where there is too much fluid in the body). Findings include: 1) Review of Hemodialysis Flowsheets from 09/20/24 to 09/30/24 for P4 was conducted. Noted BP readings on 09/20/24 at 09:50 AM was 200/99, at 09:51 AM was 202/96, on 09/23/24 at 09:49 AM was 184/93, on 09/25 at 09:44 AM was 186/91, at 09:49 AM was 183/84, at 10:01 AM was 188/99, at 10:31 AM was 187/89, on 09/27/24 at 09:39 AM was 192/103 and 201/103, at 09:44 AM was 189/97, at 09:45 AM was 190/93, on 09/30/24 at 09:38 AM was 199/100, 09:45 AM was 190/95, and 10:01 AM was 185/93. There was no documentation that the Registered Nurse (RN) was notified of the elevated BP by the Patient Care Technician (PCT). On 10/03/24 at 02:46 PM, concurrent interview and record review was conducted with Clinical Specialist (CS)1 in the conference room. CS1 confirmed that the PCTs were supposed to notify the RN if the patient’s BP were out of range based on the facility’s policy or the physician’s order if applicable. A review of the facility policy titled, “Reportable Parameters to CN [Charge Nurse],” with a revision date of 01/2021 was conducted. The policy documented, “PCT [Patient Care Technician]/CCHT [Certified Clinical Hemodialysis Technician]/LPN [Licensed Practical Nurse]: Report to Charge Nurse INTRA-DIALYSIS. B/P: Systolic > (greater than) 180 or < (less than) 100, Diastolic >100.” 2) Review of the Hemodialysis Flowsheets from 09/17/24 to 09/28/24 for P5 conducted. P5’s ordered EDW was 67 kg (kilograms). P5’s weight after treatment on 09/19/24 was 69.2 kg, on 09/21/24 was 70.8 and on 09/28/24 was 68.9 kg. There was no documentation that P5 was offered additional treatments to remove the excess fluid to bring him down to his ordered EDW. On 10/03/24 at 02:46 PM, concurrent interview and record review was conducted with CS1. Asked CS1 if the staff are supposed to offer patients additional treatments if they are not able to go down to their EDW. CS1 said the staff are supposed to offer additional treatments if the patients are 1.0 kg above their EDW.”

“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, the facility failed to maintain a complete and accurate medical record for one of nine patients (Patient (P)8) sampled for record review. Failure to maintain a complete and accurate medical record could lead to physicians having inaccurate information regarding patient’s status and will not provide documentary evidence of care provided. Findings include: On 10/01/24 at 09:57 AM, review of the documents requested from the facility during the entrance conference was conducted. P8 was identified as a discharged patient categorized as “lost to follow up.” A review of P8’s Electronic Health Record (EHR) was conducted. P8 was a 60-year-old patient admitted to the facility on 10/08/20 for in-center hemodialysis and discharged on 06/08/24. Further review of the EHR revealed that the last monthly note made by the provider on 05/06/24 stated, “. . . He (P8) is traveling to the Philippines and Indonesia from 5/7 to 5/28/24 (05/07/24 to 05/28/24) . . .” Another note from the dietitian entered on 07/08/24 stated, “Pt (patient) was discharged 06/26/24 - lost to follow-up. No further services of this RD (Registered Dietitian) required at this time.” On 10/01/24 at 02:14 PM, a concurrent interview and record review was conducted with Clinical Specialist (CS)1 in the conference room. Asked CS1 if a discharge summary was completed for P8. CS1 was not able to find a discharge summary in the EHR. On 10/02/24 at 11:23 AM, an interview was conducted with the Facility Administrator in the conference room regarding P8’s discharge status. Facility Administrator said, “The RN (registered nurse) used the wrong discharge classification. Patient (P8) was not lost to follow up. He traveled to Philippines and was admitted to the hospital upon his return due to COVID and expired at the hospital.” Review of facility policy titled “Medical Records” stated, “. . . All closed records must include: 1. A discharge summary will be completed within 30 days after the patient is inactivated/discharged . . . 2. All involved disciplines will complete documentation concerning the discharge of the patient . . .” Review of facility policy titled “Admission/Discharge of Patients and End of Treatment Day Discharge” stated, “. . . Discharge of Patients . . . d. Lost to follow-up: . . . Patient stopped attending dialysis and his/her whereabouts are unknown . . .””

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 47783 Based on record reviews and interviews, the facility failed to ensure staff documented promptly and completely into the Electronic Health Records (EHR) the Blood Pressure (BP) readings and patient monitoring for three of nine patients (Patient (P) 2, P3 and P6) sampled for record review. This deficient practice has the potential to negatively impact the safety of the patients if they are not monitored closely during their treatments. Findings include: 1) On 10/03/24, a review of P2’s Hemodialysis Flowsheets from 09/19/24 to 10/01/24 was conducted. It was noted that on 09/19/24 at 08:01 AM, BP and machine readings were recorded, and staff documented observations at 08:02 AM. The next BP and machine readings were recorded at 08:31 AM, and staff documented observations at 09:30 AM. For one hour and 28 minutes between 08:02 AM and 09:30 AM, no other staff monitoring was documented. 2) On 10/03/24, a review of P3’s Hemodialysis Flowsheets from 09/17/24 to 09/28/24 was conducted. It was noted that on 09/17/24 at 12:31 PM, BP and machine readings were recorded, and staff documented observations at 12:31 PM. The next BP and machine readings were recorded at 01:31 PM, and staff documented observations at 01:43 PM. For one hour and 12 minutes between 12:31 PM and 01:43 PM, no other staff monitoring was documented. On 09/24/24 at 12:31 PM, BP and machine readings were recorded, and staff documented observations at 12:33 PM. The next BP and machine readings were recorded at 01:31 PM, and staff documented observations at 01:37 PM. For one hour and four minutes between 12:33 PM and 01:37 PM, no other staff monitoring was documented. 3) On 10/03/24, a review of P6’s Hemodialysis Flowsheets from 09/06/24 to 09/18/24 was conducted. It was noted that on 09/06/24 at 04:31 PM, BP and machine readings were recorded, and staff documented observations at 04:36 PM. The next BP and machine readings were recorded at 05:01 PM, and staff documented observations at 05:37 PM. For one hour and one minute between 04:36 PM and 05:37 PM, no other staff monitoring was documented. Another 59-minute gap in observation was noted between 06:06 PM and 07:05 PM. On 09/16/24 at 06:31 PM, BP and machine readings were recorded, and staff documented observations at 06:34 PM. The next BP and machine readings were recorded at 07:01 PM, and staff documented observations at 07:53 PM. For one hour and 19 minutes between 06:34 PM and 07:53 PM, no other staff monitoring was documented. On 10/03/24 at 02:26 PM, concurrent interview and record review was conducted with Clinical Specialist (CS)1 in the conference room. CS1 reviewed the Hemodialysis Flowsheets for P2, P3 and P6. Asked CS1 why there were gaps of over 30 minutes between patient observations for the three patients. CS1 said sometimes the staff could be attending to other patient’s needs and are not able to document observations right away. When that happens, the staff are supposed to note in the EHR if it is a late entry. Review of facility policy titled “Medical Records” stated, “. . . When documenting a late entry, present date/time will be used, followed by the words “late entry”. The original date/time will be documented after the words “late entry”. . .” Review of facility policy titled, “Intradialytic Monitoring of Patient” stated, “. . . Vital signs: Obtained and documented at least every 30 minutes . . .””