Usrc Mercy Plaza Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 50072 Based on Policy review, observations, and interview, the facility failed to ensure staff performed infection control practices to minimize the spread of infections or bloodborne pathogens in the dialysis facility in accordance with the facility’s policy. The facility staff reported an in-center hemodialysis patient census of 67, 17 peritoneal dialysis (PD) patients, and 1 home hemodialysis patient at the time of the survey. Failure to disinfect dialysis treatment stations according to policy can lead to cross contamination to other patients and surfaces, potentially placing all patients receiving care and treatment at the facility at risk for infections. Findings for 2 of 2 staff observations (Staff H and Registered Nurse [RN] I) include: 1. Review of facility policy #C-IC-0080, Disinfection and Cleaning of Dialysis Machine Equipment, revised 07/2023, reads in part, “Disinfection Procedure...7.Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on the pole, attached computer monitors and keyboard/mouse. 8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. 9. Clean counter tops behind patient station.” 2. Two of two observations on 03/31/25 showed Staff H disinfecting dialysis treatment station #17 at 9:58 AM. Staff H failed to completely wipe the front of the dialysis machine. Staff H also failed to completely disinfect the counter behind the dialysis treatment station. At 10:29 AM, Staff H disinfected treatment station #20 and failed to wipe down the left side of the dialysis machine, the back side of the treatment chair and the counter surrounding the treatment station. 3. During an observation on 4/1/25 at 10:52 AM, RN I cleaned peritoneal dialysis room #4 following Patient 9’s clinic visit with a bleach moistened paper towel. RN I cleaned the patient chair and the chair the patient’s care partner used, the paper towel was no longer moistened and RN I continued to use the dried paper towel to wipe the external surfaces of the two chairs. 4. In an interview on 4/1/25 at 11:09 AM, the FA reported that room #4 would be re-cleaned. 5. During an interview with on 04/01/25 at 2:40 PM, the administrator reported the counters are part of the treatment station and would need to be disinfected between patients. 44475”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 50072 Based on review of policy, facility training documents and interview, the facility failed to ensure that all staff who provide direct patient care received annual training in infection control, isolation practices, and catheter care. At the time of the survey, the facility reported an in-center hemodialysis patient census of 67; 17 peritoneal dialysis patients, and 1 home hemodialysis patient. Failure to ensure staff have proper training regarding infection control could potentially place all patients receiving dialysis treatments at risk for infections. Findings include: 1. Review of facility policy #EO-9001, Schedule of Competency Completion, revised 04/2023, intended to provide guidance for employees initial and annual skills competency completion, reads in part: “The Facility Administrator will ensure each employee’s record contain the required completed education and competencies within the designated timeframes. 2. An audit of each employee’s record will be performed at least bi-annually per the Quality Management Workbook schedule or more frequently as needed.” Further review of the policy shows a table pertaining to In-Center Direct Patient Care staff and required annual skills checks including: Catheter Skills Checklist, Clinical Skills Checklist, and Isolation Skills Checklist annually. 2. Review of 1 of 3 personnel files showed Staff A’s annual competencies were due for review in January 2025. There is no documentation to show Staff A’s competencies have been reviewed since 01/12/24. 3. During an interview on 03/31/25 at 3:29 PM, the Facility Administrator reported staff receive annual training in infection control, isolation practices and catheter care and on review of Staff A’s personnel file, the last training received in those areas was 01/12/24. The administrator acknowledged the findings.”

“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: 51639 Based on review of the facility’s policies, medical record review, and staff interview, the facility failed to implement the ordered dialysis prescription for 2 of 4 patients (Patient #3 & #4). At the time of the survey, the facility staff reported an in-center hemodialysis patient census of 67. Findings include: 1. The facility’s policy C-AD-0240 titled, “Patient Rights and Responsibilities,” with the last revision date of February 2023, included in part, “Patient’s Rights ...The right to - receive the necessary services required by the regulations regarding the patient plan of care. This includes the right to receive individualized care as determined by the interdisciplinary team, be included on that team and have all reasonable requests responded to promptly and adequately within the capacity of the facility.” 2. Patient #3’s dialysis treatment orders dated 1/31/25, showed a blood flow rate (BFR) of 450 and a dialysis flow rate (DFR) of 600. 3. A review of Patient #3’s hemodialysis flowsheet from 3/12/25 to 3/26/25, showed the following: a. The dialysis treatment flowshet dated 3/12/25 lacked documentation to show the dialysis flow rate was deliverd as precribed throughout the entire dialysis treatment. b. The dialysis treatment flowshet dated 3/14/25 lacked documentation to show the dialysis flow rate was deliverd as precribed throughout the entire dialysis treatment. Addtionally the flowsheet showed the treatment BFR was 400 milliliters per minute instead of the prescribed 450 milliliters per minue. c. The dialysis treatment flowsheet dated 3/17/25 lacked documentation of the prescribed dialysis flow rate for 2.5 hours of the dialysis treatment. d. The dialysis treatment flowshet dated 3/21/25 lacked documentation to show the dialysis flow rate was deliverd as precribed for the entire dialysis treatment. e. The dialysis treatment flowshet dated 3/24/25 lacked documentation to show the dialysis flow rate was deliverd as precribed for the entire dialysis treatment. 4. Patient #4’s dialysis treatment orders dated 2/28/25 showed a prescribed blood flow rate (BFR) of 450 and a dialysate flow rate (DFR) of 800. 5. Review of Patient #4’s treatment flowsheets showed the following: a. The dialysis treatment flowshet dated 3/12/25 lacked documentation to show the dialysis flow rate was deliverd as precribed for the entire dialysis treatment. b. The dialysis treatment flowshet dated 3/14/25 lacked documentation to show the dialysis flow rate was deliverd as precribed for the entire dialysis treatment. 36083 6. On 4/1/25 at 2:30 PM, the facility administrator (FA) verified the incorrect BFR and the lack of proof that the dialysis flow rate was documented and/or monitored on the dates identified. The FA acknowledged the importance of assessment and documentation of data related to the DFR.”

“H-MEET RD52:2004 CFR(s): 494.100(c)(1)(v) The facility must meet testing and other requirements of ANSI/AAMI RD52:2004. In addition, bacteriological and endotoxin testing must be performed on a quarterly, or more frequent basis as needed, to ensure that the water and dialysate are within the AAMI limits. This Standard is not met as evidenced by: 44475 Based on interview, clinical record, and review of facility policy, the facility failed to test a home hemodialysis patient for color blindness prior to initiation of home treatment. The facility staff reported 1 home hemodialysis patient at the time of the survey. Failure to ensure patients, or their care partners if applicable, have color blindness testing to determine if they have a color blindness deficiency could result in an inaccurate total chlorine test result. Elevated chlorine levels in the water used to prepare the dialysate for the patient’s home dialysis treatment could cause adverse patient outcomes. Findings for 1 of 1 home hemodialysis patient clinical record review (Patient 5) include: The facility policy titled “Color Blind Testing-Patient/Care Partner”, last revised January 2020, directed, in pertinent part, to complete upon initiation of home hemo (dialysis) dialysis and to document results and file in the patient’s medical record. The Clinical Record for Patient 5 lacked documentation of color blindness for either the patient or the patient’s care partner. In an interview on 4/1/25 at 12:11 PM, Staff J, Clinical Specialist, reported that she looked through the patient’s chart and was not able to find color blindness testing, Staff J further reported that a past administrative assistant may not have scanned the test into the patient’s clinical record.”