Idaho Kidney Center - Pocatello

“BACT CONTROL-SUPPLY LINE DISINFECTED CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: machine supply line disinfected Users should establish a procedure for regular disinfection of [the line between the outlet from the water distribution system and the back of the dialysis machine]. This Standard is not met as evidenced by: 39430 Based on observation, and staff interview, it was determined the facility failed to ensure patients were protected from potential exposure to unsafe peracetic acid levels. This failure impacted all patients dialyzing at the facility and put them at risk of adverse reactions to germicide exposure. The findings include: The National Center for Biotechnology Information described peracetic acid sterilant as “a strong oxidant that causes extensive protein denaturation and gross hemolysis.” (Retrieved from https://www.ncbi.gov/books/NBK220001, 2010) Mosby’s Review of Hemodialysis for Nurses, 9th edition, 6/15/15, defined hemolysis as the break up of the red blood cells resulting in the release of hemoglobin and intracellular potassium. This reference also stated “acute hemolysis during the dialysis treatment is a medical emergency.” During observations in the facility treatment area, on 6/10/24 beginning at 12:45 PM , 4 bottles of peracetic acid residual test strips were examined. The expiration date for one of the bottles of test strips was 2/15/24. The residual test strips are used to test for the presence of peracetic acid prior to starting patients treatment, post water loop and or machine disinfection. The FA was interviewed at the time of the observations. She confirmed the expired strips and discarded them. The facility failed to ensure patients were protected from potential harm from peracetic acid exposure.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 42316 Based on record review and staff interview, it was determined the facility failed to ensure services were provided in accordance with the POC for 1 of 7 ICHD patients (Patient #1) whose records were reviewed. Not meeting the prescribed BFR and DFR had the potential for inadequate dialysis treatment. Findings include: Patient #1 was a male patient receiving ICHD via tunneled CVC. His incenter treatment sheets were reviewed for 13 treatments between 5/11/24 and 6/08/24. His ordered BFR was 450 and his ordered DFR was 800. He did not meet his prescribed BFR/DFR for 9 of 13 treatments as follows: - 5/11/24: The BFR throughout treatment was 400. The DFR throughout treatment was 500 and was switched to the correct DFR of 800 about 30 minutes before the end of treatment. The nursing note stated, “He was able to meet his prescribed access flow rate.” There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/14/24: The BFR throughout treatment was 400. There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/16/24: The BFR throughout treatment was 400. The DFR throughout treatment was 500 and was switched to the correct DFR of 800 8 minutes before the end of treatment. There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/23/24: The BFR throughout treatment was 400. The nursing note stated, “He was able to meet his prescribed access flow rate.” There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/25/24: The BFR throughout treatment was 400. The nursing note stated, “He was able to meet his prescribed access flow rate.” There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/28/24: The BFR throughout treatment was 400. There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 5/30/24: The BFR throughout treatment was 400. There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 6/04/24: The DFR started correctly at 800 then was turned down to 500 without reasoning documented. There was no documentation why Patient #1 did not meet his prescribed access flow rate. - 6/08/24: The BFR throughout treatment was 400. The nursing note stated, “He was able to meet his prescribed access flow rate.” There was no documentation why Patient #1 did not meet his prescribed access flow rate. The FA was interviewed on 6/12/24 at 8:31 AM and Patient #1’s treatment sheets were reviewed. She confirmed Patient #1 did not meet his prescribed access flow rates for the above treatments. She confirmed there should have been documentation why the prescribed access flow rate was not met. The facility failed to ensure prescribed access flow was met for Patient #1.”