Fmc - Glenview Dialysis Center

“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: 27125 Based on document review, observation and interview, it was determined that for 1 of 2 technicians (E#1), the facility failed to ensure the catheter exit site was kept uncovered while drying to apply new dressing to prevent potential contamination. Findings include: 1. The Facility’s policy titled, “Changing the Catheter Dressing Procedure (5/2/2022)” was reviewed on 11/29/2023 and included, “Inspect and remove the old dressing. ... Cleaning the site: ... Remove swabstick from package by stick end without touching foam applicator. ... Using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing.” 2. During a tour of the dialysis unit on 11/29/2023 from 9:30 AM to 11:30 AM the following was observed: - 10:00 AM, E#1 removed the old dressing from the catheter site of the patient at station #18. E#1 pulled back the patients shirt, cleaned the area around the catheter and walked away to allow to dry. The shirt went back over the open catheter site and remained there for approximately 2 minutes. The nurse (E#2) then took tape and taped the shirt away from the open catheter exit site. E#1 then placed a sterile dressing over the catheter exit site 3. During an interview on 11/29/2023 at 10:10 AM, the nurse (E#2) stated, “The shirt should not have been allowed to cover and touch the open catheter exit site after clearing. Since it did, we should have recleaned the area.” E#2 stated that patients are instructed to wear button down shirts.”

“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: 27125 Based on document review and interview, it was determined that for 1 of 1 (Pt. #2) patients reviewed with labile (unstable) blood pressure readings, the facility failed to monitor the blood pressure when administering PRN (as needed) medications, as required. Findings include: 1. The Facility’s policy titled, “Intradialytic Hypotension (7/3/2023)” was reviewed on 11/29/2023 and included, “Ensure that blood pressure [BP] has returned to a comfortable level for the patient. Monitor and record the BP at least every 5 minutes until any symptoms related to hypotension have resolved.” 2. The Facility’s policy titled, “Medication Preparation and Administration (2/6/2023)” was reviewed on 11/29/2023 and required, “Document reason for PRN drug administration and effectiveness of medication post administration in the patient’s medical record.” 3. The clinical record of Pt. #2 was reviewed on 11/28/2023. Pt. #2 was admitted on 6/3/2019 with the diagnosis of end stage renal disease. A physician’s order, dated 9/8/2023 included, “Midodrine 5 mg [milligrams] [treat low blood pressure that causes severe dizziness and fainting] oral PRN - may repeat one time for hypotension [low blood pressure]. The following are examples of treatment sheets included in the clinical record that indicated when a PRN medication was administered and the BP was not monitored as required: - 11/24/2023 - Treatment ended at 11:23 AM with vital signs documented as 136/76 (sitting) and 125/61 (standing). Midodrine PRN, administered at 12:00 PM. The record lacked documentation of any symptoms (reason for administering) or any repeat blood pressure prior to discharge to ensure effectiveness. - 11/20/2023 - Treatment ended at 11:36 AM with vital signs documented as 142/68 (sitting) and 105/50 (standing). Midodrine PRN was administered at 12:37 PM. A nurse’s note (E#2) at 12:37 PM, “Post tx [treatment] sit to stand BP’s 50 mmHg [millimeters mercury] drop, patient dizzy standing, Midodrine PRN given.” An additional note at 1:05 PM included, “Discharged ambulatory, no complaints, vital signs stable.” The clinical record lacked documentation of any other blood pressure, before or after, administration of the medication prior to discharge to ensure effectiveness. - 11/17/2023 - Treatment ended at 11:30 AM with vital signs documented as 102/55 (sitting) and 101/55 (standing). Midodrine PRN was administered at 1:12 PM. A nurse’s note (E#2) at 1:13 PM included, “1:00 PM sit BP 102/50; patient dizzy standing up; Midodrine 5 mg [milligram] given.” A nurse’s note at 1:28 PM included, “Discharged ambulatory, no complaints, vital signs stable. The clinical record lacked documentation of blood pressure after administration of medication prior to discharge to ensure effectiveness. 4. During an interview on 11/29/2023 at approximately 1:30 PM, the registered nurse (E#2) stated that the staff know the patient very well and know when [Pt. #2] needs the medication. 5. During an interview on 11/29/2023 at 1:40 PM, the clinic manager stated, “The blood pressure should be documented when a PRN is given until the patient is stable.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for 1 of 5 (Pt. #5) patients care plan, the physician did not sign the care plan within 30 days of care plan meeting as required. Findings include: 1. The Facility’s policy titled, “Comprehensive Interdisciplinary Assessment [CIA] and Plan of Care (7/3/2023)” was reviewed on 11/29/2023 and requires, “The attending Physician reviews the CIA and indicates with his/her signature on the plan of care their oversight of the patient’s Plan of Care within 30 days.” 2. The clinical record of Pt. #5 was reviewed on 11/29/2023. Pt. #5 was admitted on 4/21/2023 with a diagnosis of end stage renal disease. The care plan dated 8/11/2023 was signed by the attending physician on 9/22/2023 (42 days later). 3. During an interview on 11/29/2023 at approximately 1:00 PM, the clinic manager (E#3) stated that the plan of care should be signed within 30 days.”