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“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: 49555 Based on observation, document review, and staff interview, it was determined that for 2 of 4 staff (E #2 and E #3) observed for hand hygiene practices, the Facility failed to ensure staff performed hand hygiene between delivery system contact. Findings include: 1. On 4/22/2024 between 12:30 PM and 4:00 PM, an observational tour of the hemodialysis area was conducted, and the following was observed: a. At approximately 12:50 PM, Patient Care Technician (PCT) (E #3) walked from station #7 to station #4 with gloves on to silence an alarm. E #3 then went back to station #7 and performed patient care. No hand hygiene was performed before or after contact between delivery systems. b. At approximately 1:05 PM, Registered Nurse (RN) (E #2) walked from station #5 to station #3 with gloves on to silence an alarm. E #2 proceeded to station #1 to silence another alarm. No hand hygiene was performed before or after contact between delivery systems. 2. The policy titled “Hand Hygiene” (published 11/6/23) was reviewed on 4/24/2024. The policy noted, “Hands Will Be ...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ...After contact with other objects within the patient station or treatment space.” 3. During the observational tour an interview was conducted with Clinical Manager (E#1). E#1 verbally agreed that E#2 and E#3 did not follow the Facility’s policy and staff should perform hand hygiene before and after contact with delivery systems.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 32822 Based on observation, document review and interview, it was determined in 1 of 2 (E #2) Registered Nurses, the Facility failed to ensure the proper cleansing of single and multidose vial to prevent the potential for cross contamination. 1. a. On 4/23/2024 at approximately 9:25 AM, an observation of registered nurse (E#2) was made at the medication preparation area. E #2 failed to clean the septum of the single dose vial Ondasetron (Zofran) 4 mg/2 ml (2 mg/ml) prior to inserting needle to withdraw medication. b. On 4/23/2024 at approximately 9:35 AM, an observation of registered nurse (E #2) was made at the medication preparation area. E #2 failed to clean the septum of the mulitdose vial of Heparin 30,000 USP Units/30 ml , prior to inserting needle to withdraw medication.. 2.The policy titled “Medication Preparation and Administration” (published 2/6/2023) was reviewed on 4/23/2024 at approximately 12:00 PM. The policy states under “Infection Control: Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with alcohol each time the vial is accessed with a needle using friction and 70% alcohol. Allow to dry before inserting a device into the vial.” 3. An interview was conducted on 4/23/2024 at approximately 1:00 PM with the Clinical Manager (E #1). E #1 stated, “I will follow up and remind the staff that our policy requires the septum to be cleansed at all times when entering a medication vial.”

“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: 32822 Based on observation and document review, it was determined for 1 of 3 (Pt #6) patients observed during the provision of patient care, the End Stage Renal Disease (ESRD) Facility failed to ensure the patient was wearing a face mask during Central Venous Catheter (CVC) termination of treatment. Findings include: 1. On 4/22/24 at 2:30 PM,Registered Nurse (E #2) was observed performing termination of treatment on Pt #6 at station #8. E #2 failed to provide a mask for Pt #6 prior to the procedure. 2. On 4/22/2024 at 4:00 PM the policy titled “Termination of Treatment Using a Central Venous Catheter and Optifux Single Use Ebeam Dialyzer (published 2/7/2022). The policy required, “ Place mask on patient, perform hand hygiene then don new gloves.” 3. On 4/22/2024 at approximately 4:15 PM, an interview with the Clinical Manager (E #1) was conducted. E #1 stated “the staff are not following procedure. The patient should have been wearing a mask.””

“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: 49555 Based on document review and interview, it was determined for 1 of 5 (Pt #1) patients, the Facility failed to ensure medications were administered as ordered. Findings include: 1. On 4/23/24 at approximately 1:00 PM the clinical record of Pt #1 was reviewed. Pt #1 was admitted for in-center hemodialysis on 6/20/17 with a diagnosis of End Stage Renal Disease (ESRD). A physician’s order dated 8/18/23 noted Clonidine HCl 0.1 mg oral during dialysis PRN- may repeat x1 hypertension. Pt #1’s treatment sheets dated 3/30/24 - 4/15/24 noted: a. On 3/30/24 Pt #1’s treatment started at 6:29 AM the following blood pressures were noted throughout treatment: 221/144 at 6:31 AM, 231/138 at 7:01 AM, 207/126 at 7:32 AM, 220/133 at 8:01 AM and 208/129 at 8:32 AM. The clinical record lacked documentation that Clonidine was administered for hypertension per the physician’s order. b. On 4/3/24 Pt #1’s treatment started at 7:02 AM the following blood pressures were noted: 220/135 at 8:01 AM, 190/125 at 8:31 AM, 200/124 at 9:01 AM, and 203/121 at 9:31 AM. The clinical record lacked documentation that Clonidine was administered for hypertension per the physician’s order. c. On 4/15/24 Pt #1’s treatment started at 6:49 AM the following blood pressures were noted throughout treatment: 190/114 at 7:32 AM, 196/115 at 8:03 AM, 204/121 at 8:31 AM, 209/127 at 9:01 AM, 218/130 at 9:34 AM, 221/133 at 10:00 AM, and 202/129 at 10:30 AM. The clinical record lacked documentation that Clonidine was administered for hypertension per the physician’s order. 2. On 4/23/24 at approximately 2:45 PM an interview was conducted with Clinical Manager (E #1). E #1 reviewed Pt #1’s record and verbally agreed the clinical record lacked documentation that Clonidine was administered and should have been. E #1 explained “the parameters we follow for hypertension are a systolic blood pressure greater than 180 and diastolic blood pressure greater than 100. I am sure the nurse offered Pt #1 Clonidine, but the patient usually refuses it. We just have probably not been documenting it.””

“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: 32822 A. Based on document review and staff interview, it was determined for 2 of 4 (Pt #2 and Pt #3) patient records reviewed for BFR and DFR, the ESRD Facility failed to ensure the patient’s BFR and/or DFR was achieved and maintained in accordance with the dialysis prescription. Findings include: 1. The Facility policy titled “Patient Assessment and Monitoring” (published 05/01/2023) was reviewed on 4/24/2024 at approximately 3:00 PM. The policy required, “Check machine settings and measurements: check prescribed blood flow rate is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” 2. On 4/24/42024 at approximately 10:00 AM, Pt #2’s record was reviewed. Pt #2 was admitted to the facility on 3/23/2021 with a diagnosis of ESRD. Pt #2’s clinical record contained a physician order dated 3/8/24 that noted the BFR of 450 ml/min. Pt #2’s treatment sheet dated 4/7/2024 and 4/12/2024 (2 of 13 treatments ) indicated Pt #2 was dialyzed at a BFR of 300-400. The record lacked documentation as to why the prescribed blood flow was not ran.. 3. On 4/24/2024 at approximately 1:00 PM, Pt #3’s record was reviewed. Pt #3 was admitted to the facility on 12/11/2019 with a diagnosis of ESRD. Pt #3’s clinical record contained a physician order dated 4/10/2024 that noted the DFR of 500 ml/min. Pt #3’s treatment sheet indicated the following: 4/7/2024 ran at 800 throughout the dialysis treatment duration 4/10/2024 ran at 800 throughout the dialysis treatment duration 4/15/2024 ran at 800 at start of treatment 11:47 AM to 1:37 PM, then DFR changed to 500 ml/min from 1:37 PM to 2:02 PM when DFR changed at 2:02 PM to 800 ml/min to end of treatment at 2:29 PM. 4/22/2024 ran at 800 throughout the dialysis treatment duration The record lacked documentation as to why the prescribed dialysate flow was not achieved. 4. On 05/31/23 at 3:00 PM, an interview with the Clinical Manager (E #1) was conducted. E #1 reviewed the treatment records and verbally agreed the BFR and DFR were not achieved and there was no documentation in the records indicating why.”