Fmc - Greenwood Avenue Dialysis Center

“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: 40079 Based on observation, document review, and interview, it was determined that for 3 of 7 staff (E #2, E #3 and E #4) observed performing initiation and discontinuation of dialysis for patients with AV (arteriovenous) fistulas or grafts (dialysis access) and CVCs (central venous catheter), the Facility failed to ensure staff adhered to hand hygiene practices, as required. Findings include: 1. During observational tour of the treatment floor conducted on 09/24/2024 between 9:30 AM to 10:50 AM, the following was observed: -At approximately 9:49 AM, a Patient Care Technician (PCT-E #2) was observed at station #20 performing a discontinuation of dialysis treatment on a patient with a CVC. E #2 was working on the dialysis computer screen with gloved hands, then turned to the patient and clamped the blood lines from the CVC ports, then turned back to work on the computer screen, then returned to the patient to disconnect one of the lines from the of the CVC ports and flushed the lines with saline solution without performing hand hygiene between tasks. -At approximately 9:55 AM, a PCT (E #3) was observed at station #7 performing a discontinuation of dialysis treatment on a patient with an AV fistula/graft. E #3 with gloved hands had the patient stand up to check blood pressure and temperature, after the patient sat down, E #3 clamped the blood lines, then returned to work on the computer. E #3 then walked over to a cabinet where supplies are stored and reached in to grab clean 4x4 gauze, then returned to station #7 and disconnected one blood line and applied the clean gauze to the site. E #3 did not perform hand hygiene during this time. -At approximately 10:10 AM, a PCT (E #2) was observed at station #17 performing an initiation of dialysis treatment on a patient with a CVC. E #2 with gloved hands was observed removing the dirty gauze from the blue and red CVC ports and discard the gauze. E #2 then cleaned and inserted a syringe to each port. In the meantime, a Registered Nurse (RN/E #6) administered heparin. E #2 then turned to work on the dialysis computer, then took the two blood lines from the priming stating and connected the blood lines to the CVC ports after the heparin was administered without performing hand hygiene between tasks. -At approximately 10:24 AM, a PCT (E #4) was observed at station #10 performing an initiation of dialysis treatment on a patient with an AV fistula/graft. E #4 with gloved hands was observed working on the dialysis computer screen, E #4 took the dialysis machine lines and primed them, and while holding the lines with one hand, used the other hand to work on the dialysis computer screen. E #4 then turned to connect the lines to the blood lines without performing hand hygiene between tasks. 2. On 09/24/2024, the Facility’s policy titled, “Hand Hygiene” (revised 11/06/2023), was reviewed and included, “...Hand hygiene will be decontaminated using alcohol-based hand rub or by washing hands ... Immediately after removing gloves ... after contact with inanimate objects near the patient ... After contact with other objects within the patient station or treatment space.” 3. On 09/24/2024, at approximately 12:10 PM, an interview was conducted with the Clinical Manager (E #1). E #1 stated that all staff must perform hand hygiene after touching the dialysis screens or inanimate objects and before accessing any vascular access or performing a new task.”

“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: 40079 Based on observation, interview, and document review, it was determined that for 1 of 2 (E #6) Registered Nurses observed, the Facility failed to ensure staff compliance with aseptic technique when dispensing intravenous medications. This potentially affects 13 patients on the second shift schedule on 09/24/2024. Findings include: 1. On 09/24/2024 at approximately 09:50 AM, the Nurse (E# 3) was observed preparing two syringes with heparin (blood thinner) from a previously opened vial. E #3 inserted an empty syringe with needle into the vial of heparin and withdrew the medication and placed a cap on the syringe. E #3 then inserted a second syringe with needle and withdrew medication from the vial and placed a cap on syringe. E #3 did not wipe the rubber stopper each time prior to withdrawing the medication. 3. On 09/24/2024, the Facility’s policy titled “Medication Preparation and Administration” (revised 02/06/2023) was reviewed and included “...All doses of IV (intravenous) medication must be drawn up (prepared)...by a qualified clinical staff member...and knowledge of aseptic technique...Infection Control...Aseptic technique will be used to prepare... IV medications...Cleanse the diaphragm of a vial prior to accessing the vial...Allow to dry before inserting a device into the vial...” 4. On 09/24/2024 at approximately 12:05 PM, an interview with the Clinical Manager (E #1) was conducted. E #1 stated that when preparing intravenous medications from a multi-use vial, the rubber stopper must be disinfected prior to inserting a new syringe to prevent cross contamination.”

“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: 40079 Based on observation, document review, and interview it was determined for 1 of 2 (Pt. #10) in-center 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 appropriately during Central Venous Catheter (CVC) exit site care and throughout per Facility policy. Findings include: 1. On 09/24/2024, between 9:30 AM - 10:50 AM, an observational tour of the treatment area was conducted. During the tour the following was observed: - At approximately 9:49 AM, the Patient Care Technician (PCT-E #2) was at station #20 discontinuing Pt. #10’s dialysis treatment. Pt. #10’s dialysis access was a CVC. E #2 donned clean gloves, and clamped the red and blue line and disconnected each blood line. E #2 then flushed each port with saline solution. E #2 unclamped each port and removed the dirty clamps on both the CVC hubs and continued to provide care. E #2 did not ensure that (Pt. #10) placed face mask over the nose throughout the procedure. 2. On 09/24/2024, the Facility’s policy titled, “Initiation and Termination of Treatment Using a Central Venous Catheter” (undated) was reviewed and required, “Staff, patients, and care partners must use personal protective equipment (PPE) ... A mask must be worn that covers the nose and mouth by staff, patient, and care partner for all procedures that require accessing the catheter ...” 3. On 09/24/2024 at approximately 12:05 PM, an interview with the Clinical Manager (E #1) was conducted. E #4 stated that staff are required to ensure that patients have their mask on appropriately especially during care of CVC to prevent infection.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 40079 Based on observation, document review and interview, it was determined that for 1 of 3 patients observed receiving hemodialysis treatments, the Facility failed to ensure that the dialysis access site was visible during hemodialysis treatment to promote patient safety. Findings include: 1. On 09/24/2024 between 9:30 AM through 11:00 AM, an observational tour of the dialysis treatment area was conducted. Between approximately 09:35 AM through 10:35 AM, at station #14, the patient’s hemodialysis access site was covered with a blanket. During the time, no staff was checking on the patient at station #14 to ensure that the hemodialysis access site was secure and visible. 2. On 09/24/2024, the Facility’s policy titled, “Patient Assessment and Monitoring” (revised 05/01/2023) was reviewed and required, “... Monitoring During Treatment... Access: Observe connections are secure and visible... Ensure access remains uncovered throughout the treatment...” 3. On 09/24/2024, at 10:35 AM, findings were discussed with a Registered Nurse (RN/E #6). E #6 stated that the access site should remain visible during hemodialysis treatments. E #6 stated that if patient covers the access site, the staff should check to make sure there is no bleeding and remind the patient to keep site visible.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 3 of 10 (Pt #1, Pt. #6 and Pt #9) in-center hemodialysis clinical records reviewed, the Facility failed to monitor the BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate) to ensure that the prescribed BFR was maintained for adequate hemodialysis. Findings include: 1. On 9/25/2024, the Facility’s policy titled, “Patient Assessment and Monitoring” (dated 5/1/2023) was reviewed and required, “Check prescribed blood flow is achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and prescribed flow is being delivered...” 2. On 9/25/2024, Pt #1’s dialysis treatment records (dated 9/10/2024 thru 9/21/2024) were reviewed and indicated: -Pt #1’s hemodialysis prescription treatment order (dated 8/13/2024) noted “BFR 400, DFR 800ml/min.” -Pt. #1 treatment record dated 9/10/2024 noted BFR 300-350 (not the prescribed 400). There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR. -Pt.#1’s treatment record dated 9/12/2024 noted BFR 350 (not the prescribed 400). There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR. -Pt. #1’s treatment record dated 9/17/2024 noted DFR 500 (not the prescribed 800). There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed DFR. -Pt #1’s treatment record dated 9/21/2024 noted BFR 275-300 (not the prescribed BFR 400). There was no documentation in Pt #1’s clinical record regarding the reason for not following the prescribed BFR. 3. On 09/25/2024, the clinical record of Pt #6 was reviewed. Pt #6’s clinical record contained a physician’s order dated 02/06/2024, and included “Hemodialysis...for 3 hours 15 minutes ... Blood Flow Rate (BFR): 400 ...Dialysate Flow Rate (DFR): 600...” The clinical record lacked documentation of a reason for not meeting the prescribed DFR on the following dates: -On 06/04/2024, Pt. #6 was dialyzed with a DFR of 800 from 12:33 PM to 3:07 PM (3 hours and 4 minutes). -On 06/11/2024, Pt. #6 was dialyzed with a DFR of 800 from 12:18 PM to 1:52 PM (1 hour and 34 minutes) and a DFR of 700 from 1:53 PM to 3:31 PM (1 hour and 38 minutes). -On 06/29/2024, Pt #6 was dialyzed with a BFR of 400 from 12:58 PM to 2:35 PM (1 hour and 37 minutes). 4. On 9/25/2024, Pt #9’s dialysis treatment records (dated 9/11/2024 thru 9/23/2024) were reviewed and indicated: -Pt #9’s hemodialysis prescription treatment order (dated 9/18/2024) noted “BFR 400 and DFR 600 ml/min.” -Pt #9’s treatment records dated 9/23/2024 noted BFR between 350 (not the prescribed BFR 400) and DFR 700 ml/min (not the prescribed 600 ml/min). There was no documentation in Pt #9’s record regarding the reason for not following the prescribed BFR and DFR. 5. On 9/25/2024 at 10:00 AM, an interview was conducted with the Clinical Area Manager (E #1). E #1 stated that each patient’s prescribed BFR and DFR should be followed.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that the Facility failed to ensure that a quality indicator was analyzed to identify the cause of patient deaths, in order to monitor and implement performance actions aimed at the improvement of care in the Facility. Findings include: 1. On 9/24/2024, the Facility’s policy titled, “Quality Assessment and Performance Improvement Policy” (dated 5/2/2022) was reviewed and required, “QAPI (quality assessment and performance improvement) is a continuous ongoing process that includes monitoring the data, prioritizing areas for improvement, determining potential root causes, developing action plans, and focusing on patient safety and improving outcomes...” 2. On 9/24/2024 at approximately 1:00 PM, the Facility’s QAPI activities were reviewed with the Clinical Area Manager (E #1). Review of patient deaths, indicated that in 2024, there were 3 patient deaths (3 in-center hemodialysis patients). The primary cause was unknown for all 3 deaths. The QAPI performance activities did not include the specific primary causes of death, that would be required in order to analyze and track trends in patient deaths at the Facility. 3. On 9/24/2024 at 1:10 PM, an interview was conducted with the Clinical Area Manager (E #1). E #1 stated that that the facility does not fill out any form or investigate the cause of death for quality meetings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 10 (Pt #6) clinical records reviewed for shortened treatments, the Medical Director failed to ensure that the staff adhered to patient care policies, by notifying the physician of shortened hemodialysis treatments and ensuring that an AMA (against medical advice) form was completed. Findings include: 1. The Facility’s policy titled, “Early Termination or Arriving Late for Treatment” (dated 11/07/2022), was reviewed on 9/25/2024, and required, “If a patient requests to leave early ... RN (registered nurse) is responsible to notify the physician and document on the ‘AMA’ or Against Medical Advice form ... If patient arrives after their scheduled time for dialysis treatment start the patient’s treatment as soon as possible. Staff should do their best to accommodate the patient’s prescribed treatment time.” 2. The clinical record for Pt #6 was reviewed on 09/25/2024. Pt #6 was admitted to the Facility on 2/28/2024, with a diagnosis of ESRD (end stage renal disease). The Treatment Orders (dated 02/08/2024), included a treatment time of 3 hours and 15 minutes. Pt #6’s treatment sheets from 06/04/2024 -06/29/2024, were reviewed and included the following days with shortened treatments: -On 06/04/2024 “Duration 2 hours and 44 minutes. Treatment Status: Completed, Unexpected Request, Provider/Physician Notified.” - On 06/06/2024, “Duration 2 hours and 12 minutes. Treatment Status: Completed, Unexpected, Patient Request.” -On 06/25/2024, “Duration 1 hour and 53 minutes. Treatment Status: Completed, Late arrival with inability to Extend.” -On 06/29/2024, “Duration 2 hours and 36 minutes. Treatment Status: Completed, Late arrival with inability to Extend.” Pt #16s clinical record lacked completed AMA forms and/or notification to the physician of shortened treatments for these shortened treatment dates. 3. On 09/24/2024 at approximately 9:30 AM, the Clinical Manager (E #1) stated that patients should sign the AMA form if they are cutting their treatments short. E #1 stated that the completed forms should be kept in the patient’s medical record.”