Ara - Crystal Lake 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: 50411 Based on document review, observation and interview, it was determined that for 2 of 3 staff (E#1 and E#3- registered nurses) observed, the Facility failed to ensure that gloves were worn, and hand hygiene performed during and between tasks in accordance with policy. Findings include: 1. The Facility’s policy titled, “G40 Infection Control” (Revised 11/29/2022) was reviewed and required, “7. Gloves are required whenever caring for a patient or touching the patient’s equipment or supplies. ... 8. Hands are always washed after gloves are removed and between patient contacts.” 2. The Facility’s policy titled, “G47 Keyboards in the treatment Area: Infection Control” (Effective 1/2021) was reviewed and required, “Option I: 6. The keyboard area and top of the cart that houses the monitor and terminal are designated as CLEAN areas. ... 8. Gloves are prohibited when using the keyboards in the patient treatment area.” 3. During a tour of the Facility’s dialysis treatment area on 4/1/2024 from 8:50 AM to 10:15 AM, the following were observed: - At approximately 9:00 AM, E#1 was at Station #5 and was typing on the computer and touching the dialysis machine controls while wearing gloves and back to typing on the computer - At approximately 9:12 AM, E#3 was observed typing on the computer with gloves on near Station #12. - At 9:41 AM, E#1 was observed at Station #9 wearing gloves while typing on the computer and touching the dialysis machine controls and back to typing on the computer. - At 9:45 AM, E#1 was adjusting the machine at station #9 with gloves on, went to the clean medication area, removed gloves and obtained a lidocaine spray can without performing hand hygiene. 4. An interview was conducted with Clinical Manager (E#2) on 4/1/2024 at approximately 9:47 AM. E#2 stated that the computer is considered clean so gloves should not be worn. Hand hygiene should always be performed after removing gloves.”

“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: 50411 Based on document review, observation and interview, it was determined that for 1 of 3 staff (E#1 - registered nurse) observed, the Facility failed to ensure that appropriate infection control measures to prevent CVC (central venous catheter) related infections were followed. This could potentially affect the 2 patients with a CVC on census. Findings include: 1. The Facility’s policy titled “ICO5A CVC Initiation & Discontinuation of Treatment” (Last Revision Date:9/1/2023), was reviewed and required, “Actions - 17. Disinfect the arterial connection prior to disconnection.” 2. During a tour of the Facility’s dialysis treatment area on 4/1/2024 from 12:00 PM to 12:40 PM, the following was observed: - at approximately 12:13 PM, E#1 was observed terminating dialysis treatment for patient with a CVC at Station #15. E#1 disconnected the arterial line, attached a pre-filled saline syringe, and flushed the catheter without disinfecting the arterial connection prior to disconnection. 3. During an interview on 4/3/2024 at approximately 11:00 AM, the clinic manager (E#2) stated that the arterial line connection needs to be disinfected prior to disconnection.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #4) patients with an unstable care plan, the Facility failed to ensure an assessment and care plan was completed monthly. Findings include: 1. The Facility’s policy titled, “Comprehensive Assessment (CA) and Plan of Care (POC) (revision 3/1/2019)” was reviewed on 4/3/2024 and included, “Comprehensive Reassessment ... must be conducted: ... Monthly for unstable patients.” 2. The clinical record of Pt. #1 was reviewed on 4/1/2024. Pt. #1 was admitted on 4/20/2022 with the diagnosis of end stage renal disease (ESRD). The record included the last care plan was completed on 12/27/23, and Pt. #1 was identified as unstable. The clinical record did not include any monthly assessments from 12/27/2023 - 4/1/2024. 3. The clinical record of Pt. #4 was reviewed on 4/1/2024. Pt. #4 was admitted on 8/15/2022 with the diagnosis of ESRD. The record included the last care plan was completed on 4/26/2023 and Pt. #4 was identified as unstable. The clinical record did not include any monthly assessments from 4/26/2023 - 4/1/2024. 4. During an interview on 4/3/2024 at approximately 11:30 AM, the registered nurse (E#3) stated that actually both patients should have been changed to stable, but both patients were still listed in the computer system as unstable. E#3 was not able to explain why an additional monthly assessments were not triggered, so the error could have been identified.”

“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: 27125 Based on document review and interview it was determined that the Facility failed to ensure that the quality program included trending and analysis of data collected for mortality to improve outcomes. Findings include: 1. The Facility’s policy titled, “Quality Assessment & Performance Improvement (QAPI) (effective 1/2021) was reviewed on 4/3/2024 and included, “Reporting tools will be used to: ... document ongoing measurement, analysis, and tracking of aggregate quality indicators. ... Allow for identification, prevention, and reduction of ... mortality and morbidity.” 2. The Quality data from 01/2023 - 03/2024 was reviewed for mortality on 4/3/2024. The data included that the facility had 4 deaths during 2023. Three deaths included the cause as “expired” and 1 death included a cause of sepsis. The individual deaths were never trended for cause or an analysis of the deaths conducted. 3. During and interview on 4/3/2024 at approximately 1:30 PM, the Clinical Manager (E#2) stated that each member of the team is assigned an outcome to follow. When a trend is identified, that team member reports it to quality. E#2 stated, “A cause of death should be listed so that an evaluation of any trends can be conducted. The information needs to be discussed in the quality meeting so the team can evaluate all the data together.””