Nocturnal Dialysis Spa

“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 1 of 2 staff (E#2) observed, the Facility failed to ensure that gloves were worn, and hand hygiene was performed during and between tasks in accordance with the facility’s policy. Findings include: 1. The Facility’s policy titled, “Section III. Infection Control” (undated) was reviewed and required, “Personal Protective Equipment...Procedure: 1. Gloves are required whenever caring for a patient or touching the patient’s equipment (i.e. alarms and documentation of vital signs.)...” 2. During an observational tour of the Facility’s dialysis treatment area on 9/16/2024 between 11:30 AM and 12:45 PM, the following were observed: - At approximately 11:35 AM, the Patient Care Technician (PCT/E #2) was observed responding to a machine alarm at station #11. E#2 was observed holding a glove in their hands; however, proceeded to touch the dialysis machine without donning gloves. - At approximately 11:54 AM, E#2 was observed wiping down a dialysis machine at station #6. E#2 was observed removing the gloves, but did not perform hand hygiene after removal of the gloves. - At approximately 12:03 PM, E#2 was observed responding to a machine alarm at Station #4. E#2 was observed holding a glove in their hands; however, proceeded to touch the dialysis machine without donning gloves. 3. An interview was conducted with E#2 on 9/18/2024 at approximately 12:15 PM. E#2 stated that gloves should always be worn when operating the dialysis machine and performing patient care. E#2 stated that hand hygiene should always be performed after glove removal.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 50411 A. Based on document review, observation and interview, it was determined that for 1 of 1 Patient Care Technicians (E #2) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. This had the potential to affect all 10 in-center hemodialysis patients on census. Findings include: 1. On 9/16/2024, the Facility’s policy titled, “Section III. Infection Control”(undated) was reviewed and indicated, “...Cleaning and Disinfection...19) The dialysis station components will be cleaned and disinfected (i.e. chairs, beds, tables, machines) between patients using 1:100 bleach solution. Special attention should be given to machine surfaces frequently touched and containers that hold prime waste fluid. Medical equipment e.g. stethoscope, BP [blood pressure] cuff, not contaminated with blood, can be cleaned with a low level disinfectant...” 2. On 9/16/2024 between 11:30 AM and 12:45 PM, an observational tour was conducted of the dialysis treatment area. The following was observed: - At approximately 11:52 AM, the Patient Care Technician (E #2) was observed wiping the dialysis machine at station #6. E#2 was observed only wiping the top half of the dialysis machine. E#2 did not wipe the sides of the dialysis machine. 3. On 9/16/2024 at approximately 12:40 PM, an interview was conducted with E#2. E#2 stated that the dialysis machine should be wiped down after each patient treatment from top to bottom. B. Based on document review, observation and interview, it was determined that for 1 of 1 Patient Care Technicians (PCT/E #2) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by failing to disinfect the dialysis station after a patient leaves the dialysis station, as required. This had the potential to affect all 10 in-center hemodialysis patients on census. Finding includes: 1. On 9/16/2024, the Facility’s policy titled “Section III. Infection Control - Cleaning and Disinfection: Exterior Surfaces of the Delivery System, Dialysis Chair and Other Related Equipment” (undated) was reviewed and indicated, “...2) All exterior surfaces of all delivery systems and equipment surfaces such as dialysis chairs and pillows will be disinfected at the end of the patient treatment before setting up for the following patient treatment...” 2. On 9/16/2024 between 11:30 AM and 12:45 PM, an observational tour was conducted of the dialysis treatment area. The following was observed: - At approximately 11:52 AM, the PCT (E#2) was observed wiping down the dialysis machine at station #6 while a patient was still seated in the dialysis chair next to the dialysis machine at station #6. 3. An interview was conducted with E#2 on 9/16/2024 at approximately 12:40 PM. E#2 stated that the dialysis machine and chair will only be disinfected after the patient leaves the dialysis station.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 50411 Based observation and interview, it was determined that for 4 of 4 patients (Pt’s. #2, #3, #6 & #7), the facility failed to ensure that vascular access sites were assessed post-dialysis treatment for the presence of a bruit (sound of blood flowing through access) and a thrill (vibration indicating blood flow). Findings include: 1. The facility’s policy of post dialysis vascular access care was requested on 9/16/2024, and was unavailable for review. 2. During a tour of the dialysis treatment area on 9/16/2024 between 11:30 AM and 12:45 PM, the following were observed: - At approximately 11:45 AM, dialysis needles were removed from a patient (Pt.#6) at station #6 post treatment. The Patient Care Technician/PCT (E#2) secured the site with a clamp on the first access site. E#2 then proceeded to remove the needle for the second site and secured with a clamp. Both clamps remained on until approximately 11:55 AM. E#2 did not assess the site during the use of clamps or after, nor prior to the patient leaving the treatment floor. - At approximately 12:18 PM, dialysis needles were removed from a patient (Pt.#2) at station #12 post treatment. E#2 secured the site with a clamp on the first access site. E#2 then proceeded to remove the needle for the second site and secured with a clamp. Both clamps remained on until approximately 12:30 PM. E#2 did not assess the site during the use of clamps or after, nor prior to the patient leaving the treatment floor. - At approximately 12:26 PM, dialysis needles were removed from a patient (Pt.#3) at station #1 post treatment. PCT (E#3) secured the site with a clamp on the first access site. E#3 then proceeded to remove the needle for the second site and secured with a clamp. Both clamps remained on until approximately 12:35 PM. E#3 did not assess the site during the use of clamps or after, nor prior to the patient leaving the treatment floor. - At approximately 12:39 PM, dialysis needles were removed from a patient (Pt.#7) at station #10 post treatment. E#2 secured the site with a clamp on the first access site. E#2 then proceeded to remove the needle for the second site and secured with a clamp. Both clamps remained on until approximately 12:45 PM. E#2 did not assess the site during the use of clamps or after, prior to the patient leaving the treatment floor. 3. An interview was conducted with the PCT (E#3) on 9/18/2024 at approximately 11:08 AM. E#3 stated that it is the facility’s normal protocol to remove both needles and utilize clamps for both access sites. E#3 stated that the access site is assessed for thrill and bruit before the patient leaves the treatment floor. 4. An interview was conducted with the Registered Nurse (RN/E#4) on 9/18/2024 at approximately 10:53 AM. E#4 stated that there is no need for an order for the use of clamps for the patient’s dialysis access. E#4 stated that the PCT’s should assess the access site after dialysis and before the patient leaves and will notify the RN for any issues or concerns. 5. An interview was conducted with the Facility Administrator (E#1) on 9/16/2024 at approximately 3:00 PM. E#1 stated that their facility does not have a specific policy for the use of clamps and for assessing the dialysis access post dialysis.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that for 5 of 5 patient’s (Pt.#1, Pt. #2, Pt. #3, Pt. #4, and Pt.#5), the facility failed to ensure that a physician assessed and documented a progress note of the patient’s current status and the plan of care, at a minimum of monthly. Findings include: 1. On 9/18/2024, the facility’s policy titled “Patient Assessments: Initial and Ongoing” (undated) was reviewed and included, “ ...3. Documentation of ongoing assessment of patient’s status by each discipline of the healthcare team is done in patient’s chart or EMR (electronic medical record). Documentation of ongoing assessment will be documented in but not limited to the following documents/records: a. Discipline specific progress notes ...”. 2. On 9/16/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted on 8/04/2017 with a diagnosis of ESRD (End Stage Renal Disease). The clinical record lacked documentation of a physician’s progress note for 6/2024 through 9/18/2024. 3. On 9/16/2024, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 11/01/2023 with a diagnosis of ESRD. The clinical record lacked documentation of a physician’s progress note for 6/2024 through 9/18/2024. 4. On 9/16/2024, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 12/19/2018 with a diagnosis of ESRD. The clinical record lacked documentation of a physician’s progress note for 6/2024 through 9/18/2024. 5. On 9/16/2024, the clinical record for Pt. #4 was reviewed. Pt. #4 was admitted on 7/19/2024 with a diagnosis of ESRD. The clinical record lacked documentation of a physician’s progress note for 7/19/2024 through 9/18/2024. 6. On 9/16/2024, the clinical record for Pt. #5 was reviewed. Pt. #5 was admitted on 1/07/2022 with a diagnosis of ESRD. The clinical record lacked documentation of a physician’s progress note for 6/2024 through 9/18/2024. 7. On 9/18/2024 at approximately 10:30 AM, an interview with the facility Administrator (E #1) was conducted. E #1 confirmed that patient’s (Pt. #1, Pt. #2, Pt. #3, Pt. #4, and Pt. #5) medical records did not contain physician progress notes. E #1 stated that the Medical Director (MD #1) does perform assessments of the facilities patients but does not document a progress note every month as required.”