Dcc - Olympia Fields

“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: 32741 Based on document review, observation and interview, it was determined that for 1 of 3 Patient Care Technicians (E #2) observed cleaning and disinfecting dialysis stations, the Facility failed to ensure the patient vacated the dialysis station prior to disinfecting the dialysis machine. Findings Include: 1. On 11/27/2023, the Facility’s policy titled, “Cleaning and Disinfecting Dialysis Surfaces & Equipment” (effective 12/21/2020) was reviewed and required, “...Clean and disinfect the dialysis station after patient has completely vacated with a 1:100 bleach solution...” 2. On 11/27/2023 between 8:40 AM and 11:15 AM, an observational tour was conducted in the dialysis treatment area. At approximately 9:30 AM, the Patient Care Technician (E #2) was cleaning the dialysis station #21 prior to the patient vacating the dialysis chair. 3. On 11/27/2023 at approximately 11:15 AM, an interview was conducted with the E#2. E #2 stated that the dialysis station should be cleaned and disinfected after the patient vacates the dialysis chair.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 32741 Based on document review, observation, and interview, it was determined that for 2 of 4 Patient Care Technicians - PCT (E #4 and E #5) observed for disinfecting AVF (arteriovenous fistula) cannulation sites, the Facility failed to ensure that staff followed infection control practices to disinfect and prevent contamination of AVF sites, as required. Findings include: 1. On 11/27/2023, the Facility’s policy titled, “Preparation of the Vascular Access Site” (dated 3/8/2019) was reviewed and indicated, “Follow the steps in the table below to prepare the selected access sites for cannulation...If using alcohol to prep the cannulation sites - Clean each site for one minute using multiple alcohol pads immediately prior to cannulation...” 2. An observational tour of the dialysis treatment area was conducted on 11/27/2023, between approximately 8:45AM and 11:00 AM. The following was observed: - At approximately 10:15 AM, a PCT (E #4) was at station #20, preparing to initiate dialysis for a patient with an AVF. E#4 wiped the first access site with alcohol for a total of 6 seconds (not the required one minute), then immediately inserted the catheter needle. E#5 then wiped the second access site with alcohol for a total of 10 seconds (not the required one minute), then immediately inserted the catheter needle. -At approximately 10:20 AM, a PCT (E#5) was at station #16, preparing to initiate dialysis for a patient with an AVF. E #5 wiped the first access site with alcohol for a total of 10 seconds (not the required one minute), then immediately inserted the catheter needle. E #5 then wiped the second access site with alcohol for a total of 10 seconds (not the required one minute), then immediately inserted the catheter needle. 3. On 11/27/2023 at 11:10 AM, E #5 stated that each site for AVF site should be disinfected for one minute prior to cannulation.”

“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: 32741 Based on document review, observation and interview, it was determined that for 2 of 4 Patient Care Technicians - PCT ( E #2 & E #4), the Facility failed to ensure that staff demonstrated knowledge of the Facility’s infection control practices for the disinfection of CVC (central venous catheter - used for dialysis access) insertion site for initiation of the dialysis treatment, as required. Findings include: 1. On 11/27/2023, the Facility’s policy titled, “Initiating Dialysis Treatment with a Central Venous Catheter using ClearGuard HD Antimicrobial End Caps” (dated 4/25/2023) was reviewed and indicated, “...A 15-30 second 70% alcohol scrub must be performed on CVC hubs with every connection and disconnection during initiation, duration and termination of treatment...” 2. On 11/27/2023 between 8:45 AM to 11:00 AM, an observational tour of the dialysis treatment area was conducted. At approximately 10:30 AM, a Patient Care Technician (E #2) was observed disinfecting CVC hubs prior to connection at station #6. E #2 disinfected the CVC hub with 70 % alcohol for 5 seconds instead of 15-30 seconds, as required. 3. On 11/27/2023 at approximately 10:35 AM, a Patient Care Technician (E #4) was observed disinfecting CVC hubs prior to connection at station #22. E #4 disinfected the CVC hubs for 6 seconds instead of 15-30 seconds, as required. 4. On 11/27/2023 at 11:00 AM, an interview was conducted with E #2. E #2 stated that the CVC hubs should be wiped with an alcohol pad for 20 seconds.”

“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: 32741 Based on document review, observation, and interview, it was determined that for 3 of 10 Patients’ (Pt #7, Pt #8 & Pt #9) vascular access sites observed, the Facility failed to ensure that the vascular access sites were in view at all times during dialysis treatment. Findings include: 1. On 11/27/2023, the Facility’s policy titled, “Monitoring During Dialysis Treatment” (dated 5/11/2020) was reviewed and indicated, “Monitor the patient’s access to ensure no needle dislodgements, hemodialysis access is visible and all hemodialysis lines are intact...” 2. On 11/27/2023 between 8:45 AM and 11:00AM, an observational tour of the hemodialysis treatment area was conducted. Between 8:45 AM and 9:45 AM, Pt #7, Pt #8 & Pt #9’s AVF vascular access sites were covered with a blanket and not in view. 3. On 11/27/2023 at 11:05 AM, an interview was conducted with the Patient Care Technician (E #3). E #3 stated that a patient’s access site should remain visible at all time to ensure access lines are connected.”

“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 2 of 7 (Pt #1 and Pt #5) in-center hemodialysis clinical records reviewed, the Facility failed to monitor the BFR (Blood Flow Rate) to ensure that the prescribed BFR was maintained for adequate hemodialysis. Findings include: 1. On 11/29/2023, the Facility’s policy titled, “Hemodialysis Vascular Access - Blood Flow Rate Standing Order” (undated) was reviewed and indicated, “Ensure that all current orders are being consistently followed, i.e., treatment time, blood flow rate (BFR), dialysis flow rate (DFR), and frequency of dialysis...” 2. On 11/29/2023, Pt #1’s dialysis treatment records (dated 11/13/2023 thru 11/27/2023) were reviewed and indicated: -Pt #1’s hemodialysis prescription treatment order (dated 10/28/2023) noted “BFR 350...” -Pt #1’s treatment records dated 11/13/2023, 11/15/2023, 11/17/2023, 11/24/2023 and 11/27/2023 noted BFR 400 (not the prescribed BFR 350). There was no documentation in Pt #1’s clinical record regarding the reason for not following the prescribed BFR. 3. On 11/29/2023, Pt #5’s dialysis treatment records (dated 11/15/2023 thru 11/27/2023) were reviewed and indicated: -Pt #5’s hemodialysis prescription treatment order (dated 11/4/2023) noted “BFR 450...” -Pt #5’s treatment records dated 11/15/2023, 11/17/2023, 11/20/2023, 11/22/2023 and 11/27/2023 noted BFR between 350-400 (not the prescribed BFR 450). There was no documentation in Pt #5’s record regarding the reason for not following the prescribed BFR. 4. On 11/29/2023 at 9:00 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 11/29/2023, the Facility’s policy titled, “Quality Assessment and Performance Improvement Policy” (dated 4/23/2021) was reviewed and required, “The Facility will develop and implement a quality assessment and performance improvement program...The quality process includes: monitoring data/information, prioritizing areas for improvement, determining potential root causes, developing and implementing action plans...” 2. On 11/29/2023 at approximately 12:00 PM, the Facility’s QAPI activities were reviewed with the Clinical Area Manager (E #1). Review of patient deaths, indicated that in 2023, there were 3 patient deaths (3 in-center hemodialysis patients). One of the 3 deaths, primary cause was documented as “noncompliant” on the QAPI dashboard. The remaining 2 of 3 deaths, included primary cause as, “home” on the dashboard. 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 11/29/2023 at 12:10 PM, an interview was conducted with the Clinical Area Manager (E #1). E #1 stated that that the causes of death should be listed. E #1 stated that the facility used to fill out a form after a patient expired but no longer fills out the form.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. 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 patient safety events were analyzed or investigated as part of the quality improvement activities. Findings include: 1. On 11/29/2023, Facility’s policy titled, “Quality Assessment and Performance Improvement Policy” (dated 4/23/2021) was reviewed and required, “The dialysis facility will 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 include but are not limited to: medical injuries & errors (clinical variances, occurrences, and adverse events)...” 2. On 11/29/2023 at 12:00 PM, the Facility’s QAPI activities were reviewedwith the Clinical Area Manager (E #1). There were no adverse events tracked in the QAPI dashboard in 2023. 3. On 11/29/2023 at 12:15 PM, an interview was conducted with E #1. E#1 stated that adverse events should be tracked and analyzed in QAPI meetings. E #1 stated that the adverse events are documented in the computer and discussed with the team but not tracked in QAPI.”

“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: 32741 Based on document review and interview, it was determined that for 2 of 7 (Pt #1 and Pt #3) in-center hemodialysis clinical records reviewed for shortened treatments, the Medical Director failed to ensure that the staff adhered to patient care policies, by ensuring that an AMA (against medical advice) form was completed, as required. Findings include: 1. On 11/29/2023, the Facility’s policy titled, “Early Termination of the Dialysis Treatment” (dated 7/8/2022) was reviewed and indicated, “...An Against Medical Advice (AMA) form will be completed and signed by the patient each time a request is made to shorten his/her treatment time...” 2. On 11/29/2023, Pt #1’s treatment records dated 11/1/2023 and 11/15/2023 were reviewed. Pt #1 was admitted to the Facility on 3/20/2021, with a diagnosis of ESRD (end stage renal disease). Pt #1’s Treatment Orders (dated 10/28/2023), included a treatment time of 3 hours and 15 minutes. Pt #1’s treatment sheets dated 11/1/2023 and 11/15/2023 were reviewed and included the following days with shortened treatments: - On 11/1/2023: “Dialyzed time: 2 hours 41 minutes: Discharge comments: treatment ended 1/2 hour early per patient request...” - On 11/15/2023: “Dialyzed time 2 hours 50 minutes: Discharge comments: treatment ended 25 minutes early per patient request...” Pt #1’s clinical record lacked completed AMA forms for these shortened treatment dates. 3. On 11/29/2023, Pt #3’s treatment records dated 11/13/2023 thru 11/27/2023 were reviewed. Pt #3 was admitted to the Facility on 12/14/2020, with a diagnosis of ESRD. Pt #3’s Treatment Orders (dated 11/16/2023), included a treatment time of 3 hours and 30 minutes. Pt #3’s treatment sheet dated 11/17/2023 noted, “Dialyzed time - 3 hours: Discharge comments: treatment terminated 30 minutes early per patient request...” Pt #3’s clinician record lacked a completed AMA form for the shortened treatment. 4. On 11/29/2023 at 11:55 AM, an interview was conducted with the Clinical Area Manager (E #1). E #1 stated that the patient 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.”