Dialysis Care Center - Hazel Crest

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that the Facility failed to ensure that a sanitary environment was maintained, by not following protocol/policies related to pest control on the treatment floor. Findings include: 1. The Facility’s policy titled, “Bed Bug Management in the Dialysis Facility” was reviewed, and required, “...Procedure: Follow the steps in the table below to get rid of bed bugs if suspected or confirmed on a patient, bedding, or equipment...Notify the Charge Nurse, Clinical Manager, Vice President of Operations, Quality & Regulatory Department, the Attending Physician and Medical Director of a potential infestation. Contact Facility Maintenance who will then notify Housekeeping, Environmental Services or Pest Control if applicable...” 2. The Facility’s grievance log from 4/2024-8/2024, was reviewed. A grievance (dated 7/10/2024) included, “Subject of Complaint: Flies on unit more than 1 time...” 3. The Facility’s Adverse Events from 4/2024-9/16/2024, were reviewed. An adverse event related to Pt #1 (dated 9/14/2024), indicated that a bed bug was collected (on 9/14/2024). Pt #1’s clinical record was reviewed and lacked any documentation (MD notification, Clinical manager notification, Pest control notification) regarding the suspected bed bug sighting. 5. The Facility’s QAPI meeting minutes from 7/2023-7/2024 were reviewed. The meeting minutes did not include any documentation of discussion of bugs (flies, gnats, or bedbugs). 6. On 9/16/2024 at 9:50 AM-11:50 AM, an observational tour of the dialysis treatment area was conducted. During the tour, flying bugs were noted and near patient dialysis stations. 7. On 9/18/2024 at 2:30 PM, an interview was conducted with the Clinical Manager (E #1). E #1 acknowledged that the Quality meeting minutes did not include any documentation regarding pest control. E #1 stated that the staff should follow the protocol if there are suspected bed bug sightings.”

“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: 34411 Based on document review, observation, and interview, it was determined that 1 of 1 medication refrigerator, the Facility failed to ensure that expired medications were discarded and not available for patient use. Findings include: 1. The Facility’s policy titled, “Medication Preparation and Administration” (dated 11/20/2021), was reviewed, and required, “...If multi-dose vial been opened or accessed, the vial should be dated and initiated upon opening and discarded within 28 days...Tubersol [TB] will be discarded on 30 days as stated per manufacturer directions. The beyond-use date should never exceed the manufacturer’s expiration date...” 2. On 9/16/2024 at 9:50 AM, an observational tour of the dialysis treatment area was conducted. During the tour, the medication refrigerator was observed for medication expiration dates. The medication refrigerator contained 1 opened tubersol (TB) vial dated 7/8/2024 (greater than 28 days); 1 box of Daptomycin (antibiotic) with an expiration date of 8/2024; and 5 pneumococcal syringes with an expiration date of 8/2024. 3. On 9/16/2024 at 9:55 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that once the TB vial is opened, it is good for 28 days. E #2 stated that expired meds should be discarded once they have expired.”

“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: 34411 Based on document review, observation, and interview, it was determined that for 1of 2 (E #3) staff observed performing CVC (Central Venous Catheter) disinfection, the Facility failed to ensure that the appropriate infections control measures were adhered, in order to prevent catheter-related infections. Findings include: 1. The Facility’s procedure titled, “Changing an External Catheter Dressing” (dated 7/5/2023), was reviewed and required, “Catheter dressings will be changed in accordance with [Facility] policy and procedures...” 2. On 9/16/2024 between 9:50 AM and 11:50 AM, an observational tour of the dialysis treatment area was conducted. During the tour, the following was observed: - At approximately 10:45AM, at Station #12, the PCT (E #3/Patient Care Technician), removed Pt #8’s old catheter exit site dressing, prior to initiating treatment. Pt #8’s treatment was initiated. However, Pt #8’s exit site was not cleaned and covered with a new dressing until after the treatment was initiated. 3. On 9/16/2024 at 11:00 AM, an interview was conducted with E #3. E #3 stated that the patient’s catheter dressings should be done prior to starting the treatment.”

“PE-COMFORTABLE TEMPERATURE CFR(s): 494.60(c)(2) The dialysis facility must: (i) Maintain a comfortable temperature within the facility; and (ii) Make reasonable accommodations for the patients who are not comfortable at this temperature. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 1 of 1 treatment floor, the Facility failed to ensure that the environmental temperature was maintained at a comfortable temperature for the patients. Findings include: 1. The Facility’s “Patient Grievance Log”, from 4/2024-8/2024, was reviewed. The log’s grievance (dated 6/2/2024), included, Subject of Complaint: Temp of treatment floor...Date of Resolution: 6/3 emailed maintenance...” 2. On 9/19/2024, maintenance logs were requested. The Facility was unable to provide. 3. On 9/18/2024 at 1:45 PM, a tour of the Facility was conducted. The Facility’s temperature was not at a comfortable temperature. During the tour, patients were interviewed regarding the Facility’s temperature. Pt #9 stated that the Facility’s temperature has been cold for years. Pt #9 stated that the temperature fluctuates and that it is hard for them to regulate the thermostat. Pt #9 stated that the staff are aware that a lot of the patients complain about the temperature. 4. On 9/16/2024 at approximately 9:15 AM, an interview was conducted with the Administrative Assistant (E #4). E #4 stated that the Facility is cold all the time and that it is hard to control the temperature. E #4 stated that patients do complain about the treatment area being cold. 5. On 9/19/2024 at 9:45 AM, an interview was conducted with the Clinical Manager (E #1). E #1 acknowledged that the Facility’s temperature was under 70 degrees Fahrenheit. E #1 stated that the temperature should be set at 73 degrees Fahrenheit.”

“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: 34411 A. Based on document review, observation, and interview, it was determined that for 1of 3 patients (Pt #7) observed for order verification, the Facility failed to ensure that the correct dialyzer was on the hemodialysis machine and the heparin was administred, as ordered. Findings include: 1. The Facility’s policy titled, “Management of Hemodialysis Adequacy In-Center Hemodialysis (ICHD), dated 8/5/2021, was reviewed, and required, “...Factors Effecting Adequacy: Dialyzer: Interventions: Evaluate for appropriate dialyzer size based on TW [target weight] with the physician. Is patient dialyzing on the correct dialyzer type and size based on prescription?” 2. The clinical record of Pt #7 was reviewed on 9/16/2024. Pt #7’s hemodialysis orders included an order (dated 8/10/2024) for a dialyzer F160. 3. On 9/16/2024 at 9:50 AM, an observational tour of the dilaysis treatment area was conducted. Duirng the tour, the preseciptions of 3 patients whose treatments were initiated, were verified by matching the order with the machine. At Station #8, Pt #7’s machine contained a F180 dialyzer. However, Pt #7’s prescription required a F160. 4. On 9/16/2024 at 10:20 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that prescriptions should be followed as ordered. B. Based on document review and interview it was determined that in 3 of 6 (Pts. #1, 2 and 4) records reviewed for dialysis prescription, the facility failed to ensure the blood flow rates were administered as ordered. Findings include: 1. The Facilitiy’s policy titled “Monitoring During Dialysis Treatment” (dated 5/11/2020) was reviewed on 9/19/2024, and required “...Check and record the following machine parameters and any problems...Blood Flow Rate...” 2. On 9/18/2024, the clinical record of Pt #1 was reviewed. Pt #1 was admitted on 6/18/2024, with a diagnosis of ESRD (end stage renal disease). Pt #1’s clinical record included an order (dated 9/17/2024) for Pt #1 to be dialyzed with a blood flow rate (BFR) of 400 for 3 hours. However, the following were noted on the dialysis treatment sheets: - On 8/27/2024, Pt #1 was dialyzed with a BFR of 300 from 10:36 AM until 1:32 PM (2 hours and 56 minutes) - On 9/3/2024, Pt #1 was dialyzed with a BFR of 300 from 12:44 PM until 1:32 PM (48 minutes) 3. On 9/18/2024, the clinical record of Pt #2 was reviewed. Pt #2 was admitted on 3/1/2024, with a diagnosis of ESRD. Pt #2’s clinical record included an order (dated 3/1/2024) for Pt #2 to be dialyzed with BFR of 400 for 2 hours and 45 minutes. However, the following were noted on the dialysis treatment sheets: - On 8/28/2024, Pt #2 was dialyzed with a BFR of 300 from 3:08 PM until 5:07 PM (1 hour and 59 minutes) - On 9/2/2024, Pt #2 was dialyzed with BFR of 300 from 3:08 PM until 4:388 PM (1 hour 30 minutes) 4. On 9/18/2024, the clinical record of Pt. #4 was reviewed. Pt. #4 was admitted on 3/2/2020, with a diagnosis of end stage renal disease (ESRD). Pt. #4’s clinical record contained a physician’s order dated 8/6/2024 that required Pt. #4 be dialyzed with a blood flow rate (BFR) of 450 for 3 hours and 30 minutes. However, the following were noted on the dialysis treatment sheets: - On 8/21/2024 Pt. #4 was dialyzed with a BFR of 300 from 4:33 PM until 6:43 PM (2 hours and 10 minutes). - On 8/27/2024 Pt. #4 was dialyzed with a BFR of 350 from 11:02 AM until 1:59 PM (2 hours and 57 minutes). 5. On 9/19/2024 at approximately 10:30 AM, findings were discussed with E #1 (Clinical Manager). E #1 stated that the physician order should have been 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: 34411 Based on document review and interview, it was determined that for 10 of 10 patients reviewed for mortality, the Facility failed to ensure that a quality indicator was analyzed to identify the cause of patient deaths, as a part of the Quality Improvement Plan, in order to monitor and implement performance action plans. Findings include: 1. The Facility’s policy titled, “Quality Assessment and Performance Improvement” (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...” 2. On 9/19/2024 at 10:00 AM, the Facility’s QAPI activities and meeting minutes were reviewed with the Clinical Manager (E #1). Review of mortality data indicated that from 1/2024-7/2024, there were 10 patient deaths. The QAPI performance activities related to mortality, included the number of deaths. However, there was no data indicating the cause of death or any documentation that analyzed and tracked trends in patient deaths at the Facility. 3. On 9/19/2024 at 10:15 AM, an interview was conducted with the Clinical Manager (E #1). E #1 acknowledged that the QAPI meetings lacked analysis of patient deaths.”