Usrc NW Indianapolis

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure the staff instructed the patients on the proper use of hand hygiene after holding their access with a gloved hand during 3 of 3 observations. (Patients: #4, 12, and 15) (Employee: PCT 3(3 times)) Findings include: 1. A review of a US Renal Care policy revision date 08/2020, titled, “Hand Hygiene” indicated but was not limited to, “ HAND HYGIENE consists of either: 1. Handwashing with soap and water. 2. Use of an alcohol-based formulation ... HAND HYGIENE will be performed: After gloves are removed ...”. 2. During an observation on 05/07/2025 at 11:26 AM, observed Patient #4 remove their glove from their right hand after holding their pressure dressing on their left access site. PCT 3 obtained the patient’s weight, and temperature at the scale and Patient #4 left the treatment area after gathering their blanket and phone. PCT 3 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. 3. On 05/07/2025 a sign was posted on the wall above the sink by the scale that stated, “Handwashing Prevents Infection.” 4. During an observation on 05/07/2025 at 2:10 PM, observed Patient #15 remove their glove from their left hand after holding their pressure dressing on their right access site. PCT 3 assisted Patient #15 with their walker to the scale. The PCT obtained the patient’s weight, and temperature at the scale and Patient #15 left the treatment area. PCT 3 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. 5. During an observation on 05/07/2025 at 2:36 PM, observed Patient #12 remove their glove from their left hand after holding their pressure dressing on their right access site. The PCT obtained the patient’s weight, and temperature at the scale and Patient #12 left the treatment area. PCT 3 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. 6. A review of the personnel record for PCT 3, contained a document titled “Clinical Orientation Checklist-Initial” revision date 05/2023. The checklist evidenced PCT 3 completed by return demonstration and verbalization on 08/17/2024 infection control precautions. During an interview on 05/07/2025 at 2:56 PM, when queried about post dialysis treatment instructions to patients, PCT 3 indicated after temperature and weight they were to encourage hand washing.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure the safety and functionality of the facility was in for patients and staff as observed over 1 of 1 observations. Findings Include: 1. A review of a US Renal Care policy revision date 04/2023, titled “Facility Space/Design and Safety Requirements” indicated but was not limited to, “ ... Facilities will provide a physical environment that protects the health and safety of patients, staff, and public ... “ 2. During a treatment floor observation on 05/07/2025 at 9:07 AM, observed brown-rust colored substance surrounding the drainage pipe and cabinet shelf of the cabinet under the dirty sink in the lab area. During an interview on 05/07/2025 at 9:0+9 AM, when quired regarding the brown substance surrounding the drainage pipe and cabinet shelf, the Biomed Technician confirmed the strain valve corroded and needed replaced. 3. During an observation on 05/12/2025 at 8:35 AM, noted the in the hallways across from the FA’s office the wall bubbled and cracked from the baseboard to approximated 2 feet of the wall and 3 feet in width. During an interview on 05/12/2025, the FA confirmed the damage to the wall was from a water leak in the treatment area.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 44232 Based on record review and interview, the agency failed to ensure direct patient care staff monitored the patients during their dialysis treatment within the timelines to ensure patient safety in 2 of 2 active clinical records reviewed. (Patients: #1 and 4) Findings include: 1. A review of a US Renal Care policy revision date 07/2024, titled “Intradialytic Monitoring of Patient” indicated but was not limited to, “ ... for the delivery of a safe, effective and comfortable treatment ... Vital signs: obtained and documented at least every 30 minutes ... “ 2. A review of the clinical record for Patient #1contained treatment sheets dated 03/03/2025 through 05/05/2025 evidenced the following: Treatment sheet dated 03/05/2025, the CM completed an assessment with a blood pressure and pulse check at 11:43 AM. PCT 2 completed the next blood pressure and pulse check at 12:48 PM. Treatment sheet dated 05/05/2025, the PCT 3 completed a blood pressure and pulse check at 2:04 PM. PCT 3 completed the next blood pressure and pulse check at 3:04 PM. During an interview on 05/07/2025 at 2:56 PM, when queried regarding the process of pre, during, and post patient care, PCT 3 indicated blood pressure and pulse safety checks are to be done every 30 minutes during dialysis treatment. 3. A review of the clinical record for Patient #4 contained treatment sheets dated 04/14/2025 through 05/07/2025 evidenced the following: Treatment sheet dated 04/23/2025, PCT 3 completed a blood pressure and pulse check at 9:33 AM. PCT 3 completed the next blood pressure and pulse check at 9:33 AM. Treatment sheet dated 04/25/2025, PCT 2 completed a blood pressure and pulse check at 9:35 AM. PCT 2 completed the next blood pressure and pulse check at 10:20 AM. Treatment sheet dated 05/02/2025, PCT 3 completed a blood pressure and pulse check at 9:27 AM. PCT 2 completed the next blood pressure and pulse check at 10:59 AM. Treatment sheet dated 05/05/2025, PCT 3 completed a blood pressure and pulse check at 9:57 AM. PCT 3 completed the next blood pressure and pulse check at 11:06 AM. During an interview on 05/07/2025 at 9:40 AM, when queried regarding the patient process pre, during and post dialysis treatment, PCT 2 indicated safety checks including a blood pressure and pulse were to be completed on the patients during dialysis treatment every 30 minutes.”