Fmc - Carmel

“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: 51751 Based on observation, record review, and interview, the facility failed to ensure adequate infection control practices were performed to prevent CVC infections with 2 of 3 CVC’s observed. (Patient #6,11) Findings Include: 1. According to the ‘Changing the Catheter Dressing Procedure’ policy (Version 8, 02/05/2024), staff must use 2% Chlorhexidine (a skin disinfectant) to disinfect the CVC exit site for 30 seconds and use a sterile alcohol pad to disinfect the CVC hubs after cap removal for 10-15 seconds. 2. During an observation on 03/06/2025 at 12:40 PM, PCT 2 disinfected Patient #11’s CVC exit site using Chlorhexidine (a skin disinfectant) for 20 seconds. 3. During an observation on 03/06/2025 at 10:40 AM, RN 3 initiated Patient #6’s CVC. RN 3 disinfected the hubs of the CVC for 7 seconds each with an alcohol pad. 4. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that CVC exit sites are disinfected with Chlorhexidine for 30 seconds and the catheter hubs are disinfected with an alcohol pad for 20 seconds.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 51751 Based on record review and interview, the facility failed to complete total chlorine testing of the water system every 4 hours for 1 of 1 facility reviewed. Findings Include: 1. According to the ‘Carbon Filtration Monitoring for Incenter Water Systems Policy’ policy (Version 11, 02/03/20252) staff must complete Total Chlorine testing every 4 hours during patient treatments. 2. According to a ‘Post Worker Carbon Tank - TCL - 1’ document, a chlorine check was completed on 02/22/2025 at 5:40 AM with the next chlorine check completed at 3:10 PM. 3. During an interview on 03/06/2025 at 9:10 AM the Area Operations Team Manager (ATOM) indicated that on 02/22/2025 a new nurse reported to the FA that the total chlorine was checked every 4 hours, however, it was not recorded in the Electronic Record system. The ATOM indicated the involved staff failed to hit the save button, thus not recording the encounter. 4. During an interview on 03/06/2025 at 9:15 AM, Biomed indicated the requirement is to check for chlorine prior to the first patient starting treatment and every 4 hours during treatments. 5. During an interview on 03/07/2025 at 9:20 AM, PCT 4 indicated that chlorine testing is to be completed daily prior to starting patient treatments and then every 4 hours, verified by 2 staff members, an RN and a PCT. 6. During an interview on 03/06/2025 at 10:40 AM, the FA indicated it was a requirement to test and document total chlorine every 4 hours. On 02/22/2025 he received a text message from RN 2 indicating that the PCT failed to hit the save button when the chlorine tests were recorded in the electronic record keeping system. RN 2 assured the FA that the chlorine tests were completed but were not documented. The FA indicated that RN 2 did not document the results in any other place. 7. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that chlorine testing is to be completed a minimum of every 4 hours. On 02/22/2025 RN 2 indicated that the chlorine checks were completed by a new PCT who failed to save and close the results of the chlorine tests in the electronic record system. All the chlorine checks were completed on time that day but were not documented anywhere else.”

“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: 51751 Based on observation, record review, and interview, the medical director failed to ensure staff followed all policies and procedures to include disinfection of an access site using an alcohol pad for 30 seconds and allowing too dry for 1 of 3 Arterial Venous Fistula (AVF) (a dialysis access) observations (Patient #9), failed to follow policy and procedures related to blood pressure (BP) and pulse readings every 30 minutes but not to exceed every 45 minutes for 1 of 5 records reviewed (Patient #3), failed to follow policy and procedure related to physician ordered Dialysate Flow Rates (DFR) for 4 of 5 patients reviewed (Patient #1, 3, 4, & 5), and failed to follow policy and procedure related to completing a nursing assessment prior to starting a new patient’s dialysis treatment for 1 of 1 new admission reviewed. (Patient #3) Findings Include: Access Assessment and Cannulation According to the ‘Access Assessment and Cannulation’ policy (Version 4, 05/06/2024) staff must disinfect the cannulation site using an alcohol pad for 30 seconds and allow to dry. During an observation on 03/06/2025 at 11:55 AM, PCT 4 initiated Patient #9’s AV Fistula. PCT 4 disinfected the fistula site for 15 seconds with alcohol, then inserted the needles to initiate treatment. PCT 4 failed to disinfect the site for 30 seconds and failed to allow the site to dry before cannulation. During an interview on 03/06/2025 at 12:08 PM, PCT 4 indicated AVF sites are to be disinfected with alcohol for 30 seconds and allowed to dry completely before cannulating. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated AVF sites should be disinfected using an alcohol pad for 30 seconds and allowed to dry. Patient Assessment & Monitoring According to the ‘Patient Assessment and Monitoring’ policy (Version 4, 05/01/2023) staff must obtain BP and pulse rates every 30 minutes or more as needed but not to exceed 45 minutes. The clinical record for Patient #3 was reviewed and evidenced the following: A treatment sheet dated 02/21/2025 for Patient #3 indicated a BP & pulse check completed at 12:35 PM with a subsequent BP & pulse check completed at 1:33 PM. A treatment sheet dated 02/28/2025 for Patient #3 indicated a BP & pulse check completed at 12:03 PM, 1:06 PM, and again at 2:04 PM. A treatment sheet dated 03/03/2025 for Patient #3 indicated a BP & pulse check completed at 1:04 PM, 2:03 PM, and again at 3:03 PM. During an interview on 03/07/2025 at 9:20 AM, PCT 4 indicated BP’s should be assessed and documented every 30 minutes. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that BP’s are to be assessed and documented every 30 minutes. Dialysis Flow Rate 1. According to the ‘Patient Assessment and Monitoring’ policy (Version 4, 05/06/2024), staff must assess and document the dialysate flow rate setting every 30 minutes but not to exceed 45 minutes. 2. The clinical record for Patient #1 was reviewed and evidenced the following: A treatment sheet dated 02/12/2025 for Patient #1 indicated a physician ordered DFR of 800. Patient #1 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 02/14/2025 for Patient #1 indicated a physician ordered DFR of 800. Patient #1 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 02/21/2025 for Patient #1 indicated a physician ordered DFR of 800. Patient #1 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 03/03/2025 for Patient #1 indicated a physician ordered DFR of 800. Patient #1 rana DFR of 700 the entire treatment. Staff failed to document the reason and/or notify the RN. 3. The clinical record for Patient #3 was reviewed and evidenced the following: A treatment sheet dated 02/21/2025, for Patient #3, indicated a physician ordered DFR of 600. Patient #3 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. 4. The clinical record for Patient #4 was reviewed and evidenced the following: A treatment sheet dated 02/14/2025 for Patient #4 indicated a physician ordered DFR of 800. Patient #4 ran a DFR of 500 the entire treatment. Staff failed to document the reason. A treatment sheet dated 02/28/2025 for Patient #4 indicated a physician ordered DFR of 800. Patient #4 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. 5. The clinical record for Patient #5 was reviewed and evidenced the following: A treatment sheet dated 02/10/2025 for Patient #5 indicated a physician ordered DFR of 800. Patient #5 ran a DFR of 500 for greater than 3 hours of treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 02/14/2025 for Patient #5 indicated a physician ordered DFR of 800. Patient #5 ran a DFR of 600 the entire treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 02/19/2025 for Patient #5 indicated a physician ordered DFR of 800. Patient #5 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. 6. During an interview on 03/07/2025 at 9:20 AM, PCT 4 indicated that DFR’s are set to physician orders, and a second staff member verifies the patient is running on the correct prescription. If a patient is not meeting the physician order, the PCT is to notify the nurse and/or physician and document any interventions provided and the reason the patient isn’t meeting the prescription. 7. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that DFR’s are to be documented every 30 minutes. If a patient is not running the correct DFR, the nurse is to be made aware. RN 2 further indicated that the PCT’s tend to verbalize this information to the nurses but fail to chart the nurse was made aware and/or the reason why the prescription isn’t followed. New Patient Assessment According to the ‘Comprehensive Interdisciplinary Assessment and Plan of Care:’ policy (Version 6, 07/03/2023), the RN must complete an assessment prior to starting a new patient’s first dialysis treatment. A document titled, “Patient Transfer” indicated an admission date of 02/05/2025 for Patient #3. A treatment sheet dated 02/05/2025 indicated a first treatment start time of 12:20 PM with the initial RN assessment completed at 12:24 PM. During an interview on 03/06/2025 at 11:20 AM, the Senior Director of Operations indicated there was a 15-minute time frame from a new patient ’ s start of treatment and when the initial assessment needs to be completed. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that prior to a new patient starting their initial dialysis treatment, the RN is responsible for completing an initial assessment. A treatment sheet dated 02/14/2025 for Patient #5 indicated a physician ordered DFR of 800. Patient #5 ran a DFR of 600 the entire treatment. Staff failed to document the reason and/or notify the RN. A treatment sheet dated 02/19/2025 for Patient #5 indicated a physician ordered DFR of 800. Patient #5 ran a DFR of 500 the entire treatment. Staff failed to document the reason and/or notify the RN. During an interview on 03/07/2025 at 9:20 AM, PCT 4 indicated that DFR’s are set to physician orders, and a second staff member verifies the patient is running on the correct prescription. If a patient is not meeting the physician order, the PCT is to notify the nurse and/or physician and document any interventions provided and the reason the patient isn’t meeting the prescription. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that DFR’s are to be documented every 30 minutes. If a patient is not running the correct DFR, the nurse is to be made aware. RN 2 further indicated that the PCT’s tend to verbalize this information to the nurses but fail to chart the nurse was made aware and/or the reason why the prescription isn’t followed. 4. According to the ‘Comprehensive Interdisciplinary Assessment and Plan of Care:’ policy (Version 6, 07/03/2023), the RN must complete an assessment prior to starting a new patient’s first dialysis treatment. A document titled, “Patient Transfer” indicated an admission date of 02/05/2025 for Patient #3. A treatment sheet dated 02/05/2025 indicated a first treatment start time of 12:20 PM with the initial RN assessment completed at 12:24 PM. During an interview on 03/06/2025 at 11:20 AM, the Senior Director of Operations indicated there was a 15-minute time frame from a new patient ’ s start of treatment and when the initial assessment needs to be completed. During an interview on 03/07/2025 at 9:55 AM, RN 2 indicated that prior to a new patient starting their initial dialysis treatment, the RN is responsible for completing an initial assessment.”