Fmc - Muncie Dialysis

“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: 45607 Based on observation, policy review, and interview, the ESRD facility failed to ensure staff followed their policies related to hand hygiene and personal protective equipment (PPE) for 1 of 4 Registered Nurses (RN 2) and 1 of 5 Patient Care Technicians (PCT 5) observed on the treatment floor. Findings include: 1. Review of the “Hand Hygiene” policy, revised 11/06/23, indicated hand hygiene must occur including but not limited to after contact with wound dressings, when entering and leaving the treatment area, after contact with inanimate objects near the patient, and immediately after removing gloves. 2. Review of the “Personal Protective Equipment” policy, revised 11/06/23, indicated hand hygiene must always be performed after glove removal. 3. During a treatment floor observation on 8/21/24, RN 2 changed gloves at 9:58 AM without performing hand hygiene after removing the gloves. At 10:12 AM, RN 2 returned from wheeling a patient to the lobby and donned gloves without first performing hand hygiene. RN 2 then went to Station 4 and touched the machine. During an interview on 8/21/24 at 10:15 AM, RN 2 relayed she should perform hand hygiene before or after gloves and before touching a patient. During an interview on 8/21/24 at 3:58 PM, the Clinical Manager relayed staff should perform hand hygiene including but not limited to before and after gloves and before and after touching the machine or the patient. 44714 4. An observation of a central venous catheter (CVC, used to provide access to a large vein) site care for Patient #12 occurred on 8/21/2024 at 10:20 AM. Patient Care Technician (PCT) 5 removed the old bandage and discarded it. PCT 5 removed a cleaning swab and cleaned the access site. PCT 5 failed to remove gloves and complete hand hygiene after removing the soiled dressing. During an interview on 8/21/2024 at 1:45 PM, PCT 5 indicated hand hygiene and glove change occurred after cleaning the access site and prior to the application of the new dressing. PCT 5 indicated she was unsure if she changed her gloves during the process. During an interview on 8/21/2024 at 3:50 PM, the Clinical Manager indicated hand hygiene and glove change should occur after removing the soiled dressing and cleaning the access site.”

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff followed infection control policies for 1 of 1 Registered Nurse (RN) observed providing central venous catheter (CVC) exit site care (RN 2). Findings include: 1. The “Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer” policy, revised 2/07/22, indicated the threads and end of the luer lock, or hub, should be scrubbed with an alcohol pad for 10 to 15 seconds each time caps are removed or bloodlines are disconnected. 2. The “Central Venous Catheter (CVC) Dressing Change” policy, revised 5/06/24, indicated when using povidone iodine to disinfect, the site should be disinfected for 30 seconds and allowed to dry for at least two minutes. 3. During an observation of RN 2 discontinuing dialysis and performing CVC exit site care for Patient #9 on 8/21/24 beginning at 9:46 AM, RN 2 scrubbed the red hub and the blue hub for 7 seconds each with alcohol swabs after disconnecting the dialysis tubing. After discontinuation of dialysis and CVC dressing removal, RN 2 cleansed the exit site with povidone iodine for 15 seconds and applied the dressing immediately after cleansing the site. 4. During an interview on 8/21/24 at 10:15 AM, RN 2 indicated she usually cleanses the CVC exit site for 30 seconds and indicated she thought it was supposed to be 15 to 30 seconds. RN 2 further indicated she was supposed to let the povidone iodine dry before applying the dressing but that Patient #9 likes it applied while a little bit damp. RN 2 also indicated CVC hubs should be scrubbed for 15-30 seconds. 5. During an interview on 8/21/24 at 3:38 PM, the Clinical Manager relayed the CVC exit site should be cleansed for 30 seconds with povidone iodine and allowed to dry before applying the dressing and further indicated CVC hubs should be scrubbed for 15 seconds when disconnecting from dialysis.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 44714 Based on observation, record review, and interview, the dialysis facility failed to ensure expired medical supplies were removed from labratory area during for 1 of 1 flash tour observations, which had the potential to affect all ICHD patients. Findings include: During a tour on 8/20/2024 at 8:50AM, observed expired laboratory supplies in the facility laboratory area. Two boxes of 4 bottle blood culture kits expired 7/31/2024. During an interview at 8:50 AM, registered nurse (RN) 1 indicated all staff were responsible to check expiration dates prior to using the supplies.”

“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: 44714 Based on observation, record review and interview, the medical director failed to ensure clinical staff stored and accessed medications per the facility policy for 1 of 1 oral medication administration observation and 2 of 2 heparin storage areas inspected on 8/20/2024. Findings include: 1. The Medication Preparation and Administration policy, dated 2/6/2023, indicated medications should be locked in a cabinet when not in use. The policy indicated a multidose vial required the date, time and initials of the staff person who first accessed the vial. Additionally, the policy indicated medications in a syringe that were not administered immediately required a label with medication name, dosage, route (how the medication was to be administered), patient name, date, time, and initials of the staff who prepared the medication. 2. The first treatment floor observation occurred on 8/20/2024 at 8:50 AM. Observed on the medication preparation area were 4 medication cups with one or more capsules inside. The medication cups contained a label with the patient’s name and medication for Patients #18, 19, 20, and 21. During an interview moments after the observation, Registered nurse (RN) 1 indicated they could set up medications ahead of time since they labeled the medication cups. RN 1 then left the medication area, leaving the medications unattended. During an interview on 8/21/2024 at 3:45 PM, the Clinical Manager indicated medications should not have been left unattended on the counter. 3. During an inspection of the heparin storage on 8/20/2024 at 10 AM, one supply cart contained an open and partially used vial of heparin. The vial failed to include a notation of the date and time the vial was opened. The second supply cart contained 3 syringes filled with heparin. The syringes lacked a label with patient name, medication and dosage and date/ time and initials of staff who drew up the medication. During an interview on 8/20/2024 at 10:15 AM, RN 1 indicated they could not identify the date the vial was accessed and indicated the vial should have included the date and time it was opened. RN 1 indicated the medication could have been extra or not needed. RN 1 could not identify which patients should have received the medication. RN 1 indicated the syringes should have been labeled with patient name, date, and time if it was not used immediately after being prepared. During an interview on 8/21/2024 at 3:45 PM, the Clinical Manager indicated the staff person who first accessed the heparin should have dated and timed the heparin vial. The Clinical Manager further indicated there should never be filled syringes without a patient label which included the name, date, dosage, route, and person who prepared the syringe. 4. During an interview on 8/21/2024 at 4:10 PM, the Medical Director indicated the staff failed to manage the medications per policy and the Medical Director was responsible for the clinical policies and to ensure staff followed them.”

“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: 45607 Based on record review and interview, the dialysis facility failed to ensure as needed (PRN) medication was offered for a patient with elevated blood pressure (BP) during treatment for 1 of 5 patient records reviewed (Patient #3). Findings include: 1. The Hypertension policy indicated “Staff will recognize, report, and immediately address systolic blood pressures greater than 180 ... If hypertension is not related to hypervolemia, notify the physician for additional orders/ interventions ... Document in patient’s treatment record.” 2.Review of Patient #3’s clinical record included treatment run sheets from 7/08/24 through 7/24/24. On 7/08/24, treatment began at 5:19 AM. Patient #3’s BP was 213/82 at that time. The patient’s BP was 225/99 at 5:31 AM, 207/91 at 6:02 AM, 199/76 at 6:33 AM, 200/82 at 7:04 AM, 213/93 at 7:33 AM, and 204/85 at 8:01 AM. A comment in the treatment run sheet by RN 2 at 8:02 AM indicated PRN Clonidine (a medication to treat high blood pressure) had just been given. The clinical record failed to evidence PRN clonidine had been offered to Patient #3 that day prior to the 8:02 comment. On 7/10/24, treatment began at 5:36 AM. Patient #3’s BP was 205/79 at 5:39 AM, 201/81 at 6:02 AM, 184/72 at 6:33 AM, 194/82 at 7:03 AM, 197/83 at 7:35 AM, 206/85 at 8:32 AM, 209/82 at 8:47 AM. The clinical record failed to evidence Patient #3 was offered PRN Clonidine on 7/10/24. On 7/22/24, treatment began at 5:54 AM. Patient #3’s BP was 165/90 at that time. Patient #3’s BP was 194/88 at 6:02 AM, 199/90 at 6:32 AM, 185/83 at 7:02 AM, 180/80 at 7:31 AM, 184/77 at 8:08 AM, 211/72 at 8:32 AM. The clinical record failed to evidence Patient #3 was offered PRN Clonidine on 7/22/24. During an interview on 7/25/24 at 12:37 PM, RN 1 indicated Patient #3 is supposed to take her home BP medications when she gets home from treatment and that RN 1 has educated the patient to take her home medications, stop smoking and vaping, and avoid salty foods. RN 1 further indicated Patient #3 often declines PRN Clonidine saying he or she wants to see what her BP will do during treatment. During an interview on 7/26/24 at 4:07 PM, RN 2 indicated she determines whether to administer Clonidine based on the order parameters which are usually for a systolic greater than 180 and indicated she documents on the treatment sheet when a patient declines a PRN medication. RN relayed she was not sure whether she had offered Patient #3 PRN Clonidine on 7/8/24 but that she has offered Clonidine to that patient before. RN 2 further indicated Patient #3 has declined Clonidine when RN 2 has offered it because the patient said he or she would want to see if the BP dropped before giving it, and sometimes the patient had taken their home BP medications prior to coming to treatment and said he or she wanted to see if the home BP medications were going to work prior to accepting Clonidine. During an interview on 7/26/24 at 4:27 PM, the Clinical Manager relayed she expected RNs to follow the parameters for administering PRN Clonidine. The Clinical Manager further indicated she expected the RN to document in the treatment sheet if the patient declined a PRN medication.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 48224 Based on observation, record review, and interview, the dialysis facility failed to ensure all staff followed policies and procedures related to infection control for 4 of 7 personnel observed on the in-center treatment floor (Physician #1, PCT 2, RN 3, and RN 4). Findings include: 1. A review of agency policy “Personal Protective Equipment” indicated personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid resistant gowns, and gloves must be worn to protect employees from blood or other potentially infectious materials. 2. During observation periods on 2/09/24 from 8:52 AM to 9:34 AM and 10:53 AM to 12:14 PM, PCT 2 was observed without a face mask that covered their nose while on the treatment floor for the duration of the observations. 3. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated face masks should be worn above the nose, tucked below the chin and around the ears. 4. During an observation on 2/09/24 beginning at 9:28 AM, Physician #1 was observed wearing a disposable gown loosely on their lower arms while in Station #19, moving from Station #19 to Station #23 to Station #15 to Station #13 and then to Station #9. Physician #1 failed to secure the gown properly while rounding on the in-center patient treatment floor and failed to wear eye protection while on the treatment floor. 5. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated the gown should be worn with arms completely in the sleeves and tied in the back and indicated face masks should be worn above the nose, tucked below the chin and around the ears. 6. During an interview on 2/09/24 beginning at 5:03 PM, the Clinical Manager indicated all physicians should wear a mask, gown and eye protection while on the treatment floor. 45607 7. On 02/09/24 at 10:45 AM, RN 4 was observed, with a face mask worn below the nose and goggles on top of the head, perform a blood pressure check on the patient in Station 12. On 02/09/24 at 11:15 AM, RN 3 was observed entering Patient #10’s station with goggles on and a face mask worn below the nose. On 02/09/24 at 11:52 AM, PCT 2 was observed performing standing and sitting blood pressure checks on a patient while PCT 2 was wearing goggles and was wearing a face mask below the nose.”

“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: 48224 Based on observation, record review, and interview, the dialysis facility failed to ensure all staff and patients followed the policies and procedures related to hand hygiene for 3 of 3 personnel observed assisting patients during discontinuation of AV fistula/graft dialysis (Physician #1, RN 4 and PCT 5). Findings include: 1. A review of agency policy “Personal Protective Equipment” indicated staff must remove gloves and wash hands after patient care, exposure to blood and body fluids and touching any surfaces within the patient station. 2. A review of agency policy “Hand Hygiene” indicated hand hygiene should be performed before and after direct contact with patients; after contact with the dialysis wall box, concentrate, drain or water lines and after contact with other object within the patient station or treatment space. 3. During an observation on 2/09/24, Personal Care Technician (PCT) 5 was observed handing Patient #15 a glove to don to hold pressure on their left arm. PCT 5 failed to instruct Patient #15 to perform hand hygiene prior and failed to provide hand sanitizer to the patient prior to handing the patient the glove. 4. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated when patient’s hold their access site gauze, they should do it with a gloved hand. The Clinical Manager also indicated the patient should perform hand hygiene before putting on a glove and the facility staff is responsible to provide hand sanitizer to the patient. 5. During an observation on 2/09/24, Physician #1 was observed in Station #19, then moving from Station #19 to Station #23 to Station #15 to Station #13 and then to Station #9. The physician touched the machine monitor in each station, had a brief discussion with each patient and then moved to the next station without performing hand hygiene or wearing gloves. 6. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated the monitor screen is a dirty surface and hand hygiene should have been performed when leaving each station. 45607 7. RN 4 was observed performing the discontinuation of dialysis and post dialysis access care on 02/09/24. RN 4 placed a glove on Patient #8’s hand to hold gauze on his/her access site. RN 4 failed to instruct Patient #8 to perform hand hygiene and failed to provide hand sanitizer to the patient prior to placing the glove on Patient #8’s hand.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 45607 Based on observation, policy review, and interview, the dialysis center failed to ensure staff wore the required personal protective equipment (PPE) when spurting or spattering of blood might occur for 3 of 6 Personnel observed. (PCT 2, PCT 3, RN 4.) Findings include: 1. The Personal Protective Equipment policy, revised 11/06/23, indicated PPE including a full-face shield or a mask and protective goggles must be worn when performing procedures during which spurting or spattering of blood might occur. 2. The Initiation and Termination of Treatment Using a Central Venous Catheter (CVC) policy, revised 07/05/22, indicated staff must wear a mask that covers the nose and mouth for all procedures that require accessing the catheter. 3. Registered Nurse (RN) 4 was observed performing the discontinuation of dialysis and post dialysis access care of fistula or graft for Patient #8 on 02/09/24. RN 4 returned to Patient #8’s station after dialysis discontinuation to check for homeostasis of the access site with RN 4’s face mask below their nose and their goggles on top of their head. RN 4 failed to wear their face mask covering the nose and failed to wear protective goggles over the eyes when performing a procedure during which spurting or spattering of blood might occur. 4.RN 4 was observed providing care to the access of a fistula or graft for the initiation of dialysis for Patient #7 on 02/09/24 at 11:01 AM. RN 4 performed cannulation with goggles on and with a face mask worn below the nose. RN 4 failed to wear their face mask covering the nose when performing a procedure during which spurting or spattering of blood might occur. 5. Patient Care Technician (PCT) 3 was observed accessing a fistula or graft site for the Patient in Station 15. PCT 3 was wearing goggles and was wearing a face mask below the nose. PCT 3 failed to wear a full-face shield or goggles and a mask covering the nose when performing a procedure during which spurting or spattering of blood might occur. 6. PCT 2 was observed performing Central Venous Catheter (CVC) exit site care for Patient #6 on 02/09/24. PCT 2 wore a face mask below the nose and goggles during the exit site care. PCT 2 failed to wear a full-face shield or goggles and a mask covering the nose when performing a procedure during which spurting or spattering of blood might occur. 7. PCT 2 was observed performing the initiation of dialysis with a CVC for Patient #6 on 02/09/24 PM. PCT 2 wore a face mask below their nose and goggles during the entire initiation of dialysis. PCT 2 failed to wear a full-face shield or goggles and a mask covering the nose when performing a procedure during which spurting or spattering of blood might occur. 48224 8. During an observation on 2/09/24, PCT 2 was observed performing discontinuation of dialysis on Patient #14’s CVC. PCT 2 failed to ensure their face mask covered their nose for the duration of the CVC discontinuation. 9. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated face masks should be worn above the nose, tucked below the chin and around the ears.”

“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: 45607 Based on record review and interview, the dialysis facility failed to follow their policy when they failed to ensure the patient’s blood pressure (BP) was checked every 30 minutes during in-center hemodialysis (ICHD) for 2 of 3 active patient clinical records reviewed (Patient #2 and #3); failed to ensure the Registered Nurse (RN) completed an assessment within one hour of the start of hemodialysis treatment for 2 of 3 active patient clinical records reviewed (Patient #1 and #3); failed to ensure the RN was notified of high blood pressures for 1 of 2 active patient clinical records reviewed with high blood pressures recorded during ICHD treatments (Patient #1); and failed to ensure the RN performed interventions and/or reported high blood pressures to the physician for 1 of 2 active patient clinical records reviewed with high blood pressures recorded during ICHD treatments (Patient #3). Findings include: 1. Policy Patient Assessment and Monitoring, revised 05/01/23, indicated blood pressure should be monitored every 30 minutes or more often as needed but not to exceed 45 minutes during ICHD treatments. The policy indicated diastolic blood pressures greater than 100 are to be reported to the nurse. 2. Policy Nursing Supervision and Delegation, revised 11/06/23, indicated RN’s may not delegate assessment of the patient within one hour of ICHD treatment start time. 3. Policy Hypertension, dated 09/07/21, indicated staff will recognize, report, and immediately address diastolic BP’s greater than 100. The policy indicated the nurse should be notified if the diastolic BP is greater than 100. The RN should then assess the patient and decrease estimated dry weight if the hypertension is related to hypervolemia (fluid overload.) If the hypertension is not related to hypervolemia, the RN should notify the physician for additional orders or treatments, and these steps should be documented in the patient’s treatment record. 4. Patient #2’s ICHD treatment sheets dated 01/25/24 to 02/28/24, were reviewed and evidenced the following: On 01/25/24, ICHD treatment began at 6:20 AM. A BP check was conducted at 9:04 AM with a follow-up BP check at 10:30 AM, 1 hour and 26 minutes later. At 9:04 AM, Patient #2’s BP of 178/108 was obtained by an RN. The clinical record failed to evidence the RN notified the physician and/or performed interventions to address the diastolic blood pressure over 100. On 01/27/24, ICHD treatment began at 6:30 AM. A BP check was conducted at 7:32 AM with a follow-up BP check at 8:36 AM, 1 hour and 4 minutes later. A licensed practical nurse (LPN) obtained Patient #2’s BP of 169/104 at 7:03 AM and 154/103 at 7:32 AM. The clinical record failed to evidence the RN was notified of the diastolic BP’s greater than 100. At 9:02 AM, an RN obtained Patient #2’s BP of 129/109. The clinical record failed to evidence the RN notified the physician and/or performed interventions to address the diastolic blood pressure over 100. On 01/30/24, ICHD treatment began at 6:36 AM. A BP check was conducted at 8:35 AM with a follow-up BP check at 10:04 AM, 1 hour and 29 minutes later. On 02/01/24, ICHD treatment began at 6:15 AM. A BP check was conducted at 9:32 AM with a follow-up BP check at 10:30 AM, 58 minutes later. An RN obtained Patient #2’s BP of 181/104 at 8:35 AM. The clinical record failed to evidence the RN notified the physician and/or performed interventions to address the diastolic blood pressure over 100. On 02/03/24, ICHD treatment began at 6:42 AM. A PCT obtained Patient #2’s BP of 174/107 at 7:33 AM, 162/106 at 9:32 AM, 171/118 at 10:01 AM, and 170/108 at 10:20 AM. The clinical record failed to evidence the PCT notified the RN of the diastolic greater than 100. An RN obtained Patient #2’s BP of 180/106 at 6:42 AM, 168/105 at 8:02 AM, and 152/102 at 8:32 AM. The clinical record failed to evidence the RN notified the physician and/or performed interventions to address the diastolic blood pressure over 100. On 02/06/24, ICHD treatment began at 6:31 AM. A BP check was conducted at 9:03 AM with a follow-up BP check at 10:03 AM, 1 hour later. An RN obtained Patient #2’s BP of 168/101 at 10:03 AM. The clinical record failed to evidence the RN notified the physician and/or performed interventions to address the diastolic blood pressure over 100. On 02/08/24, ICHD treatment began at 6:30 AM. A PCT obtained Patient #2’s BP of 170/108 at 10:05 AM and 172/103 at 10:12 AM. The clinical record failed to evidence the RN was notified of the diastolic BP’s greater than 100. 5. During an interview on 02/09/23 beginning at 2:15 PM, the Clinical Manager indicated BP checks were missing for Patient #2 on 01/25/24, 01/27/24, 01/30/24, 02/01/24, and 02/06/24. The Clinical Manager indicated Patient #2’s treatment record did not contain documentation of notifications or interventions related to Patient #2’s diastolic BP’s greater than 100 on the dates reviewed. 48224 6. Patient #1’s ICHD treatment sheets, dated 1/24/24 to 2/08/24, were reviewed and evidenced the following: On 1/24/24, the ICHD treatment began at 1:06 PM; the RN assessment was performed at 2:15 PM, 1 hour and 9 minutes after treatment began. The BP check at 3:33 PM indicated BP of 192/96. PCT 3 failed to notify the RN regarding high BP reading. On 1/30/24, the ICHD treatment began at 6:52 AM; the RN assessment was performed at 8:04 AM, 1 hour and 12 minutes after treatment began. On 2/05/24, the ICHD treatment began at 1:07 PM, the BP check at 2:33 PM indicated BP of 183/97. PCT 3 failed to notify the RN regarding high BP reading. 7. Patient #3’s ICHD treatment sheets, dated 1/25/24 to 2/07/24, were reviewed and evidenced the following: On 1/25/24, the ICHD treatment began at 12:00 PM, the RN assessment was performed at 2:32 PM, 2 hours and 32 minutes after treatment began. and Patient #3 failed to receive the oral Vitamin D medication as prescribed during their treatment. On 1/27/24, the ICHD treatment began at 11:50 AM, the BP check was performed at 3:02 PM with a follow-up BP check at 4:02 PM, 1 hour later. On 2/07/24, the ICHD treatment began at 11:31 AM, the RN assessment was performed at 1:55 PM, 2 hours and 24 minutes after treatment began. 8. During an interview on 2/08/24 beginning at 4:38 PM, the Clinical Manager indicated the above findings for Patient’s #1 and #3 were accurate and indicated BP checks should have been performed every 30 minutes, with a fifteen-minute grace period and the RN assessment should be completed within the first hour of treatment start time. They also indicated the PCT should notify the RN when a patient’s blood pressure is elevated.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 48224 Based on record review and interview, the registered nurse (RN) failed to document the shortened run-time reason in the chairside charting and failed to document collaboration with the physician for 1 of 3 active records reviewed (Patient #1). Findings include: 1. A review of agency policy “Early Termination or Arriving Late for Treatment” indicated staff must document in Chairside the specific unexpected end reason that the treatment was shortened and all discussion with the physician must be documented in the patient’s medical record. 2. Patient #1’s hemodialysis treatment sheets, dated 1/24/24 to 2/08/24, were reviewed and evidenced a physician ordered total run time of 3 hours 45 minutes during the dialysis treatments. On 1/30/24, the treatment began at 6:52 AM and the total run time was 2 hours 43 minutes. The RN failed to document a shortened run time reason and failed notify the physician regarding the shortened run time. On 2/02/24, the treatment began at 1:01 PM and the total run time was 3 hours and 6 minutes. The RN failed to document a shortened run time reason and failed notify the physician regarding the shortened run time. On 2/05/24, the treatment began at 1:07 PM and the total run time was 3 hours 10 minutes. The RN failed to document a shortened run time reason and failed notify the physician regarding the shortened run time. On 2/08/24, the treatment began at 7:02 AM and the total run time was 2 hours and 38 minutes. The RN failed notify the physician regarding the shortened run time. 3. During an interview on 2/08/24 beginning at 4:27 PM, the Clinical Manager indicated the above run times were accurate and stated they would review the clinical records for proper documentation of the shortened run times. 4. During an interview on 2/12/24 beginning at 11:10 AM, the Clinical Manager indicated the clinical record failed to include a reason the above run times were shortened and failed to include documentation that the physician was notified regarding the shortened run times for Patient #1.”

“POC-MANAGE MINERAL METABOLISM CFR(s): 494.90(a)(3) Provide the necessary care to manage mineral metabolism and prevent or treat renal bone disease. This Standard is not met as evidenced by: 48224 Based on record review and interview, the registered nurse (RN) failed to administer Vitamin D medication as prescribed for 1 of 3 active clinical records reviewed (Patient #3). Findings include: 1. A review of agency policy “Medication Preparation and Administration” indicated medications must be administered with an order by a physician. 2. Patient #3’s hemodialysis treatment sheets, dated 1/25/24 to 2/07/24, were reviewed and evidenced a physician order for Vitamin D 0.25 mcg oral to be administered every dialysis treatment. 3. On 2/7/24, the treatment began at 11:31 AM. Patient #3 received oral Vitamin D medication that was entered into the electronic medical record (EMR) to be given during each treatment. The physican prescribed the medication to be given only on Mondays and Fridays. The patient should not have received the medication on 02/07/2024. The facility failed to ensure the patient’s oral Vitamin D prescription was entered into the EMR correctly and failed to ensure Patient #3 received the medication as prescribed by the physician. 4. During an interview on 2/08/24 beginning at 4:56 PM, the Clinical Manager indicated the Vitamin D order had been entered incorrectly on 2/02/24 and the Vitamin D should have been administered on Monday and Friday during treatment.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff followed facility policies and procedures related to fistula and graft access for 1 of 1 observations. (Registered Nurse [RN] 4.) Findings include: 1. Policy Access Assessment and Cannulation, revised 07/05/22, indicated cannulation sites are not to be touched after skin disinfection. 2. On 02/09/24 at 11:01 AM, RN 4 was observed accessing Patient #7’s fistula or graft. RN 4 disinfected Patient #7’s cannulation site for 61 seconds and then touched the cannulation site with gloved fingers prior to inserting the first needle. 3. On 02/09/24 at 2:15 PM, the Clinical Manager relayed that when accessing a fistula or graft, the site should not be touched again after it was disinfected. 48224”

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure their policies were followed related to medication storage for 1 of 1 treatment floor observation. Findings include: 1. Policy Medication Preparation and Administration, revised 02/06/23, indicated all medications will be kept in a locked cabinet when not in use. 2. On 02/09/24 at 11:16 AM, a multi-dose heparin (a medication used to prevent blood clotting) bottle, dated 02/09/24 but with no time, was observed unattended on the counter near Station 24 in the patient treatment area. The bottle was observed to still be unattended on the same counter on 02/09/24 at 11:35 AM and 11:46 AM. 3. During an interview on 02/09/23 beginning at 2:15 PM, the Clinical Manager indicated Heparin could be outside the medicine cabinet within 4 hours of being open but would otherwise need to be locked up. The Clinical Manager indicated pill bottles could be left on counters when the nurse was present on the treatment floor but would otherwise need to be locked up. 48224 4. On 2/09/24 at 11:55 AM, one bottle of Azicef (a medication used to treat infection) and four bottles of Vitamin D was observed sitting on the counter nearest to Station #7 unattended; a patient was present in station #7. 5. During an interview on 2/09/24 beginning at 2:15 PM, the Clinical Manager indicated all medications should be in the locked cabinet when a nurse is not at the counter.”