Fmc - Scott County Dialysis

“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: 48658 Based on observation, record review, and interview the facility failed to ensure infection control guidelines were followed for exit site care when initiating a Central Venous Catheter (CVC) at the start of treatment for 1 of 2 CVCs observed (Patient #4). Findings include: 1. A policy titled “Changing the Catheter Dressing Procedure” indicated but was not limited to: “Cleaning the Site: Follow the steps below to clean the catheter exit site ...Remove swab stick from package ...2% Chlorhexidine and 70% alcohol ...clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds ...” 44230 2. During an observation on 08/07/2024 at 11:20 AM, Patient Care Technician (PCT) 3 removed the old dressing from Patient #4’s CVC, removed gloves, completed hand hygiene, and donned new gloves. The exit site was cleansed with 2% Chlorhexidine (topical antiseptic) for 10 seconds before applying a new dressing. PCT 3 failed to cleanse the CVC exit site for 30 seconds. 3. During an interview on 08/07/2024 at 11:36 AM, PCT 3 indicated that CVC exit sites should be cleansed for 30 seconds when using 2% Chlorhexidine and that she was not counting as she normally does when performing this task. PCT 3 denied using a clock/watch to ensure adequate CVC exit site care was completed for Patient #4. 4. During an interview on 08/07/2024 at 12:32 PM, the Clinic Manager indicated the time frame for cleansing a CVC Exit Site using 2% Chlorhexidine was one minute and further indicated she would look up the policy to verify this. At 1:43 PM the Clinic Manager indicated that after review of the policy the CVC Exit Site should be cleansed for 30 seconds with 2% Chlorhexidine. 5. During an interview on 08/09/2024 at 10:05 AM, Registered Nurse (RN) 1 indicated the time frame for cleansing a CVC Exit Site using 2% Chlorhexidine was 30 seconds. 6. During an interview on 08/09/2024 at 10:23 AM, PCT 1 indicated the time frame for cleansing a CVC Exit Site using 2% Chlorhexidine was 30 seconds.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 48658 Based on observation, record review, and interview the facility failed to ensure that privacy and confidentiality in personal medical records was maintained for 1 of 1 facility reviewed. Findings include: 1. A policy titled “Patient Rights and Responsibilities” indicated but was not limited to: “The patient has the right to ...Privacy and confidentiality in all aspects of treatment; Privacy and confidentiality in personal medical records ...” 2. During an observation on 08/07/2024 at 10:20 AM, a clipboard containing patients’ names, was lying uncovered on the ledge surrounding the nurses’ station in the treatment center. Additionally, bags labeled with patient names and containing lab supplies on the ledge surrounding the nurses’ station and at the clean sink/lab area in the treatment center. Patient information was visible to individuals walking by these areas. 3. During an interview on 08/07/2024 at 3:50 PM, Registered Nurse (RN) 1 indicated the patient names on the clipboard are at the nurses’ station and it’s not like patients are hanging out at the nurses’ station; she indicated staff walks patients from the scale to their dialysis station for treatment. She indicated the names on the clipboard and the names on the lab bags could be a HIPAA (Health Insurance Portability and Accountability Act) violation and there could be a better process for protecting patients’ information from being viewed by others. 4. During an interview on 08/07/2024 at 4:05 PM, the Administrator indicated patient names on the clipboard on the ledge at the nurses’ station and the names on the lab bags in the treatment center should not be visible in order to protect patients’ privacy.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 44230 Based on record review and interview the agency failed to ensure patient monitoring for blood pressure and pulse, during dialysis were completed every 30-45 minutes per policy for 3 of 5 patient records reviewed, (Patient #1, #4, #5) and that a pulse below 60 bpm (beats per minute) was verified manually and reported to the nurse in 1 of 5 patient records reviewed (Patient #4). Findings Include: 1. A policy titled “Patient Assessment and Monitoring” indicated but was not limited to: “During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes ...Follow the steps below for monitoring patient and machine parameters during treatment: Pulse: record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute. Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular ...Ensure vital signs and overall condition are stable for discharge ...” 2. A document titled, “Patient Transfer: Care Transitions Report” for Patient #4 indicated but was not limited to: “Special Attentions: Okay to dialyze with systolic B/P [blood pressure] 80-180, diastolic B/P 40-95, and pulse 40-120 every tx [treatment] if non-symptomatic.” 3. A treatment sheet dated 08/02/2024 for Patient #1 indicated a blood pressure/pulse assessment documented at 2:03 PM with the next blood pressure/pulse assessment documented at 4:02 PM, 1 hour and 59 minutes later. 4. A treatment sheet dated 07/24/2024 for Patient #4 indicated a pulse rate of 63-66 bpm throughout the 4 hour treatment until the last 30 minutes. A pulse rate of 36 was obtained by Patient Care Technician (PCT) 2 at 2:31 PM with an additional pulse rate of 31 at 2:57 PM. No further pulse assessment was documented on this day. Patient #4 was discharged home. PCT failed to notify the Registered Nurse (RN) of the pulse rates. 5. A treatment sheet dated 07/31/2024 for Patient #4 indicated a blood pressure/pulse assessment documented at 2:02 PM with the next blood pressure/pulse assessment documented at 3:02 PM, one hour later. 6. A treatment sheet dated 08/05/2024 for Patient #4 indicated a blood pressure/pulse assessment documented at 2:01 PM with the next blood pressure/pulse assessment documented at 3:02 PM, one hour later. 7. A treatment sheet dated 07/31/2024 for Patient #5 indicated a blood pressure/pulse assessment documented at 2:03 PM with the next blood pressure/pulse assessment documented at 3:01 PM, 58 minutes later. 8. During an interview on 08/08/2024 at 9:24 AM the Clinic Manager indicated it is the expectation that clinical staff document on patients during dialysis treatments every 30 minutes. This is to include, blood pressure, pulse, respirations, blood flow rates, dialysate flow rates, on-line clearance monitoring, venous & arterial pressures, and fluid removed. The Clinic Manager indicated that sometimes the blood pressure/pulse rates won’t show on the treatment sheets if clinical staff document within 30 seconds of dialysis machine alarming for next patient assessment. No further documentation was found in the Electronic Medical Record System per the Clinic Manager. 9. During an interview on 08/09/2024 at 10:05 AM, RN 1 indicated patient assessment, including blood pressure and pulse are to be documented every 30 minutes. If an abnormal finding is documented, such as a pulse outside of policy parameters, the PCT is not notify the RN. The RN completes an assessment and notifies the physician. 10. During an interview on 08/09/2024 at 10:23 AM, PCT 1 indicated that blood pressure/pulse assessments are documented every 30 minutes. If outside the normal range, the RN is notified.”

“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: 48658 Based on observation, record review, and interview, the facility failed to follow policy regarding securement of medications and labeling pre-drawn medications for 1 of 1 facility reviewed and failed to ensure the Registered Nurse (RN) assessment was completed prior to the start of dialysis treatment for 1 of 1 New Admission patient records reviewed (Patient #4). Findings include: 1. A policy titled “Medication Preparation and Administration” indicated but was not limited to: “Pre-drawing Medications: Medications may be pre-drawn up to 4 hours prior to administration ...These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary until delivery to the appropriate patient for administration ...Securement: The following steps must be taken for the securement: All medications will be kept in a locked cabinet except when in use ...” 2. A policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” indicated but was not limited to: “Patients changing modality are classified as new patients ...A registered nurse must perform an assessment on patients new to dialysis before initiation of their first treatment to determine immediate needs ...” 44230 3. During an observation on 08/07/2024 at 9:48 AM, six pre-drawn syringes of Heparin, (a medication used to prevent clotting during dialysis) were found in an unlocked drawer in the medication preparation area. Three labeled syringes of Heparin for Patient #5 included the following doses: 2000 units, 6000 units, and 2200 units. Three additional syringes of Heparin for Patient #4 included the following doses: 1900 units, 7000 units, and 1900 units. The labels for all 6 pre-drawn syringes failed to include the time the medication was drawn up and the staff members initials. One opened vial of Heparin was found unsecured on the medication preparation area counter. 4. During an observation on 08/07/2024 at 12:32 PM while interviewing the Clinic Manager, two vials of opened Heparin were found unsecured on the medication preparation area counter. 5. A record review for a new admission, Patient #4, indicated an admission date of 06/07/2024. The initial treatment on 06/07/2024 was completed at 11:28 AM. The initial treatment started at 11:05 AM. The facility failed to ensure the initial assessment was completed prior to the start of treatment for Patient #4. 6. During an interview on 08/07/2024 at 10:15 AM, Registered Nurse (RN) 1 indicated that all pre-drawn medications are to be labeled with the name of the patient, medication name, dose, date, and time. The staff member responsible for drawing up the medication should initial the medication label and ensure securement in a locked drawer. 7. During an interview on 08/07/2024 at 12:32 PM, the Clinic Manager indicated that pre-drawn medications should be labeled and include the patient name, name of the medication, dose, date, and time. The staff member preparing the medication should initial the label and ensure securement in a locked drawer. 8. During an interview on 08/09/2024 at 10:05 AM, Patient Care Technician (PCT) 1 indicated that pre-drawn medications should include a label with the following information; patient name, medication name, dose, date, time, and initials of staff member preparing the medication. All medications should be secured in a locked cabinet or drawer until use. 9. During an interview on 08/08/2024 at 2:35 PM, the Clinic Manager indicated that the initial assessment is to be completed prior to the start of the first dialysis treatment and indicated that there is a “hard-stop” that will not allow treatment to begin prior to the nurse completing the assessment. The assessment is completed within the Electronic Medical Record, no paper charting of assessments are completed. The Clinic Manager indicated that Patient #4 was a transfer from another clinic, a home modality, and this could be the reason the initial assessment is documented later than the treatment start time. 10. During an interview on 08/09/2024 at 1005 AM, RN 1 indicated that assessments for all new admissions are completed prior to the start of their initial treatment. The initial assessment is completed in Chairside, the electronic treatment documentation system.”