Renal Care Group - Hays

“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: 50529 Based on policy review, observation, and interview, the facility failed to ensure that patients performed hand hygiene and/or cleansed their access site (needle entry point) upon arrival and prior to treatment initiation and failed to ensure patients performed hand hygiene post treatment. This deficient practice poses a risk of contamination with the possible spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of any patient that receives dialysis treatment at this facility. Findings Include: Review of a policy titled, “Hand Hygiene,” dated 11/06/23, stated, “The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination ...Patients should perform hand hygiene if able, prior to and after dialysis treatment.” Review of a policy titled, “Access Assessment and Cannulation,” dated 05/05/25, stated, “ ...Prior to treatment, ask patient to wash access area with soap and water per hand hygiene procedure. IF patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient’s access with soap and water ...” During observation on 06/24/25 at 9:36 AM, Patient 7 entered the treatment floor without washing access and proceeded to station #10. Staff failed to remind or encourage patient to perform hand hygiene or to wash his/her access site. During observation on 06/24/25 at 9:56 AM, a patient at station #4 failed to perform hand hygiene after glove removal. The patient was not offered hand sanitizer by staff or encouraged to wash hands prior to discharging from clinic. During observation on 06/24/25 at 10:19 AM, a patient entered the treatment floor without washing access and proceeded to station #8. Staff failed to remind or encourage patient to perform hand hygiene or to wash his/her access site. During an interview on 06/25/25 at 7:57 AM, Staff G, Registered Nurse (RN), stated that when patients arrive, they are supposed to wash their hands and access with soap and water. Staff G stated, “We have forgotten or been lacking in reinforcing the washing of accesses at arrival and hand hygiene after holding sites.” During an interview on 06/25/25 at 11:23 AM, Staff A, Director of Operations, stated that it is the facility’s expectation that staff ensure patients wash accesses when entering the treatment area and to encourage hand washing or provide hand sanitizer after removing gloves from holding sites. The expectation is for staff to follow policies and procedures for hand hygiene to reduce opportunity for the spread of infection. During an interview on 06/25/25 at 12:03 PM, Staff C, Medical Director, confirmed that it is the expectation for staff to follow all infection control policies and practices to provide patient safety and protection.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 50529 Based on policy review, observation, and interview, the facility failed to ensure opened supplies were stored properly during 3 of 3 observation days. This deficient practice has the potential to negatively affect the health and well-being of any patient who receives treatment at this facility. Findings Include: Review of a policy titled, “General Cleanliness and Infection Control Guidelines,” dated 05/05/25, stated, “ ...Supplies or patient’s belongings should not be kept or stored behind the machine at the patient station ...” Review of a policy titled, “Cleaning and Disinfecting of the Dialysis Station,” dated 09/05/23, stated that in order to prevent cross contamination, the dialysis station must be cleaned and disinfected between dialysis patients. It also stated that the nature of dialysis treatments with frequent exposure to blood and body fluids, make dialysis a high-risk area for spreading infectious disease. The dialysis station and any area that could become contaminated with blood and other body fluids during treatment must be disinfected with a 1:100 bleach or EPA registered disinfectant. The dialysis station, equipment, and surface of the wall box and the area/wall around the wall box must be disinfected at the end of each treatment and/or immediately if splattered with blood. During observation on 06/24/25 at 10:07 AM, 3 opened boxes of gloves were being stored on the back counter between stations #2 & 3 and stations #6 & 7. Staff were using these gloves throughout the day and on both shifts. When the patient stations were cleaned, the area where the boxes of gloves were stored was avoided. During observation on 06/25/25 at 7:50 AM between stations #2 & 3 and #6 &7, there continued to be multiple boxes of clean gloves for use stored in this location. During an interview on 06/25/25 at 8:17 AM, Staff M, Certified Clinical Hemodialysis Technician (CCHT), stated that for easy accessibility gloves are stored in different locations on the treatment floor. Gloves have been stored on the back counter for quick access. During an interview on 06/25/25 at 11:23 AM, Staff B, Director of Operations, stated that the storage of clean supplies on the back wall is not appropriate since the back wall is considered part of the dialysis station. This practice could potentially cause the spread of germs and bacteria or cross contamination.”

“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: 50529 Based on policy review, observation, and interview, the facility failed to provide a safe environment free of obstacles that could present risks for trips and falls due to patient assistive devices being storage in a way to obstruct clear walkways on the treatment floor on 2 of 3 observation days. This deficient practice posed a risk for a trip or fall hazard that had the potential to negatively impact the health and well-being of the in-center patients that received treatments at the facility. Findings Include: Review of a policy titled, “General Cleanliness and Infection Control Guidelines,” dated 05/05/25 stated, “ ...Walkways must be kept clear of debris and free of clutter ...” During observation on 06/24/25 at 10:53 AM at station #12, a walker was stored in a manner that obstructed a walkway and prevented a clear and safes egress in case of emergency. The walker presented a possible trip/fall hazard for both staff and patients During observation on 06/25/25 at 8:36 AM at station #12, an electric wheelchair stored was stored in a manner that obstructed a walkway and prevented a clear and safes egress in case of emergency. The walker presented a possible trip/fall hazard for both staff and patients During an interview on 06/25/25 at 7:57 AM, Staff G, Registered Nurse, stated that storage of patient’s wheelchairs and walkers has been an issue. We are mindful of them when getting around them and lead patients on alternate routes to avoid them. During an interview on 06/25/25 at 11:23 AM, Staff B, Director of Operations, stated that adequate storage space for patient’s assistive devices has been a continued issue. Staff B stated, “At this time, this is our best option, but the issue has been identified and we will continue to work on a better solution moving forward.””

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 50529 Based on policy review, record review, and interview, the facility failed to ensure staff monitored patient vital signs and/or machine parameters at least every 30 minutes and notified appropriate medical personnel of findings outside of allowable parameters for 2 of 7 (Patient 1 and 7) sampled patients. This deficient practice provided and opportunity for changes in patient condition to go unrecognized and/or unaddressed that could negatively impact the health and well-being of any patient receiving treatment at this facility. Findings Include: Review of a policy titled, “Patient Assessment and Monitoring,” dated 05/01/23 stated that any changes or abnormal findings in a patient’s condition will be reported to the Registered Nurse (RN). Machine parameters and vital signs including blood pressure and pulse will be obtained and documented at a minimum of every 30 minutes. A RN is to assess any reported findings and will notify the patient’s physician of any abnormal findings. Patient 1 Patient 1’s treatment flowsheet, dated 06/18/25, failed to show documented evidence of patient monitoring of vital signs or machine parameters for 64 minutes, from 8:33 AM until 9:37 AM. Patient 7 Patient 7’s treatment flowsheet, dated 6/14/25, failed to show documented evidence of patient monitoring of vital signs or machine parameters for 65 minutes, from 10:04 AM until 11:32 AM. Patient 7’s treatment flowsheet, dated 06/17/25, revealed a diastolic blood pressure greater than 100 at 11:04 AM, 12:04 PM, 12:32 PM, and 1:02 PM without documented evidence of RN notification. Patient 7’s treatment flowsheet, dated 06/21/25, failed to show documented evidence of patient monitoring of vital signs or machine parameters for 61 minutes from 10:32 AM until 11:33 AM. During an interview on 06/25/25 at 7:57 AM, Staff G, Registered Nurse (RN), stated that vitals and treatment parameters are to be documented at least every 30 minutes unless ordered more frequently. It was stated that patients should be monitored continuously while on treatment by direct care staff. Technicians are supposed to report any changes or outliers in data collection information, patient condition, and any values that are outside allowable parameters. A nurse is to assess changes or issues and report to physician as needed. During an interview on 06/25/25 at 8:17 AM, Staff M, Certified Clinical Hemodialysis Technician (CCHT), confirmed that treatment monitoring and data entry is to be done every 30 minutes and any changes or abnormalities are to be charted and reported to the RN. During an interview on 06/25/25 at 11:23 AM, Staff B, Director of Operations, stated that it is the expectation of the staff to continuously monitoring all patients while on treatment, record vitals and machine settings at least every 30 minutes and no longer than 45 minutes. It is the responsibility of the RN to ensure that patients are running in accordance to prescribed orders and there should be documented explanation and possibly notification of the physician. It is the expectation that staff follow policies and procedures to reduce risk of impacting patient care.”

“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: 50529 Based on policy review, record review, and interview, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 3 of 5 (Patient 3, 4, & 7) sampled patients. This deficient practice has the potential to negatively impact the effectiveness of dialysis treatment and the health and well-being of any patient who receives treatment at this facility. Findings Include: Review of a policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, showed, “ ...Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is delivered ...Document any findings and interventions in the medical record ...” Patient 3 Patient 3’s treatment flowsheet dated 06/05/25, revealed a prescribed blood flow rate (BFR) of 450 mL/min. Patient 3’s BFR was documented as 300 mL/min for the entirety of the treatment without any documented rationale why the prescribed BFR was not achieved. Patient 3’s treatment flowsheet dated 06/10/25, revealed a prescribed BFR of 450 mL/min. Patient 3’s BFR was documented as 300 mL/min for 43 minutes from 10:19 AM until 11:02 AM without any documented rationale for change in BFR. Patient 4 Patient 4’s treatment flowsheet dated 06/17/25, revealed a prescribed Dialysate Flow Rate (DFR) of 600 mL/min. Patient 4’s DFR was documented as 800 mL/min for the entirety of the treatment without any documented rationale why the prescribed DFR was not achieved. Patient 4’s treatment flowsheet dated 06/21/25, revealed a prescribed BFR of 300 mL/min. Patient 4’s BFR was documented as 425 mL/min for the entirety of the treatment without any documented rationale why the prescribed BFR was not achieved. Patient 7 Patient 7’s treatment flowsheet dated, 06/12/25, revealed a prescribed BFR of 500 mL/min. Patient 7’s BFR was documented as 300 for 52 minutes from 9:41 AM until 10:33 AM without any documented rationale why the prescribed BFR was not achieved. Patient 7’s treatment flowsheet dated, 06/14/25, revealed a prescribed BFR of 500 mL/min. Patient 7’s BFR was documented as 300 for 170 minutes from 9:44 AM until 12:34 PM without any documented rationale why the prescribed BFR was not achieved. Patient 7’s treatment flowsheet dated, 06/17/25, revealed a prescribed BFR of 500 mL/min. Patient 7’s BFR was documented as 400 for the entirety of the treatment without any documented rationale why the prescribed BFR was not achieved. Patient 7’s treatment flowsheet dated, 06/21/25, revealed a prescribed BFR of 500 mL/min. Patient 7’s BFR was documented as 300 for 61 minutes from 10:32 AM until 11:33 AM and at 1:04 PM without any documented rationale why the prescribed BFR was not achieved. During an interview on 06/25/25 at 8:17 AM, Staff M, Certified Clinical Hemodialysis Technician (CCHT), confirmed that treatment prescription data is verified by 2 staff members and any changes or abnormalities during treatment are to be charted and reported to the RN. During an interview on 06/25/25 at 11:26 AM, Staff B, Director of Operations, stated the expectation of staff is to follow policy regarding data entry and following physician’s orders. Staff should document any changes made during patient treatments and a Registered Nurse should be notified by a PCT/CCHT or LPN of any changes or values outside of allowable parameters in addition to documented notification of the nurse.”