Fmc - Pittsburg Midwest

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure that an area designated for clean supplies was clearly separated from the dirty area where there is a potential for contamination with blood or body fluids and areas where contaminated or used supplies are stored for two of three survey days. The failure to separate clean areas from dirty area had the potential for contamination of clean supplies and could affect 37 in-center patients. Findings Include: Review of the facility policy’s titled, “Dialysis Precautions,” revised 01/04/12, indicated, “Clean areas should be clearly separated from dirty areas where used supplies, equipment or blood samples are handled or stored.” Observation on 03/18/24 at 11:40 AM revealed the red biohazard container used to dispose of used dialyzers and hemodialysis lines, was sitting across from Station 6 and across from the patient waiting area entrance right next to a desk area where multiple clean supplies including dialyzers, dialysis lines and initiation packs for the next patient were stored. Patent Care Technician (PCT) 6 was observed stripping the machine of soiled supplies from Station 4 and carrying it to the biohazard container across from Station 6. The red biohazard container remained next to the clean supplies throughout the rest of the observations of 03/18/24 at 2:30 PM. Observation on 03/19/24 from 8:10 AM until 9:55 AM revealed the red biohazard container was stored next to the clean desk area that supplies for the next patient across from Station 6 and the entrance to the patient treatment area. During an interview on 03/19/24 at 9:55 AM, the Clinical Manager and Director of Operations observed and confirmed the red biohazard container was stored next to clean supplies, however they should not be stored next to the clean supply area as there was a risk of contamination from the soiled dialyzer and hemodialysis lines being disposed of in the red biohazard container.”

“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: 28297 Based on observation, interview and policy review, the facility failed to ensure the patients’ mask was covering his/her nose during the discontinuation of dialysis via a Central Venous Catheter (CVC) (A hemodialysis central venous catheter is a type of access used for hemodialysis. CVCs are placed under the skin and into a large central vein, preferably the internal jugular veins. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established.) for 1 of 2 observations. The failure to ensure the mask was covering the nose as required had the potential for contamination of the CVC and increase the risk of infections and could affect 11 of 37 in- patients that have CVCs in the facility. Findings Include: Review of the facility policy “Termination of Treatment Using a Central Venous Catheter and Optiflux Ebeam Single Use Dialyzer,” revised 02/07/22, indicated, “Don gown and full-face shield with mask ...” Observation on 03/18/24 at 2:30 PM Patient Care Technician (PCT) 5 was at Station 13 discontinuing the treatment for Patient (P) 1 via a CVC. PCT5 completed CVC discontinuation, however the PCT’s mask remained below his/her nose during the entire discontinuation process. During an interview on 03/18/24 at 2:45 PM PCT 5 confirmed his/her mask was not covering the nose as required to prevent contamination but should have been to prevent cross contamination. During an interview on 03/20/24 at 12:45 PM the Clinical Manager confirmed it was part of the facility policy for staff to wear a mask covering the mouth and nose during CVC discontinuation of dialysis via a CVC to prevent contamination of the CVC.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 28297 Based on interview, record review, and policy review, the facility failed to ensure 1 of 5 sampled patients (Patient (P) 1) had an initial “Mantoux Tuberculin Skin Test (TST)” as required. The failure to have an initial TST had the potential for the patient to not be identified as a TST reactor so that Tuberculosis (TB) could be assessed as early as possible. This had the potential to affect 37 in-center patients. Findings Include: Review of the facility policy titled, “Patient Tuberculosis Testing,” revised 02/05/24 indicated, “Patients who have no documented TB test within the last year will be tested using the TST. A Physician order is required. Patients who report previous positive TST and or “Interferon-Gamma Release Assays (IGRA),(TB blood test),” or previous diagnosis of TB or latent tuberculosis infection (LTBI) require a chest x-ray to rule out TB disease. Repeat TST or IGRA tests are not necessary. A recent chest X-ray within 6 months can be used as evidence to rule out TB disease. Chest X-ray must specify no evidence of TB. Document the patients’ history of positive TST and chest x-ray results in the electronic medical record ...” Review of the medical record for P1 revealed the facility admitted the patient on 01/16/24 with diagnosis of end stage renal disease (ESRD). Review of the Registered Nurse (RN) Comprehensive Assessment completed on 03/07/24, under the section vaccinations TB skin test, revealed the RN documented “. . .pt [patient] has CXR [Chest x-ray].” During an interview on 03/20/24 at 12:45 PM, the Clinical Manager confirmed he/she was the one who did the RN Comprehensive Assessment on 03/07/24 and thought that a chest x-ray was sufficient.”

“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: 28297 Based on record review, interview, and policy review, the facility failed to ensure 2 of 5 patients (Patient (P) 3 and P5) were set for more than the recommended amount of fluid removal of 13 milliliters/kilogram/hour (ml/kg/hr) for 4 of 6 treatment flowsheet’s reviewed. There was no documentation that the patients were offered extra treatments or to increase the patient dialysis prescription time to reduce the amount of fluid that was removed per hour. Setting the patient for more than the recommended fluid removal had the potential for cardiovascular stress and increased risk of mortality and could affect 37 in-center patients. Findings Include: Review of the facility policy titled, “Volume Management of ESRD Patients on Hemodialysis,” revised 09/07/21 indicated, “ ...Considerations for reducing cardiovascular risk during hemodialysis: Evaluate underlying comorbid conditions contributing to cardiovascular risk. Consider interventions such as longer treatments to decrease ultrafiltration rate (UFR) ... Ultrafiltration Rate (UFR): Rate fluid is removed per hour. Ultrafiltration rates > l 3 ml/kg/hr are associated with higher HD patient mortality ... Intradialytic Hypotension (IDH)): Risk of IDH occurs when the UFR exceeds the rate of fluid moving from the extravascular space back into the circulatory space. IDH has been associated with adverse cardiovascular stress and health outcomes such as myocardial stunning, increased rate of hospitalization for heart failure and volume overload, more rapid loss of residual renal function, and increased mortality. The duration of the dialysis session is a significant factor to consider in management of intradialytic hypotension. Longer session length allows the necessary total ultrafiltrate volume to be removed at a slower rate (lower UFR). Also, patient and family education around the need to avoid excessive IDWG can be very helpful in volume management ...” Patient 3 Review of the medical record for P3 revealed the facility admitted the patient on 12/19/19 with diagnosis including end stage renal disease (ESRD). Review of the dialysis flow sheets from 03/06-03/18/24 provided by the facility revealed the following: 1. 03/06/24- P3’s dry weight was 74.5 kilograms (kg). The patients’ pre-weight was 77.8 kg. The treatment time was 2 hours and 45 minutes. The max fluid volume to remove based on the 13 ml/kg/hr was 968 ml per hour with a total amount recommended was 2663 ml for a run of 2 hours and 45 minutes. The total fluid volume removed was 3595 ml with an hourly rate of 1440 ml per hour. P3 blood pressure dropped to 100/50 and the facility administered 200 ml of saline for low blood pressure. The patients post weight was 75.2 kg, .7 kg over the dry weight. There was no documentation of offering an extra treatment or extending the treatment time. 2. 03/09/24- P3’s dry weight was 74.5 kg. The patients’ pre-weight was 80.3 kg. The treatment time was 2 hours and 45 minutes. The max fluid volume to remove based on the pre-weight was 1043 ml per hour with a total amount recommended was 2870 ml for a run of 2 hours and 45 minutes. The total volume removed was 3983 ml with an hourly rate of 1450 ml/hr. P3 post weight was 76.8 kg, 2.3 kg over the dry weight. There was no documentation that the patient was offered an extra treatment or to extend the treatment time. 3. 03/15/24-P3’s dry weight was 74.5 kg. The patients’ pre-weight was 77.8 kg. The treatment time was 2 hours and 45 minutes. The max fluid volume to remove based on the pre-weight was 1001 ml per hour with a total amount recommended was 2781 ml for a 2 hour and 45-minute run. The total volume removed was 3800 ml with an hourly rate of 1430 ml/hr. P3 post weight was 74.6 kg. There was no documentation of extending the treatment to decrease the fluid removal amount per hour. 4. 03/18/24-P3’s dry weight was 74.5 kg. The patients’ pre-weight was 79.9 kg, 5.4 kg over the dry weight. The treatment time was 2 hours and 45 minutes. The max fluid volume to be removed based on the pre-weight was 1038 ml with a total recommended was 2858 ml for 2 hours and 45-minute run. The total fluid volume removed was 4475 ml with an hourly rate of 1640 ml/hr. P3 post weight was 75.8 kg, 1.3 kg over the dry weight. The patient’s blood pressure dropped to 103/57 at the end of the treatment. There was no documentation that the patient was offered an extra treatment or to extend the treatment to decrease the fluid removal rate per hour. Review of the “Physician Provider Note,” dated 03/15/24, revealed the physician documented “. . .fluid status not acceptable,” however there is nothing documented regarding recommendations or interventions for high fluid removal rates. During an interview with the Physician (interim Medical Director) on 03/20/24 at 12:35 revealed he/she was the Physician for P3. The Physician stated if the patient has good adequacy they will cut their treatment time however if their fluid gains are too high they will not cut the patient’s time. He/she stated they do encourage longer treatment times and acknowledged they should have better documentation of interventions on high fluid removal rates. Patient 5 Review of the medical record for P5 revealed the facility admitted the patient on 05/10/23 with diagnosis including ESRD. Review of the dialysis flow sheets from 03/05/24-03/16/24 provided by the facility revealed the following: 1. 03/05/24- P5’s dry weight was 72.0 kg. The patients’ pre-weight was 77.4 kg. The treatment time was 3 hours and 15 minutes. The max fluid volume to remove based on the 13 ml/kg/hr was 1006 ml per hour with a total amount recommended was 3270 ml for a run of 3 hours and 15 minutes. The total fluid volume removed was 4878 ml with an hourly rate of 1660 ml per hour. The patients post weight was 72.4 kg. There was no documentation of offering an extra treatment or extending the treatment time due to excess fluid removal rate. 2. 03/07/24- P5’s dry weight was 72.0 kg. The patients’ pre-weight was 76.5 kg. The treatment time was 3 hours and 15 minutes. The max fluid volume to remove based on the 13 ml/kg/hr was 994 ml per hour with a total amount recommended was 3232 ml for a run of 3 hours and 15 minutes. The total fluid volume removed was 4133 ml with an hourly rate of 1390 ml per hour. The patients post weight was 71.9 kg. There was no documentation of offering an extra treatment or extending the treatment time due to excess fluid removal rate. 3.03/09/24- P5’s dry weight was 72.0 kg. The patients’ pre-weight was 75.4 kg. The treatment time was 3 hours and 15 minutes. The max fluid volume to remove based on the 13 ml/kg/hr was 980 ml per hour with a total amount recommended was 3185 ml for a run of 3 hours and 15 minutes. The total fluid volume removed was 3674 ml with an hourly rate of 1200 ml per hour. The patients post weight was 71.9 kg. There was no documentation of offering an extra treatment or extending the treatment time due to excess fluid removal rate. 4. 03/16/24- P5’s dry weight was 72.0 kg. The patients’ pre-weight was 76.2 kg. The treatment time was 3 hours and 15 minutes. The max fluid volume to remove based on the 13 ml/kg/hr was 990 ml per hour with a total amount recommended was 3219 ml for a run of 3 hours and 15 minutes. The total fluid volume removed was 4404 ml with an hourly rate of 1450 ml per hour. The patients post weight was 71.8 kg. There was no documentation of offering an extra treatment or extending the treatment time due to excess fluid removal rate. Review of the “Physician Provider Note,” dated 03/07/24. For P5 revealed the physician documented “. . .still having high intradialytic weight gain (IDWG), emphasized salt and fluid restriction in diet ...” however there is nothing documented regarding recommendations or interventions for high fluid removal rates or high IDGW. During an interview on 03/20/24 at 11:00 AM the Dietician stated the patients who have excess fluid gains over 13/ml/kg/hr are tracked using the fluid dashboard in the Quality Assessment and Performance Improvement Program. The Dietitian stated that the Clinical Manager oversaw patient treatment times and that he/she referred to the nurses on patients who have excess fluid gains, however patients are usually set for fluid removal to the dry weight. During an interview on 03/20/24 at 12:15 PM, Registered Nurse (RN) 1, patients were usually set for fluid removal based on the dry weight. RN1 stated that it does show up on the pre-dialysis screen if the fluid removal is greater than 13 ml/kg/hr and if patients are over that amount on a regular basis, extra treatment will be offered. RN1 acknowledged there should be better documentation when patients are over the recommended 13 ml/kg/hr fluid removal. During an interview on 03/20/24 at 12:45 PM, the Clinical Manager acknowledged there should be better documentation and offers to extend treatments or offer extra treatments when patients were over the recommended 13 ml/kg/hr fluid removal to decrease stress on the heart.”