Fkc - Lenexa

“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 observation, policy review, and interview, the facility failed to ensure patients washed their hands or performed hand hygiene after holding their dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) access site (a surgically created entry point into the bloodstream) after treatment. This deficient practice provided a mode of contamination with the potential spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 56 patients that received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Hand Hygiene,” dated 11/06/23, showed, “...Patients should perform hand hygiene if able, prior to and after each dialysis treatment ...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family member or other patients, hand hygiene must be performed...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids ...To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.” An observation of the treatment floor on 04/08/25 at 11:25 AM, showed staff failed to offer hand sanitizer or remind a patient to wash their hands after holding access sites (site where needles were removed) after treatment. During an interview on 04/08/25 at 3:38 PM, Staff A, Clinical Manager (CM), stated that hand hygiene for patients after holding sites is an expectation, as well as staff following facility policy and procedure. Failure to follow policy could increase the risk of the possible spread of infectious pathogens. An observation of the treatment floor on 04/09/25 at 9:15 AM, showed Staff K, Patient Care Technician (PCT), assist the patient at station #4 with the removal of his “dirty” glove but failed to offer hand sanitizer or remind patient to wash hands before leaving the treatment floor. During an interview on 04/09/25 at 9:22 AM, Staff K, PCT, stated that he/she knew that offering hand sanitizer or reminding patients to wash hands after holding access sites and before leaving the treatment floor was in the facility policy but had forgotten. Staff K stated that failure to ensure hand hygiene of some form is performed puts patients, staff, and visitors at risk for cross contamination.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to contain biohazardous medical waste (blood or other bodily fluids) prior to transporting waste across the dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatment floor to nearest biohazardous waste bin. Failure to contain medical waste prior to transport has the potential to spread pathogens (organisms that may cause disease or infection), which could negatively impact the health and well-being of the 56 patients who receive treatments at the facility. Findings Include: Review of a policy titled, “General Cleanliness and Infection Control Guidelines,” dated 11/04/24, showed that blood or other potentially infectious materials are to be placed in a container that prevents leakage during collection, handling, and transport. Observation of the treatment floor on 04/09/25 between 9:29 AM and 10:11 AM showed staff carrying used dialyzers and bloodlines containing blood/blood products from the dialysis stations across the treatment floor to one of two centralized biohazardous containers without being contained in a manner to prevent spills/leaks. During an interview on 04/08/25 at 3:38 PM, Staff A, Clinical Manager, stated that staff carrying non-contained biohazardous waste across the treatment floor is against facility policy. Staff A confirmed this practice increases infection risk and endangers staff and patients.”

“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 monitor patient vital signs and/or machine parameters according to facility policy for 4 (Patient 1, 2, 3, and 6) of 4 sampled in-center patients. This deficient practice provided an opportunity for changes in vital signs to go unrecognized and unaddressed which could negatively impact the health and well-being of the 56 in-center patients who receive treatments at the facility. Findings Include: Review of a policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, showed, “ ...Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations...” Patient 1 Patient 1’s treatment sheet, dated 04/02/25, showed blood pressure and pulse were not documented for 76 minutes, from 2:40 PM until 3:36 PM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 1’s treatment sheet, dated 03/24/25, showed blood pressure and pulse were not documented for 52 minutes, from 3:14 PM until 4:06 PM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 1’s treatment sheet, dated 03/24/25, showed monitoring of machine parameters were not documented for 48 minutes, from 6:06 PM until 6:54 PM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 2 Patient 2’s treatment sheet, dated 04/02/25, showed blood pressure and pulse were not documented for 61 minutes, from 4:32 PM until 5:33 PM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 2’s treatment sheet, dated 04/02/25, showed blood pressure and pulse were not documented for 57 minutes, from 4:38 PM until 5:35 PM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 3 Patient 3’s treatment sheet, dated 03/27/25, showed blood pressure and pulse were not documented 59 minutes, from 8:32 AM until 9:31 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 3’s treatment sheet, dated 04/03/25, showed blood pressure and pulse were not documented for 51 minutes, from 6:11 AM until 7:02 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 3’s treatment sheet, dated 04/03/25, showed monitoring of machine parameters were not documented for 49 minutes, from 8:33 AM until 9:22 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 6 Patient 6’s treatment sheet, dated 03/29/25, showed blood pressure and pulse were not documented for 107 minutes, from 9:31 AM until 11:18 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 6’s treatment sheet, dated 04/05/25, showed blood pressure and pulse were not documented for 48 minutes, from 8:30 AM until 9:18 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 6’s treatment sheet, dated 04/05/25, showed blood pressure and pulse were not documented for 52 minutes, from 9:18 AM until 10:09 AM. Documentation failed to show rationale why patient monitoring data was not completed. Patient 6’s treatment sheet, dated 04/05/25, showed blood pressure and pulse were not documented for 42 minutes, from 10:36 AM until 11:18 AM. Documentation failed to show rationale why patient monitoring data was not completed. During an interview on 04/08/25 at 11:05 AM, Staff E, Registered Nurse (RN), stated that staff are expected to chart on and monitor patients every 30 minutes. Staff E could not speak to the risks, only that he/she knew it was the policy. During an interview on 04/08/25 at 3:38 PM, Staff A, Clinical Manager, (CM), stated that the expectation is for staff to monitor patients the entire time they’re on treatment, but treatment data is to be entered every 30 minutes.”

“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 and record review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 4 (Patient 1, 2, 3, and 6) of 4 sampled in-center patients. Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 56 in-center patients who received dialysis treatments at the 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 the prescribed blood flow. Check the dialysate flow rate setting is correct, and the prescribed flow rate is being delivered ...” Review of a policy titled, “Physician Order Documentation,” dated 07/03/23, showed “ ...It is the nurses’ responsibility to ensure that all treatments, medications, labs or any care provided to the patient have an accurately documented physician order ...Nurse practice acts requires nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders ...” Patient 1 Patient 1’s treatment sheet, dated 03/24/25, showed a prescribed dialysate flow rate (DFR) of 700 milliliters per minute (mL/min) and prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). The DFR was documented as 800 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed DFR was not attained. Patient 1’s treatment sheet, dated 03/26/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The DFR was documented as 800 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed DFR was not attained. Patient 1’s treatment sheet, dated 03/28/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 300 mL/min at 2:56 PM. Documentation failed to show rationale why the prescribed DFR and BFR was not attained. Patient 1’s treatment sheet, dated 03/31/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 300 mL/min and 350 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed DFR was not attained. Patient 1’s treatment sheet, dated 04/04/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 250 mL/min and 350 mL/min from 4:16 PM until 4:31 PM. Documentation failed to show rationale why the prescribed DFR was not attained. Patient 2 Patient 2’s treatment sheet, dated 03/31/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 350 mL/min at 4:36 PM and was documented as 325 mL/min at 5:31 PM & 6:01 PM. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 2’s treatment sheet, dated 04/04/25, showed a prescribed DFR of 700 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 300 mL/min from 5:35 PM until 6:31 PM. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 3 Patient 3’s treatment sheet, dated 03/29/25, showed a prescribed DFR of 800 mL/min and prescribed BFR of 500 mL/min. The BFR was documented as 300 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 3’s treatment sheet, dated 04/01/25, showed a prescribed DFR of 800 mL/min and prescribed BFR of 500 mL/min. The BFR was documented as 400 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 3’s treatment sheet, dated 04/03/25, showed a prescribed DFR of 800 mL/min and prescribed BFR of 500 mL/min. The BFR was documented as 300 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 6 Patient 6’s treatment sheet, dated 03/27/25, showed a prescribed DFR of Auto that based on treatment pressures and fluid removal that fluctuates from 600 mL/min to 800 mL/min and prescribed BFR of 400 mL/min. The BFR was documented as 450 mL/min at 8:01 AM and 415 mL/min for 119 minutes from 9:05 AM until 11:04 AM. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 6’s treatment sheet, dated 04/01/25, showed a prescribed DFR of 800 mL/min and prescribed BFR of 500 mL/min. The BFR was documented as 350 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed BFR was not attained. Patient 6’s treatment sheet, dated 04/05/25, showed a prescribed DFR of 800 mL/min and prescribed BFR of 500 mL/min. The BFR was documented as 350 mL/min during the entire treatment. Documentation failed to show rationale why the prescribed BFR was not attained.”