Fmc - Prestonsburg

“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: 50873 Based on observation, interview, and facility policy review, 2 (Registered Nurse [RN] #8 and Patient Care Technician [PCT] ##15) of 7 facility staff failed to perform hand hygiene as directed by the facility policy. Findings included: A facility policy titled “Hand Hygiene,” published 11/06/2023, indicated “Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water When * Before and after direct contact with patients * Entering and leaving the treatment area * Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medication * Immediately after removing gloves * After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressing if hands are not visibly soiled * After contact with inanimate objects near the patient * When moving from a contaminated body site to a clean body site of the dame patient” During an observation on 12/03/2024 at 10:22 AM, RN #8 left patient treatment station #9 after he performed dialysis access cannulation, without removal of their gloves, and gathered supplies from the clean supply cart located in front of patient treatment station #15. RN #8 then returned to patient treatment station #9 to continue to provide care for the patient who was about to begin dialysis there. During an observation on 12/03/2024 at 11:38 AM, RN #8 left patient treatment station #14 after reinfusing the extracorporeal circuit of the patient whose dialysis treatment was ending at that station, without removal of their gloves or hand hygiene. RN #8 went to the nurses’ station and gathered supplies then returned to patient treatment station #14. During an observation on 12/03/2024 at 12:16 PM, PCT #15 was noted not to perform hand hygiene or change their gloves after she removed a dirty central venous catheter (CVC) dressing and before she placed a clean dressing over the patient’s CVC exit site. During an observation on 12/03/2024 at 12:46 PM, RN #8 was noted not to perform hand hygiene before he administered a parenteral medication to the patient in patient treatment station #1. During an interview on 12/03/2024 at 12:51 PM, RN #8 confirmed that he did not change gloves and perform hand hygiene prior to entering patient treatment station #1 to administer medication and stated it was because she did not touch anything. RN #8 stated whether to perform hand hygiene or change gloves was dependent on whether or not anything was touched. During an interview on 12/04/2024 at 4:16 PM, PCT #15 stated she should change her gloves and perform hand hygiene when she went from one patient to another patient and when she left a patient treatment station. According to PCT #15, sometimes she might not change her gloves if she did not touch anything in the patient treatment station. During an interview on 12/04/2024 at 6:00 PM, the Clinical Manager (CM) confirmed gloves should be changed and hand hygiene performed after the removal of a soiled dressing during CVC dressing site care. The CM also confirmed hand hygiene should be performed when staff entered and left a patient treatment station. During an interview on 12/05/2024 at 8:52 AM, Medical Doctor #20, who covered for the Medical Director during the survey, confirmed facility staff were expected to perform hand hygiene when they entered and left a patient treatment station, and gloves should be changed and hand hygiene performed after removal of a dirty CVC dressing.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility document review, the facility failed to provide nutrition care and counseling for 1 (Patient #3) of 7 sampled patients. Findings included: An undated facility document titled, “Nutritional Management of the Home Dialysis Patient” indicated, “At the clinical quality level, we want to hold PD [peritoneal dialysis] clinics to the same standard of quality as hemodialysis clinics, meaning that we want to strive for the same level of reduced mortality risk. As we saw of the previous slide, PD patients can have a lower albumin level and still have the same mortality risk as hemodialysis patients do at an albumin level of 4.0. Therefore, we allow clinics to be considered meeting goal if patients are at 3.7 or greater.” Patient #3’s laboratory flowsheet showed the patient had an albumin value of 3.9 grams per deciliter (g/dL) on 09/05/2024 and 3.8 g/dL on 10/01/2024, 11/04/2024, and 12/02/2024. Patient #3’s “Nutrition Progress Note,” dated 10/31/2024, indicated the patient’s albumin was below goal. There was no documentation to indicate how the facility addressed Patient #3’s below goal albumin level. Patient #3’s “Nutrition Progress Note,” dated 11/25/2024, indicated the patient’s albumin was below goal. There was no documentation to indicate how the facility addressed Patient #3’s below goal albumin level. During an interview on 12/04/2024 at 11:18 AM, Registered Nurse (RN) #12 confirmed that there was no evidence in Patient #3’s medical record of interventions to address the patient’s consistent albumin levels that were below the outcome goal of 4.0 g/dL. Per RN #12, the dietician would address the patient’s t albumin levels that did not meet the goal. During an interview on 12/04/2024 at 3:32 PM, the Registered Dietitian (RD) indicated that the albumin goal for a patient who received peritoneal dialysis was 3.7 g/dL. Per the RD, interventions would not be implemented for patients with an albumin level above 3.7 g/dL. According to the RD, the facility used 3.7 g/dL as the albumin goal for peritoneal dialysis patients. During an interview on 12/05/2024 at 8:52 AM, Medical Doctor (MD) #20, who covered for the Medical Director during the survey, confirmed that for any patient that did not meet their goal, the facility expectation would be for staff to implement interventions to address the goal not being met. MD #20 clarified that for patients who did not meet their albumin goal, interventions would include supplementation and dietary counseling/education. MD #20 confirmed that the albumin goal was 4.0 g/dL for all patients but stated the facility peritoneal dialysis albumin goal for a patient was 3.7 g/dL.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to monitor the patient’s access per policy during 1 of 2 observations of dialysis access cannulation. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “Access Record access findings, Evaluate the patient’s access per policy: * ASK: complaints of pain, numbness, tingling, coldness and tenderness, fever * Look * Listen * Feel.” A facility policy titled, “Access Assessment and Cannulation,” published 05/06/2024, revealed “*NOTE: Staff/patients/care partners who have been trained to auscultate vascular accesses should listen to the entire length of the access for changes in the sound of the bruit - a normal low-pitched bruit should be present.” During an observation of patient treatment station #9 on 12/03/2024, the surveyor noted Registered Nurse (RN) #8 did not auscultate or palpate the patient’s access site prior to cannulation. During an interview on 12/03/2024 at 12:51 PM, RN #8 stated staff should auscultate every time. RN #8 stated he knew the patients so most of the time, he did not feel the access and was good with that. RN #8 confirmed that he did not auscultate the access during the observed cannulation that took place in patient treatment station #9. During an interview on 12/04/2024 at 6:00 PM, the Clinical Manager confirmed the clinic expectation was that auscultation be performed as part of the dialysis access assessment prior to each cannulation. During an interview on 12/05/2024 at 8:52 AM, Medical Doctor #20, who covered for the Medical Director during the survey, confirmed that auscultation was a routine part of access evaluation and should be done prior to each treatment.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to wash the access area with soap and water per the policy during 1 of 2 observations of dialysis access cannulation. Findings included: A facility policy titled, “Access Assessment and Cannulation,” published 05/06/2024, revealed “Step 1 Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the 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 an observation of patient treatment station #9 on 12/03/2024 at 10:16 AM, the surveyor noted Registered Nurse (RN) #8 did not wash the patient’s access site prior to cannulation. During an interview on 12/03/2024 at 12:51 PM, RN #8 stated staff should wash the patient’s access site with a wipe. RN #8 confirmed that he did not clean the patient’s access site with a wipe prior to cannulation. During an interview on 12/04/2024 at 6:00 PM, the Clinical Manager confirmed the clinic expectation was the patient’s access sites were washed prior to each cannulation. During an interview on 12/05/2024 at 8:52 AM, Medical Doctor #20, who covered for the Medical Director during the survey, confirmed that washing the patient’s access should be done prior to cannulation.”