Dci - Frankfort

“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, facility document review, and facility policy review, the facility failed to ensure 5 (Physician Assistant [PA] 3, Patient Care Technician [PCT] 11, PCT13, Registered Nurse [RN] 6, and RN8) of 8 staff observed wore gloves and/or performed hand hygiene per the facility’s policy and “Infection Control Plan.” The findings include: Review of the facility’s policy titled, “Hand Hygiene and Use of Alcohol-Based Hand Sanitizers,” issued 01/16/2019, indicated, “Purpose: To provide guidance for hand hygiene using hand sanitizers and hand washing to reduce the spread of germs to patients.” The policy specified, “Hand hygiene should be performed: - Before eating; - Before and after having direct contact with a patient’s intact skin (taking a pulse or blood pressure, performing physical examinations); - After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; - After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; - If hands will be moving from a contaminated-body site to a clean-body site during patient care; - After glove removal; and - After using the restroom.” The policy revealed, “1. Staff must remove gloves and wash hands between each patient and station.” Review of the facility’s “Infection Control Plan,” revised 09/09/2022, revealed section “B. Aseptic Technique,” that specified, “2. Because exposure to blood and potentially contaminated items can be routinely anticipated during dialysis, gloves must be worn whenever touching a patient or touching the patient’s equipment or machine [sic] this is to include any part of the dialysis machine (including the computer screen/keyboard), extracorporeal circuit and all treatment records i.e. [id est, that is] flowsheets).” Observation on 06/03/2025 at 10:40 AM, revealed PCT11 initiated dialysis for a patient with a central venous catheter in Station 3. While setting up the machine, PCT11 attached the fluid hose connectors to the dialyzer, touched the dialysis machine, and changed her gloves. PCT 11 did not perform hand hygiene between changing her gloves, and she continued to administer the patient’s treatment. Observation on 06/03/2025 at 11:05 AM, revealed RN6 changed her gloves upon entering Station 2 but did not perform hand hygiene between changing gloves. Observation on 06/03/2025 at 11:11 AM, revealed PCT13 initiated treatment for a patient with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) in Station 9. PCT13 donned (put on) a single glove, touched the dialysis machine, then removed the glove and applied gloves on both hands. She did not perform hand hygiene after removing the first glove and prior to putting on the clean pair of gloves. PCT13 then retrieved a bolster from Station 8, cleaned it, removed her gloves, returned to Station 9, put the bolster in place, and donned a pair of clean gloves. PCT13 did not perform hand hygiene when she removed her gloves after cleaning the bolster, nor prior to donning clean gloves upon return to Station 9. After cannulating (inserting a needle) the patient’s access site, PCT13 initiated the dialysis treatment, then removed one glove, and touched the dialysis machine with her gloved hand. PCT13 performed hand hygiene, donned a single glove to touch the machine, then removed the glove and went to a clean area to get a syringe. She did not perform hand hygiene after removing her glove, before leaving the treatment station, or prior to accessing patient supplies in a clean area. PCT13 donned clean gloves, removed the gloves, adjusted the patient’s blood pressure cuff, then donned a single glove without performing hand hygiene, and touched the machine to re-check the patient’s blood pressure. PCT13 then left Station 9 and did not perform hand hygiene or don gloves on return to the station, prior to adjusting the patient’s television. Observation on 06/03/2025 at 11:40 AM, revealed RN8 checked the patient’s feet in a home therapies patient room. RN8 donned gloves without first performing hand hygiene, and once the patient’s foot check was completed, she changed gloves without performing hand hygiene. Observation on 06/04/2025 at 10:01 AM, revealed PA3 entered Station 7, performed hand hygiene but did not don gloves, assessed the patient’s lower extremities, and auscultated the patient’s chest with a stethoscope he wore into the treatment station around his neck. PA3 returned the stethoscope to hang around his neck and then proceeded to touch the patient’s dialysis machine with bare hands. Observation on 06/04/2025 at 10:05 AM, revealed PA3 left Station 7 without performing hand hygiene and entered Station 8. PA3 did not perform hand hygiene or don gloves when entering Station 8 and proceeded to touch the patient’s dialysis machine. Observation on 06/04/2025 at 10:07 AM, revealed PA3 left Station 8 without performing hand hygiene and entered Station 1. He did not perform hand hygiene or don gloves in Station 1 before he touched the patient’s legs. PA3 then touched the dialysis machine, removed the stethoscope from around his neck, auscultated the patient’s chest, and hung it back around his neck when finished. PA3 left the treatment station and went to the nurses’ station without performing hand hygiene. PA3 did not don personal protective equipment (PPE) including gloves, face mask, shield, goggles, or gown at any time during the observations. During an interview on 06/04/2025 at 10:15 AM, PA3 stated he was trained to perform hand hygiene and wear PPE such as gloves, face shields, masks, and goggles when caring for patients. During a telephone interview on 06/06/2025 at 9:04 AM, RN8 stated it was her normal practice to perform hand hygiene between glove changes, but she might have forgotten to do that due to being nervous. During a telephone interview on 06/06/2025 at 12:27 PM, PCT11 stated the facility’s training on infection prevention included the use of PPE and hand hygiene. PCT11 stated hand hygiene should be done between touching the dialysis machines, patients, or computers, and staff should wash their hands after a blood spill. During an interview on 06/06/2025 at 1:06 PM, RN6 stated the facility’s infection control training included wearing PPE such as gloves, caring for Hepatitis B positive patients, and performing hand hygiene. RN6 stated hand hygiene should occur when coming and going from the clinic floor, before and after patient contact, when going from the machine to the patient, when going between stations, and between glove changes. RN6 stated she normally performed hand hygiene and did not realize she had not done so at the time she was observed. During a telephone interview on 06/06/2025 at 4:16 PM, the Medical Director stated the facility’s expectation was for hand hygiene to be performed per the facility policy. The Medical Director stated the facility expected nurses to bring it to the attention of the provider if a provider failed to perform hand hygiene and wear PPE or if they used a personal stethoscope. The Medical Director stated he was unaware of any infection control training done by the facility for providers. He stated providers often rushed between facilities to see all their patients and would sometimes forget to use PPE or not to use their own stethoscopes.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility document review, the facility failed to ensure 2 of 6 staff observed performing in-center hemodialysis care disinfected reusable items when removing them from the dialysis treatment area and prior to taking them into another dialysis treatment area or to a common clean area, Physician Assistant [PA] 3 and Patient Care Technician [PCT] 11. The findings include: Review of the facility’s “Infection Control Plan,” revised 09/09/2022, revealed section “D. Other Measures,” that specified, “3. ABSOLUTELY NO supplies intended for patient use will be kept in PPE [personal protective equipment] gown or scrub pockets. There is a risk of sharing supplies that could introduce cross-contamination.” The plan indicated, “6. Any inanimate object taken to a patient station example being (phoenix meter [a handheld device used to measure dialysate properties], thermometer, and telephone) with the patient present will need to be wiped with a 1:100 bleach cloth before being taken to another patient’s station or clean area.” Observation on 06/04/2025 at 10:01 AM, revealed PA3 entered Station 7 with a stethoscope hanging around his neck. PA3 auscultated a patient’s chest with the stethoscope and returned it to his neck when he was finished. Observation on 06/04/2025 at 10:03 AM, revealed PCT11 wrote on a clipboard in Station 8. PCT11 clipped the pen she used to her gown without disinfecting it and exited the treatment station. Observation on 06/04/2025 at 10:05 AM, revealed PA3 left Station 7 and went to Station 8. PA3 did not disinfect his stethoscope prior to leaving Station 7 or upon entering Station 8. Observation on 06/04/2025 at 10:07 AM, revealed PA3 left Station 8 and went to Station 1. PA3 did not disinfect his stethoscope prior to leaving Station 8 or upon entering Station 1. He removed the stethoscope from his neck and used it to auscultate a patient’s chest, then placed it back around his neck when finished. PA3 then left the treatment station and went to the nurses’ station without disinfecting the stethoscope which remained around his neck. During an interview on 06/04/2025 at 10:15 AM, PA3 stated he was trained to disinfect his stethoscope between patients but did not usually do that. During a telephone interview on 06/06/2025 at 12:27 PM, PCT11 stated any items used in treatment stations should be disposed of or disinfected. PCT11 stated staff was allowed to have their own pen in their pocket, but it would still need to be disinfected when they left the treatment station. PCT11 acknowledged she had not disinfected her pen when she went from one treatment station to another. During an interview on 06/06/2025 at 1:06 PM, Registered Nurse (RN) 6 stated items taken into the treatment stations should be disinfected when they were removed, but that was not always the practice at the clinic. RN6 also stated staff was not supposed to use their own pens. During a telephone interview on 06/06/2025 at 4:16 PM, the Medical Director stated the facility’s expectation was that items used in treatment stations would be disposed of or disinfected before being taken into another treatment station. The Medical Director stated the facility expected nurses to bring it to the attention of the provider if a provider used their personal stethoscope. The Medical Director stated he was unaware of any infection control training done by the facility for providers. He stated providers often rushed between facilities to see all their patients and would sometimes forget not to use their own stethoscopes.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to adequately maintain the building in which dialysis services were furnished to ensure the safety of the patients, staff, and the public. The findings include: Review of the facility’s policy titled, “Facility Maintenance of the Physical Environment,” issued 12/20/2019, indicated, “It is the policy of the facility to provide clean, well maintained, and professional practice facilities and equipment.” Observation of Mechanical Room 2 with the Biomedical Technician and the Nurse Manager on 06/02/2025 at 11:48 AM, revealed a rust-colored drain was noted on the floor between two Heating, Ventilation, and Air Conditioning (HVAC) units. White polyvinyl chloride (PVC) pipes extended from both units and to the area above the drain. The Biomedical Technician identified a pile of papers on the floor as blueprints of the facility. There was a black substance on the papers, and they had a warped appearance. During a concurrent interview, the Nurse Manager and the Biomedical Technician stated the black substance on the blueprints looked like mold, and the papers appeared to have been damaged by water. The Biomedical Technician stated he was not certain, but thought the blueprints had been on the floor in that condition for approximately two years. Observation with the Biomedical Technician and the Nurse Manager on 06/02/2025 at 12:09 PM, revealed a puddle of water was noted under the reverse osmosis (RO) machine, and there was no identifiable source of a leak. Water noted on the floor underneath the post-carbon 1 sample port ran toward the drain, and water dripped from the hardness sample port into a white bucket. During a concurrent interview, the Biomedical Technician stated the bucket held about five gallons and was full, and his best guess was that the bucket had been there for about three years. He stated that when the bucket was full or overflowing, he emptied it, and the last time he did that might have been about one year ago. The Biomedical Technician stated he was unsure if other staff members had been emptying the bucket. The Nurse Manager confirmed that a work order needed to be placed regarding the leak. Observation with the Biomedical Regional Manager (BRM) on 06/02/2025 at 2:37 PM, revealed he verified there was leakage from Distribution Pump B, Post Ultrafilter Valve #V28, and the Clean-in-Place (CIP) tank used by technical staff during disinfecting procedures. The BRM stated he expected the Biomedical Technician to notify him of any leaks, and they also depended on clinical staff to place work orders. Observation with the Biomedical Technician on 06/06/2025 at 8:40 AM, revealed Distribution Pump B continued to leak. During a concurrent interview, the Biomedical Technician stated he planned to address the leak when he did the heat disinfection of the system. He acknowledged there was no reason to wait to complete the repair as it did not require special parts or tools and could be done after patient treatments were completed for the day. During a telephone interview on 06/06/2025 at 4:16 PM, the Medical Director stated that the expectation was that the building would be well maintained for the safety of the patients and staff. The Medical Director stated he was aware there was a leak in the past, but to his understanding, it had been fixed.”

“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: 50873 Based on interview, record review, facility document review, and facility policy review, the facility failed to report patients’ out-of-range blood pressures according to facility policy for 5 of 8 sampled patients, Patient (P) 1, P2, P4, P6, and P7. The findings include: Review of the facility’s policy titled, “Monitoring During Dialysis,” revised 06/05/2019, indicated, “Purpose: To be proactive in reducing the incidence of treatment related complications during dialysis.” The policy specified, “Procedure: A. Monitoring the Patient: 1. Check vital signs - take B/P [blood pressure] and pulse every ½ hour and PRN [pro re nata, as needed] as indicated by patient condition. Record on flow sheet.” Review of an undated facility document “Parameter Reporting Guidelines” outlined normal parameters for pre-treatment, during (intradialytic) treatment, and post-treatment blood pressures and listed out-of-range values that should be reported to the charge nurse and the physician. The document indicated that staff should report to the charge nurse if pre-treatment systolic blood pressure readings were greater than 180 millimeters of mercury (mmHg) or less than 90 mmHg, or diastolic blood pressure readings were greater than 100 mmHg or less than 40 mmHg. The document revealed staff should report to the charge nurse if intradialytic blood pressure readings were greater than or equal to a 15 mmHg decrease from the prior reading at any time during the treatment or increased to a systolic blood pressure greater than or equal to 180 mmHg. The document indicated staff should report to the charge nurse if post-treatment systolic blood pressure readings were greater than 180 mmHg. The “Parameter Reporting Guidelines” specified the charge nurse should report to the physician if pre-treatment systolic blood pressure readings were greater than 180 mmHg or less than 85 mmHg, intradialytic systolic blood pressure readings were greater than 180 mmHg or less than 85 mmHg one hour into the treatment, and post-treatment systolic blood pressure readings were greater than 180 mmHg. 1. Review of P1’s “Hemodialysis Flowsheet [facility location],” dated 05/26/2025, revealed Registered Nurse (RN) 6 noted the patient had a standing post-treatment blood pressure (BP) of 181/94 mmHg. The flowsheet revealed no documentation to indicate the physician was notified of the out-of-range reading. 2. Review of P2’s “Hemodialysis Flowsheet [facility location],” dated 05/19/2025, revealed Patient Care Technician (PCT) 13 recorded blood pressure (BP) readings of 239/140 mmHg at 7:00 AM and 232/128 mmHg at 8:30 AM. PCT13 noted that P2 was resting, but there was no documentation to show she notified the charge nurse of the out-of-range readings. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/21/2025, revealed PCT11 recorded a standing pre-treatment BP of 230/113 mmHg, a sitting pre-treatment BP of 227/109 mmHg, and an intradialytic BP reading of 225/117 mmHg at 7:32 AM. The flowsheet revealed no documentation to show PCT11 notified the charge nurse of the out-of-range readings. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/23/2025, revealed PCT11 documented a standing pre-treatment BP of 218/117 mmHg, a sitting pre-treatment BP of 236/113, and intradialytic BP readings of 223/110 mmHg at 9:00 AM. The flowsheet revealed PCT11 documented a BP reading of 203/102 mmHg at 10:00 AM, 182/98 mmHg at 10:30 AM, and 204/105 mmHg at 11:00 AM. The flowsheet revealed no documentation to show PCT11 notified the charge nurse of the out-of-range readings. The flowsheet revealed RN5 documented a BP reading of 207/106 mmHg at 9:30 AM, but there was no evidence she reported the out-of-range blood pressure to the physician. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/26/2025, showed PCT11 documented a standing pre-treatment BP of 201/132 mmHg and a sitting pre-treatment BP of 239/140 mmHg. The flowsheet revealed the following intradialytic BP readings were documented: 227/121 mmHg at 6:38 AM by PCT11, 200/119 mmHg at 7:00 AM by PCT13, and 187/106 mmHg at 8:30 AM by PCT13. The flowsheet indicated PCT11 documented a sitting post-treatment BP reading of 202/85 mmHg. There was no documentation to show PCT11 and PCT13 notified the charge nurse of the out-of-range readings. The flowsheet revealed RN14 documented a BP reading of 221/117 mmHg at 9:00 AM, rechecked it, and obtained a reading of 197/99 mmHg. The flowsheet indicated RN14 recorded a BP reading of 204/86 mmHg at 10:30 AM. The document revealed no evidence RN14 reported the out-of-range readings to the physician. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/28/2025, showed PCT11 documented a standing pre-treatment BP of 229/119 mmHg and a sitting pre-treatment BP of 230/121 mmHg. PCT11 recorded intradialytic BP readings of 240/120 mmHg at 7:25 AM, 256/128 mmHg at 7:30 AM, 192/109 mmHg at 8:30 AM, 183/105 mmHg at 9:00 AM, 196/96 mmHg at 9:30 AM, 187/90 mmHg at 10:00 AM, 181/100 mmHg at 10:30 AM, and 193/106 mmHg at 10:46 AM. The flowsheet revealed no documentation to show PCT11 notified the charge nurse of the out-of-range readings. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/30/2025, showed PCT11 documented a standing pre-treatment BP of 246/125 mmHg and a sitting pre-treatment BP of 238/116 mmHg. PCT11 recorded intradialytic BP readings of 251/128 mmHg at 7:19 AM, 241/119 mmHg at 7:38 AM, 195/113 mmHg at 8:01 AM, 206/120 mmHg at 9:30 AM, 209/123 mmHg at 10:00 AM, 212/124 mmHg at 10:30 AM, and 212/106 mmHg at 11:30 AM. The flowsheet revealed no documentation to show PCT11 notified the charge nurse of the out-of-range readings. The flowsheet revealed RN4 recorded BP readings of 216/117 mmHg at 8:35 AM and 212/111 mmHg at 9:00 AM. The document revealed no evidence RN4 reported the out-of-range blood pressure readings to the physician. 3. Review of P4’s “Hemodialysis Flowsheet - [facility location],” dated 05/20/2025, indicated RN14 documented a sitting pre-treatment blood pressure (BP) of 211/101 mmHg. The document revealed no evidence RN14 reported the out-of-range reading to the physician. Review of P4’s “Hemodialysis Flowsheet - [facility location],” dated 05/24/2025, indicated RN14 recorded a BP of 199/109 mmHg at 6:00 AM and PCT13 recorded a BP of 129/80 mm/Hg at 6:30 AM. The flowsheet revealed no evidence PCT13 notified the charge nurse of P4’s drop in blood pressure of greater than 15 mmHg, per facility policy. Review of P4’s “Hemodialysis Flowsheet - [facility location],” dated 05/29/2025, indicated PCT12 recorded BP readings of 188/86 mmHg at 6:00 AM and 130/61 mmHg at 6:34 AM, and PCT13 recorded a further decrease in BP with a reading of 106/59 mmHg at 7:00 AM. The flowsheet revealed no evidence PCT12 and PCT13 notified the charge nurse of P4’s drop in blood pressure of greater than 15 mmHg, per facility policy. 4. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, indicated RN6 documented a standing post-treatment blood pressure (BP) of 190/91 mmHg. The flowsheet revealed no post-procedure documentation to indicate the physician was notified of the out-of-range blood pressure reading. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/26/2025, indicated PCT12 recorded a sitting pre-treatment BP of 198/109 mmHg. The flowsheet revealed intradialytic BP readings of 201/87 mmHg at 11:02 AM documented by PCT12 and 189/86 mmHg at 12:01 PM documented by PCT13. The document indicated PCT12 recorded a sitting post-treatment BP reading of 183/91 mmHg. The flowsheet revealed no evidence PCT12 and PCT13 notified the charge nurse of the out-of-range readings. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/28/2025, indicated PCT11 recorded a standing pre-treatment BP of 185/87 mmHg and a sitting pre-treatment BP of 183/88 mmHg. The flowsheet revealed no documentation to show PCT11 notified the charge nurse of the out-of-range BP readings. The flowsheet revealed RN6 recorded intradialytic BP readings of 189/81 mmHg at 2:01 PM and 182/72 mmHg at 2:22 PM, and a standing post-treatment BP reading of 182/82 mmHg. The document revealed no evidence RN6 reported the out-of-range readings to the physician. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/30/2025, indicated PCT12 recorded a sitting pre-treatment BP reading of 191/89 mmHg, and PCT13 documented an intradialytic BP reading of 188/88 mmHg at 12:32 PM. The flowsheet revealed PCT12 recorded a sitting post-treatment BP reading of 204/88 mmHg. The flowsheet showed no evidence PCT12 and PCT13 notified the charge nurse of the out-of-range readings. 5. Review of P7’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, indicated PCT13 recorded a BP reading of 184/51 mmHg at 2:32 PM. The flowsheet revealed there was no documentation to show PCT13 notified the charge nurse of the out-of-range reading. Review of P7’s “Hemodialysis Flowsheet - [facility location],” dated 05/23/2025, indicated RN6 recorded a standing post-treatment BP reading of 182/95 mmHg. The flowsheet revealed there was no documentation to show RN6 notified the physician of the out-of-range reading. Review of P7’s “Hemodialysis Flowsheet - [facility location],” dated 05/28/2025, indicated PCT13 recorded a sitting pre-treatment BP reading of 181/83 mmHg. The flowsheet revealed there was no documentation to show PCT13 notified the charge nurse of the out-of-range reading. During an interview on 06/04/2025 at 2:00 PM, the Nurse Manager stated any out-of-range vital signs, including sitting or standing blood pressures, should be reported per facility protocol. During a telephone interview on 06/06/2025 at 12:27 PM, PCT11 stated patients were monitored every 30 minutes or as needed, and staff needed to document changes in blood pressure, heart rate, or level of alertness. PCT11 stated staff would notify an RN of changes in a patient’s blood pressure of more than 15 (mmHg), heart rates outside of 60 to 100 (beats per minute), diastolic blood pressure readings outside of 60 to 100 (mmHg), and systolic blood pressure readings of less than 90 (mmHg) or greater than 160 (mmHg). During an interview on 06/06/2025 at 1:06 PM, RN6 stated patients’ blood pressures were checked and documented every 30 minutes and documentation would include any interventions that were needed. RN6 stated if patients were hypotensive (low blood pressure) or hypertensive (high blood pressure), PCTs would alert her and document it. She stated that if there was anything outside a patient’s baseline, the charge nurse would assess the patient and document their findings. RN6 stated any blood pressure lower than 90/50 (mmHg) or a systolic blood pressure greater than 200 (mmHg) should be reported to the nurse. She stated nurses should notify a physician if a patient’s blood pressure was high at the start of treatment, if it was still high after an hour, or if the blood pressure was low. During a telephone interview on 06/06/2025 at 4:16 PM, the Medical Director stated the facility’s expectation was for staff to follow reporting parameters and report anything out of the ordinary regarding patients.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50873 Based on interview, record review, facility document review, and facility policy review, the facility failed to deliver the prescribed dose of dialysis to achieve adequacy of dialysis for 6 of 8 sampled patients, Patient (P) 1, P2, P3, P4, P6, and P7. The findings include: Review of the facility’s policy titled, “Monitoring During Dialysis,” revised 06/05/2019, indicated, “All patients will be monitored during the hemodialysis procedure to ensure a safe prescription dialysis with minimum complications. All appropriate data will be recorded on the hemodialysis flow sheet.” The policy revealed, “B. Monitoring Dialyzer and Blood Lines: 1. Blood Flow Rate [BFR] - observe and record at least every ½ hour. Blood flow should be at least 180 mL/min [milliliters per minute]. Record changes in BFR.” The policy revealed, “C. Monitoring Delivery System: 5. Dialysate flow rate [DFR] - observe and record at least every ½ hour. Check jugs for adequate amount of concentrate (if not on central delivery system). Check machine for correct dialysate settings if applicable.” 1. Review of P1’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed during the timeframe from 12:01 PM through 2:31 PM, the patient’s treatment ran at a BFR of 350 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P1’s “Hemodialysis Flowsheet - [facility location],” dated 05/21/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed during the timeframe from 1:00 PM through 2:30 PM, the patient’s treatment ran at a BFR of 350 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P1’s “Hemodialysis Flowsheet - [facility location],” dated 05/28/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed during the timeframe from 11:01 AM through 11:32 AM, the patient’s treatment ran at a BFR of 350 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P1’s “Hemodialysis Flowsheet - [facility location],” dated 05/30/2025, indicated the treatment plan included an order for a DFR of 800 mL/min. The flowsheet revealed during the timeframe from 10:46 AM through 2:54 PM, the patient’s treatment ran at a DFR of 600 mL/min, and there was no documentation of a rationale for the change in DFR. 2. Review of P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/30/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed the BFR decreased from 400 mL/min to 350 mL/min at 7:38 AM, decreased from 350 mL/min to 300 mL/min at 8:01 AM, and decreased from 300 mL/min to 275 mL/min at 10:30 AM, then ran at that speed until 11:30 AM. The document did not contain a rationale for the changes in BFR. 3. Review of P3’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, indicated the treatment plan included orders for a DFR of 600 mL/min and a BFR of 400 mL/min. The flowsheet revealed during the timeframe from 11:16 AM through 2:00 PM, the patient’s treatment ran at a DFR of 800 mL/min, and during the timeframe from 11:16 AM through 2:42 PM, the patient’s treatment ran at a BFR of 350 mL/min. The flowsheet did not include documentation of a rationale for the changes in DFR and BFR. Review of P3’s “Hemodialysis Flowsheet - [facility location],” dated 05/23/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed during the timeframe from 11:30 AM through 2:33 PM, the patient’s treatment ran at a BFR of 350 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P3’s “Hemodialysis Flowsheet - [facility location],” dated 05/26/2025, indicated the treatment plan included an order for a BFR of 400 mL/min. The flowsheet revealed the BFR decreased to 315 mL/min at 11:30 AM, changed to 350 mL/min at 12:00 PM, and continued to run at that speed until 2:30 PM. The flowsheet did not include documentation of a rationale for the changes in BFR. 4. Review of P4’s “Hemodialysis Flowsheet - [facility location],” dated 05/29/2025, indicated the treatment plan included an order for a BFR of 350 mL/min. The flowsheet revealed during the timeframe from 7:38 AM through 9:00 AM, the patient’s treatment ran at a BFR of 300 mL/min, and there was no documentation of a rationale for the change in BFR. 5. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, indicated the treatment plan included an order for a BFR of 500 mL/min. The flowsheet revealed during the timeframe from 11:31 AM through 2:30 PM, the patient’s treatment ran at a BFR of 450 mL/min and decreased to 200 mL/min at 2:31 PM. The flowsheet did not include documentation of a rationale for the changes in BFR. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/21/2025, indicated the treatment plan included an order for a BFR of 500 mL/min. The flowsheet revealed during the timeframe from 1:30 PM through 3:11 PM, the patient’s treatment ran at a BFR of 450 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/23/2025, indicated the treatment plan included an order for a BFR of 500 mL/min. The flowsheet revealed during the timeframe from 10:41 AM through 2:01 PM, the patient’s treatment ran at a BFR of 400 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/26/2025, indicated the treatment plan included an order for a BFR of 500 mL/min. The flowsheet revealed the patient’s treatment ran at a BFR of 400 mL/min at 12:01 PM, decreased to 380 mL/min at 2:01 PM, and ran at that speed until 2:39 PM. The flowsheet did not include documentation of a rationale for the changes in BFR. Review of P6’s “Hemodialysis Flowsheet - [facility location],” dated 05/28/2025, indicated the treatment plan included an order for a BFR of 500 mL/min. The flowsheet revealed the patient’s treatment ran at a BFR of 400 mL/min at 1:01 PM, decreased to 350 mL/min at 2:01 PM, and decreased to 200 mL/min at 2:22 PM. The flowsheet did not include documentation of a rationale for the changes in BFR. 6. Review of P7’s “Hemodialysis Flowsheet - [facility location],” dated 05/26/2025, indicated the treatment plan included an order for a BFR of 450 mL/min. The flowsheet revealed during the timeframe from 10:52 AM through 2:36 PM, the patient’s treatment ran at a BFR of 400 mL/min, and there was no documentation of a rationale for the change in BFR. Review of P7’s “Hemodialysis Flowsheet - [facility location],” dated 05/30/2025, indicated the treatment plan included an order for a BFR of 450 mL/min. The flowsheet revealed during the timeframe from 11:17 AM through 12:33 PM, the patient’s treatment ran at a BFR of 400 mL/min, and there was no documentation of a rationale for the change in BFR. During an interview on 06/04/2025 at 2:00 PM, the Nurse Manager stated there was no reason for a patient’s DFR during treatment to be anything other than the ordered rate. During an interview on 06/05/2025 at 2:00 PM, Educator 2 stated the facility’s expectations were for staff to document a rationale for lowering the BFR, patient care technicians (PCT) were to report to the nurse and document that notification, and nurses should follow up with a note. During a telephone interview on 06/06/2025 at 12:27 PM, PCT11 stated if staff could not achieve the prescribed BFR, they would troubleshoot and lower the BFR if needed, notify the nurse, then document the reason the BFR was lowered and that the nurse was notified. During an interview on 06/06/2025 at 1:06 PM, RN6 stated if staff was unable to achieve the prescribed BFR, they would first troubleshoot, and if they were unable to improve the situation, they would then lower the BFR. RN6 stated any BFR changes should be documented along with notification of the nurse. During a telephone interview on 06/06/2025 at 4:16 PM, the Medical Director stated the facility’s expectation was that patients would receive their dialysis as prescribed. He stated if the staff was unable to achieve the ordered BFR, they should document it along with the reason they were unable to achieve it. The Medical Director also stated there was no reason for a patient to ever run at a DFR other than the ordered rate.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 50873 Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure staff provided appropriate evaluation and care for patients with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) during 2 of 3 observations of initiation of dialysis treatment. Additionally, the facility failed to ensure documentation reflected assessments and care of patients’ vascular access sites per facility policy for 4 of 8 patients sampled for medical record review, Patient (P) 1, P2, P3, and P4. The findings include: Review of the facility’s policy titled, “Cannulation of Arteriovenous Fistula (AVF) with Safety Needles,” revised 03/01/2022, indicated, “Hand hygiene must be performed prior to cannulation. Patients that [sic] are physically able should be encouraged to wash hands and vascular access site prior to entering the treatment area; if patient is physically unable, staff should complete this step chairside.” The policy revealed a section titled, “Procedure,” that specified, “5. Perform assessment of the AVF: A. LOOK at the AV fistula. Inspect for any abnormal findings. B. LISTEN to the access with a stethoscope along the entire length of the access, including the anastomosis. C. FEEL with a gloved hand for the presence of a thrill, and the depth, shape and temperature of the access. Palpate the entire length of the access, as well as above and below the access.” Review of the undated facility’s policy titled, “Cannulation of Arteriovenous Graft (AVG) with Safety Needles,” indicated, “Hand hygiene must be performed prior to cannulation. Patients that [sic] are physically able should be encouraged to wash hands and vascular access site prior to entering the treatment area; if patient is physically unable, staff should complete this step chairside.” The policy revealed a section titled, “Procedure,” that specified “5. Perform assessment of the AVG: A. LOOK at the graft. Inspect for any abnormal findings. B. LISTEN to the access with a stethoscope along the entire length of the access, including the anastomosis. C. FEEL with a gloved hand for the presence of a thrill, and the depth, shape and temperature of the access. Palpate the entire length of the access, as well as above and below the access.” Review of the facility’s policy titled, “Central Venous Catheter (CVC) Exit Site Disinfection and Dressing Change,” revised 02/07/2025, indicated, “Catheter exit-site care and dressing changes are required at every hemodialysis treatment.” The policy revealed a section titled, “Procedure,” that specified, “8. Document procedure to include status of exit site, condition of old dressing and patient response in patient medical record.” 1. Observation on 06/03/2025 at 11:11 AM, revealed Patience Care Technician (PCT) 13 initiated treatment for a patient in Station 9 who had an AVF or AVG. She cleaned the patient’s dialysis access site with alcohol, prepared supplies, then cannulated (inserted a needle) the site without first palpating or auscultating the dialysis access site. 2. Observation on 06/04/2025 at 10:45 AM, revealed PCT11 initiated treatment for a patient with an AVF or AVG, who entered Station 6 with their vascular access site wrapped in clear plastic. PCT11 removed the clear, plastic wrapping from the patient’s dialysis access site, performed hand hygiene, changed gloves, and then cleaned the vascular access site with an antiseptic. PCT11 changed gloves, performed hand hygiene between the change, cleaned the vascular access with alcohol pads, and again changed gloves, performed hand hygiene between the change, and cannulated the patient’s access site. PCT11 did not wash the patient’s dialysis access site with soap and water or auscultate the site prior to cannulation. During a telephone interview on 06/06/2025 at 12:27 PM, PCT11 stated the patient she cared for in Station 6 on 06/04/2025 was unable to wash their access site, and she should have washed it with soap and water. PCT11 stated, “I was moving fast and forgot.” She stated she normally felt access sites prior to cannulation and only auscultated if she was unable to feel them. She stated she would let a Registered Nurse know if she was unable to feel an access site. PCT11 stated she was trained to listen to the dialysis access site with a stethoscope, but for this patient’s cannulation, “I just felt it. I didn’t listen.” 3. P1’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, 05/21/2025, 05/23/2025, 05/28/2025, and 05/30/2025, revealed no evidence a CVC dressing change was completed. 4. P2’s “Hemodialysis Flowsheet - [facility location],” dated 05/21/2025, 05/23/2025, 05/26/2025, 05/28/2025, and 05/30/2025, revealed no evidence a CVC dressing change was completed. 5. P3’s “Hemodialysis Flowsheet - [facility location],” dated 05/19/2025, 05/23/2025, and 05/30/2025, revealed no evidence a CVC dressing change was completed. 6. P4’s “Hemodialysis Flowsheet - [facility location],” dated 05/22/2025 and 05/24/2025, revealed no evidence a CVC dressing change was completed. During an interview on 06/06/2025 at 1:06 PM, Registered Nurse (RN) 6 stated the facility’s expectation was CVC exit site care including dressing changes and cleaning the site were to be done and documented at every treatment. During an interview on 06/04/2025 at 2:00 PM, the Nurse Manager (NM) stated there was no evidence in the medical record that a CVC dressing change had been done during the treatments reviewed for P1. The NM stated the facility’s expectation was for CVC dressing changes to be documented, which would entail the entire procedure, including exit site care. The NM stated CVC dressing changes were to be done at each treatment. During an interview on 06/05/2025 at 2:10 PM, Educator 2 stated there were no physician orders for CVC dressing changes, but the facility’s policy indicated it was to be done at each treatment, and the expectation was for CVC dressing changes to be completed. During an interview on 06/06/2025 at 4:16 PM, the Medical Director stated the facility’s expectation was for vascular accesses to be assessed prior to treatment, and assessments of AVF and AVG access sites would include palpation and auscultation. The Medical Director stated his expectation was that CVC dressing changes and exit site care would be performed and documented at every treatment for patients who had a CVC.”