Fmc - Kuttawa Dialysis

“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 facility policy review observation, and interview, the facility failed to ensure staff performed hand hygiene to prevent contaminant transmission. Two (Patient Care Technician [PCT] #2 and Registered Nurse [RN] #4) of 6 staff observed providing patient care activities displayed the deficient practice. The findings include: A facility policy titled, “Hand Hygiene,” published 11/06/2023, revealed, “The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination.” The policy revealed, “All staff, patients, patient care givers, including physicians and non-physician practitioners, social workers, dieticians, and any other indirect patient care staff must follow the same requirements for hand hygiene.” The policy indicated that staff should complete hand hygiene “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 medications;” “Immediately after removing gloves;” “After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings 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 same patient;” “After contact with the dialysis wall box, concentrate, drain, or water lines;” or “After contact with other objects within the patient station or treatment space.” 1. During an observation on 09/10/2025 at 12:40 PM, PCT #2 was observed at Treatment Station #9. PCT #2 touched the machine, gave a patient a glove, and removed the patient’s cannulation needles. There was no glove change or hand hygiene completed after touching the dialysis machine and prior to accessing the patient’s vascular access. During an interview at the time of the observation, the Clinic Manager stated the facility expectation that staff change gloves and performed hand hygiene when going from the dialysis machine to the patient. During an observation on 09/10/2025 at 1:40 PM, PCT #2 was observed at Treatment Station #3. PCT #3 applied a tourniquet, palpated an access, cleaned the access with alcohol, palpated the access, then cannulated the first needle. This process was repeated for the second cannulation needle. PCT #2 failed to change gloves and perform hand hygiene prior to performing an invasive procedure such as vascular access cannulation. On 09/10/2025 at 3:51 PM, PCT #2 stated that hand hygiene should be performed when going from a computer or dialysis machine to a patient, when dealing with a central venous catheter, going from dirty to clean, and after assessing a patient’s access prior to cannulation. PCT #3 stated that the patient who was at Treatment #3 during the observation had a “tricky access,” which may have influenced the lapse in changing gloves and hand hygiene. 2. On 09/10/2025 at 1:21 PM, RN #4 was observed at Treatment Station #6. RN #4 touched the machine to reinfuse the patient’s blood and removed the patient’s cannulation needles. There was no glove change or hand hygiene completed after touching the dialysis machine and prior to accessing the patient’s vascular access. During an interview on 09/12/2025 at 3:15 PM, regarding the observation of the RN at Treatment Station #6 on 09/10/2025, the RN stated, “Sometimes you get busy, and you just forget.” During an interview 09/10/2025 at 4:30 PM, the Clinic Manager stated the facility expectation was for staff to perform hand hygiene per facility policy.”

“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 facility policy review, record review, and interview, the facility failed to provide necessary care and services to manage patients’ volume status when they failed to notify a nurse when patients’ heart rates or blood pressures were outside of established parameters according to their policy. The deficiency affected 4 (Patients #1, #2, #3, and #5) of 5 patients sampled for record review. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, revealed directions for staff “During Treatment” that included “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations” and “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury - unit of measurement for blood pressure readings],” “Diastolic blood pressure greater than 100 mm/Hg,” “Blood pressure less than or equal to 100 mm/Hg systolic” and “Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular.” The policy revealed, “Document any findings and interventions in the medical record.” 1. Patient #1’s treatment records, dated 08/27/2025, indicated that Patient Care Technician (PCT) #1 obtained the patient’s blood pressure reading, which was documented as 163/102 mm/Hg at 4:34 PM. The record revealed no evidence of the PCT notifying a registered nurse (RN) of the out-of-range vital sign. 2. Patient #2’s treatment records, dated 09/01/2025, indicated that Patient Care Technician (PCT) #3 obtained the patient’s heart rate reading, which was documented as 105 at 2:33 PM. The record revealed no evidence of the PCT notifying a registered nurse (RN) of the out-of-range vital sign. Patient #2’s treatment records, dated 09/03/2025, indicated that PCT #2 obtained the patient’s heart rate reading, which was documented as 48 at 5:35 PM. The record revealed no evidence of the PCT notifying an RN of the out-of-range vital sign. Patient #2’s treatment records, dated 09/05/2025, indicated that PCT #1 obtained the patient’s blood pressure reading, which was documented as 95/76 mm/Hg at 3:40 PM. The record revealed no evidence of the PCT notifying an RN of the out-of-range vital sign. 3. Patient #3’s treatment records, dated 08/27/2025, indicated that Patient Care Technician (PCT) #3 obtained the patient’s heart rate reading, which was documented as 53 at 5:34 AM, 57 at 6:11 AM, and 59 at 6:34 AM. The record revealed was no evidence of the PCT notifying a registered nurse (RN) of the out-of-range vital signs. Patient #3’s treatment records, dated 09/01/2025, indicated that PCT #3 obtained the patient’s heart rate reading, which was documented as 55 at 5:33 AM. The record revealed PCT #2 obtained a heart rate reading of 55 at 6:04 AM. Per the record, PCT #1 obtained heart rate readings of 58 at 7:09 AM and 58 at 7:32 AM. The record revealed no evidence of the PCTs notifying an RN of the out-of-range vital signs. Patient #3’s treatment records, dated 09/03/2025, indicated that PCT #3 obtained the patient’s heart rate reading, which were documented as 55 at 6:07 AM, 57 at 6:34 AM, and 59 at 8:02 AM; PCT #2 obtained the patient’s heart rate reading at 7:15 AM, which were documented as 57. The record revealed no evidence of the PCT notifying an of the out-of-range vital signs. On 09/12/2025 at 2:09 PM, PCT #1 reviewed treatment records for Patient #3 and confirmed that there was no documentation of an RN being notified of an out-of-range heart rate of 58 at 7:09 AM or 58 at 7:32 AM. The PCT stated that they thought the reporting parameter was 50, not 60 per the policy, and that may have been why it was not documented. 4. Patient #5’s treatment records, dated 09/01/2025, indicated that Patient Care Technician (PCT) #3 obtained the patient’s blood pressure reading, which was documented as 184/94 mm/Hg at 9:11 AM, and PCT #1 obtained a blood pressure reading at 10:44 AM, which was documented as 192/97 mm/Hg. The record revealed no evidence of the PCT notifying a registered nurse (RN) of the out-of-range vital sign. On 09/11/2025 at 10:55 AM, the Clinic Manager stated the expectation was for staff to notify the RNs of out-of-range vital signs per facility policy and to document the notification.”

“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 facility policy review, record review, and interview, the facility failed to ensure they provided the prescribed blood flow rate (BFR) or document the reason if they were unable to meet the prescribed rate. The deficiency affected 2 (Patient #2 and Patient #3) of 5 patients sampled for record review. Findings included: Facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, revealed directions for staff “During Treatment” that included, “Check machine settings and measurements,” which included “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow;” and “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” 1. Patient #2’s treatment records, dated 08/25/2025, revealed the patient’s machine was set for a BFR of 350 from 1:48 PM until 2:03 PM. The record revealed the dialysis prescription indicated that the BFR should have been set for 450. The record revealed no documented rationale for the deviation from the patient’s dialysis prescription. Patient #2’s treatment records, dated 08/29/2025, revealed the patient’s machine was set for a BFR of 400 from 3:50 PM until 5:43 PM. The record revealed the dialysis prescription indicated that the BFR should have been set for 450. The record revealed no documented rationale for the deviation from the patient’s dialysis prescription. Patient #2’s treatment records, dated 09/01/2025, revealed patient’s machine was set for a BFR of 400 from 3:38 PM until 5:38 PM. The record revealed the dialysis prescription indicated that the BFR should have been set for 450. The record revealed no documented rationale for the deviation from the patient’s dialysis prescription. 2. Patient #3’s treatment records, dated 09/01/2025, revealed the patient’s machine was set for a BFR of 450 from 5:09 AM until 6:04 AM. The record revealed the dialysis prescription indicated that the BFR should have been set for 500. The record revealed no documented rationale for the deviation from the patient’s dialysis prescription. On 09/12/2025 at 2:09 PM, Patient Care Technician (PCT) #1 stated that if they were unable to achieve the prescribed BFR, staff notified the registered nurse (RN) and documented that they were unable to achieve the prescribed BFR. Patient #3’s treatment records dated 09/01/2025 were reviewed, and PCT #1 stated that she missed that the BFR was not running as ordered during their patient monitoring check at 5:49 AM. On 09/11/2025 at 12:08 PM, the Clinic Manager stated the facility expectation was that staff notified the RN if they were unable to achieve the prescribed BFR and documented the rationale and the RN notification.”

“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, and facility policy review, the facility failed to assess patients’ accesses prior to cannulation per facility policy for 2 of 2 observations of access cannulation. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, revealed, “Pre-Treatment Follow the steps below for obtaining pre-treatment assessment data.” The policy specified, “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,” dated 05/05/2025, revealed, “Purpose The purpose of this procedure is to provide guidance for assessing patency and placement of needles in an AV [arteriovenous] Fistula or AV Graft to obtain access to the circulatory system for hemodialysis.” The policy specified, “Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis session.” The policy further indicated, “NOTE: Staff/patients/care partners who have been trained to auscultate vascular accesses should listen with a stethoscope to the entire length of the access for changes in the sound of the bruit- normal low-pitched bruit should be present.” An observation of Treatment Station #3 on 09/10/2025 at 1:40 PM revealed Patient Care Technician (PCT) #2 initiated dialysis treatment for a patient with an AV fistula or graft. PCT #2 applied a tourniquet, palpated the access, cleaned the access with alcohol, palpated the access again, then cannulated the first needle. PCT #2 then removed the tourniquet, taped the needle down, pulled back on the syringe at the end of the needle, and clamped the line. PCT #2 then reapplied the tourniquet, palpated the access, adjusted the tourniquet, cleaned with alcohol, palpated, then cannulated the second needle, and secured with tape. PCT #2 failed to auscultate the access prior to cannulation. An observation of Treatment Station #4 on 09/10/2025 at 2:04 PM revealed PCT #3 initiated dialysis treatment for a patient with an AV fistula or graft. PCT #3 palpated the access, cleaned the access with alcohol, removed gloves, performed hand hygiene, donned new gloves, cleaned the access with alcohol, cannulated the first needle, taped the needle in place, pulled back on the syringe, cleaned the second cannulation site with alcohol, cannulated the second needle, pulled back on the syringe, and taped the needle in place. PCT #3 failed to auscultate the access prior to cannulation. On 09/10/2025 at 3:35 PM, PCT #3 stated that to cannulate the patient the staff should look and feel the access to ensure there was nothing abnormal. PCT #3 reported that they usually listened to the access (auscultate) if the patient had recent interventions to their access and if something looked different. The PCT stated that was how they were trained to assess the access prior to cannulation. On 09/10/2025 at 3:51 PM, PCT #2 stated that to assess the access they would feel and sometimes would listen to the access if they could not feel it. PCT #2 stated that a nurse auscultated the access for the patient at Treatment Station #3, but they were also trained to listen to the access (auscultate) as part of the access assessment. PCT #2 confirmed that the clinic had stethoscopes available for staff to use. On 09/12/2025 at 2:09 PM, PCT #1 stated that access assessment included palpation and auscultation, and the clinic did provide stethoscopes for the staff to use. On 09/12/2025 at 3:15 PM, Registered Nurse (RN) #4 stated the facility expectation was for the staff member performing cannulation of an access to assess the access first. The RN stated that sometimes they would listen to the access during their nursing rounds, but the PCTs would still need to assess the access with look, listen, and feel. On 09/10/2025 at 4:30 PM, the Clinic Manager confirmed the facility expectation that staff auscultate patient accesses prior to cannulation.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview and facility document and policy review, the facility Quality Assessment and Performance Improvement (QAPI) program failed to analyze benchmark data and identify trends which created a potential for negative impact for all 27 patients who received dialysis treatment at the facility. Findings included: A facility policy titled, “Quality Assessment and Performance Improvement Program,” dated 11/04/2024, indicated, “The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven QAPI program with participation by the professional members of the interdisciplinary team (IDT). The program must reflect the complexity of the organization and services and must focus on indicators related to improved patient health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its QAPI program including continuous monitoring for the Centers for Medicare & [and] Medicaid Services (CMS) review.” A facility document titled, “Trends: Crude Mortality Rate” for the timeframe from June 2024 through May 2025 revealed an overall trend of increasing crude mortality rate. It showed a total of eight patient deaths. Potential contributing factors were documented and indicated six of the eight patient deaths had a one-month average treatment time of less than four hours, and five of the eight patient deaths had a hospital stay in the last 30 days. The sections of the document for “Current Action Plan” and “Previous Action Plan” revealed no information was recorded for “Summary of Outliers/Findings,” “Analysis of Findings (Root Causes)/Goals,” or “Actions Planned/Time Frame/Person Responsible.” The document included one note that indicated, “1 pt [patient] outlier, pt expired at home.” During an interview on 09/11/2025 at 4:04 PM, the Clinic Manager confirmed that there was no evidence of analysis of potential contributing factors of patient deaths or trends in mortality data. The Clinic Manager confirmed that of the eight patient deaths in the last 12 months, six out of eight had an average treatment time of less than four hours, and no trends were identified. The Clinic Manager stated that the IDT discussed patient deaths during QAPI, but the clinic was unable to provide evidence they analyzed the mortality data.”