Fmc - Dialysis Services of Oldham County

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, it was determined the facility failed to ensure all environmental surfaces in two (2) dialysis treatment stations (Station 9 and Station 11) were disinfected at the end of each dialysis treatment. The findings include: Review of a facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published on 09/05/2023, revealed “Background - The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses.” Further review of the policy revealed, “Equipment in the dialysis station may include (but is not limited to) the following: Dialysis machine/cycler and attachments such as IV [intravenous] pole, BP [blood pressure] cuff and hand sanitizer/holder, organizer.” During an observation of the hemodialysis treatment area on 11/20/2023 at 9:36 AM, Registered Nurse (RN) #4 was observed disinfecting Station 11 following a dialysis treatment. RN #4 failed to disinfect the IV pole prongs, the B/P cuff storage basket, or the sanitizer bottle and storage bracket. During an observation of the hemodialysis treatment area on 11/20/2023 at 9:55 AM, RN #4 was observed disinfecting Station 9 following a dialysis treatment. RN #4 failed to disinfect the IV pole prongs, the BP cuff storage basket, or the sanitizer bottle and storage bracket. During an interview on 11/20/2023 at 10:00 AM, RN #4 acknowledged the IV pole prongs, the BP cuff storage baskets, and the sanitizer bottles and storage brackets were not disinfected. During an interview on 11/20/2023 at 10:00 AM, the Director of Operations stated all environmental surfaces in the dialysis treatment stations should be disinfected after each dialysis treatment.”

“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: 35949 Based on interview, record review, and facility policy review, it was determined the facility failed to follow individualized dialysis prescriptions as determined by the medical provider for five (5) of 5 patients (Patients #1, #2, #3, #4, and #5) reviewed. The findings include: Review of a facility policy titled, “Unable to Achieve Prescribed Blood Flow Rate,” with a publication date of 11/01/2021, revealed, “Achieving prescribed BFR [blood flow rate] is a critical parameter in achieving adequate treatment Kt/V [measurement of efficacy of a dialysis session].” Further review of the policy revealed, “Notify physician/extender if unable to achieve prescribed blood flow rate” and “Document in patient’s treatment record what action [was] taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders.” Review of a facility policy titled, “Auto Flow Dialysate,” with a publication date of 04/05/2021, revealed, “Depending on the auto flow rate selected the dialysate flow rate will be either 1.5 or 2.0 times [x] the blood flow rate. The dialysate flow rate will change when the user changes the blood flow rate.” Further review of the policy revealed, “The following chart details the approximate transition points where the dialysate flow [rate] will change.” The chart in the policy indicated the blood flow rate using auto flow 1.5 at 316 to 415 (milliliters per minute; mL/min) had a dialysate flow rate of 600. 1. Review of Patient #1’s “Patient Transfer” form revealed an order with a start date of 11/06/2023 that included a prescribed dialysate flow rate (DFR) of 1.5 x the achieved BFR. Review of Patient #1’s “Treatment Sheet for Facility: [Name of Facility],” for the timeframe from 10/31/2023 through 11/21/2023, revealed the following: - On 11/08/2023, the BFR was documented at 350 mL/min (350 mL/min x 1.5 = 525 mL/min - transitioned to 600 mL/min per policy), and the DFR was documented at 800 mL/min during the entire treatment. - On 11/13/2023, the BFR was documented at 350 mL/min and the DFR was documented at 800 mL/min during the entire treatment. - On 11/17/2023, the BFR was documented at 350 mL/min and the DFR was documented at 800 mL/min from 11:32 AM until the treatment was terminated at 1:28 PM. There was no documented objective rationale for the change to the prescribed DFR. 2. Review of Patient #2’s “Patient Transfer” form revealed an order with a start date of 11/08/2023 that included a prescribed BFR of 450 mL/min. Review of Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” for the timeframe from 10/31/2023 through 11/21/2023, revealed the following: - On 11/06/2023, the BFR was documented at 400 mL/min during the entire treatment. - On 11/08/2023, the BFR was documented at 400 mL/min during the entire treatment. There was no documented objective rationale for the change to the prescribed BFR. 3. Review of Patient #3’s “Patient Transfer” form revealed an order with a start date of 11/03/2023 that included a prescribed DFR of 600 mL/min. Review of Patient #3’s “Treatment Sheet for Facility: [Name of Facility],” for the timeframe from 10/31/2023 through 11/21/2023, revealed the following: - On 11/06/2023, the DFR was documented at 800 mL/min during the entire treatment. - On 11/13/2023, the DFR was documented at 800 mL/min during the entire treatment. There was no documented objective rationale for the change to the prescribed DFR. 4. Review of Patient #4’s “Orders Summary Report” revealed an order with a start date of 11/03/2023 that included a prescribed DFR of 600 mL/min. Review of Patient #4’s “Treatment Sheet for Facility: [Name of Facility],” for the timeframe from 10/31/2023 through 11/21/2023, revealed the following: - On 11/03/2023, the DFR was documented at 800 mL/min during the entire treatment. - On 11/06/2023, the DFR was documented at 800 mL/min during the entire treatment. - On 11/08/2023, the DFR was documented at 800 mL/min during the entire treatment. There was no documented objective rationale for the change to the prescribed DFR. 5. Review of Patient #5’s “Patient Transfer” form revealed an order with a start date of 11/08/2023 that included a prescribed DFR of 800 mL/min. Review of Patient #5’s “Treatment Sheet for Facility: [Name of Facility],” for the timeframe from 10/31/2023 through 11/21/2023, revealed the following: - On 11/17/2023, the DFR was documented at 600 mL/min during the entire treatment. - On 11/20/2023, the DFR was documented at 600 mL/min during the entire treatment. There was no documented objective rationale for the change to the prescribed DFR. During an interview on 11/22/2023 at 8:40 AM, the Director of Operations confirmed the treatment sheets were reviewed, and the expected objective rationales were not documented.”