Fmc - Madisonville 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: 35949 Based on observation, interview, and facility policy review, the facility failed to appropriately perform hand hygiene during 1 of 2 observations of central venous catheter [CVC] site care. The findings included: A facility policy titled, “Central Venous Catheter (CVC) Dressing Change,” published 05/06/2024, revealed, “Discard dressing and remove gloves. Perform hand hygiene.” During an observation on 09/10/2024 at 11:23 AM, Certified Clinical Hemodialysis Technician (CCHT) #10 performed a CVC dressing change at dialysis treatment station #16. CCHT #10 performed hand hygiene and donned clean gloves. CCHT #10 removed the old CVC dressing and discarded it. CCHT #10 then proceeded to clean the CVC exit site with antiseptic. CCHT #10 did not perform hand hygiene after she removed and discarded the CVC dressing. During an interview on 09/10/2024 at 11:36 AM, CCHT #10 stated she was taught to perform hand hygiene and don new gloves if she touched anything, to include after removal of the CVC dressing. During an interview on 09/11/2024 at 4:00 PM, the Facility Administrator stated staff were expected to follow facility policy while performing CVC site care. During an interview on 09/13/2024 at 9:51 AM, the Medical Director stated staff were expected to follow facility policy when performing CVC site care.”

“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, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 4 (Patients #1, #2, #3, and #4) 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 60 in-center patients who received dialysis treatments at the facility. The findings included: A facility policy titled, “Physician Order Documentation,” published 07/03/2023, indicated, “Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders.” 1. Patient #1’s treatment sheet, dated 08/14/2024, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #1’s BFR was documented as 350 mL/min from 5:28 AM until the treatment was terminated at 9:28 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 08/16/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented between 300 mL/min and 350 mL/min from 8:33 AM until the treatment was terminated at 9:28 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 08/19/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as 350 mL/min from 6:21 AM until the treatment was terminated at 9:19 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 08/21/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented between 200 mL/min and 375 mL/min from 6:00 AM until the treatment was terminated at 9:24 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 08/23/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as 350 mL/min from 5:31 AM until the treatment was terminated at 9:18 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 08/31/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as 300 mL/min from 11:17 AM until the treatment was terminated at 3:12 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 09/03/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented between 250 mL/min and 300 mL/min from 11:33 AM until the treatment was terminated at 2:36 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet, dated 09/05/2024, revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented between 300 mL/min and 350 mL/min from 1:04 PM until the treatment was terminated at 2:53 PM. There was no rationale documented why the prescribed BFR was not achieved. 2. Patient #2’s treatment sheet, dated 08/21/2024, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #2’s BFR was documented as 300 mL/min from 1:37 PM until the treatment was terminated at 3:53 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #2’s treatment sheet, dated 09/06/2024, revealed a prescribed dialysate flow rate (DFR) of 700 mL/min. Patient #2’s DFR was documented as 800 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. 3. Patient #3’s treatment sheet, dated 08/28/2024, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #3’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 4. Patient #4’s treatment sheet, dated 08/24/2024, revealed a prescribed BFR of 400 mL/min. Patient #4’s BFR was documented between 300 mL/min and 350 mL/min from 6:33 AM until the treatment was terminated at 9:00 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #4’s treatment sheet, dated 09/07/2024, revealed a prescribed BFR of 400 mL/min. Patient #4’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. During an interview on 09/12/2024 at 8:20 AM, the Facility Administrator stated staff were trained and expected to follow the physicians’ orders and document rationales when the prescribed BFR and/or DFRs were not achieved. During an interview on 09/13/2024 at 9:14 AM, Registered Nurse #3 stated staff were trained and expected to document when a patient’s BFR and/or DFR were not as prescribed. During an interview on 09/13/2024 at 10:00 AM, the Medical Director stated staff were expected to document a rationale when the prescribed BFRs were not achieved and to inform the physician when the prescribed BFRs were not achieved over time.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs and/or machine parameters according to their policy for 3 (Patients #2, #3, and #4) of 4 sampled in-center patients. Failure to monitor patients’ vitals and machine parameters according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact the care provided to the 60 in-center patients who received dialysis treatments at the facility. The findings included: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated, “During Treatment ? 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 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” 1. Patient #2’s treatment sheet, dated 08/16/2024, revealed monitoring was not documented for 51 minutes, from 2:41 PM until 3:32 PM. Patient #2’s treatment sheet, dated 08/19/2024, revealed monitoring was not documented for 58 minutes, from 2:34 PM until 3:32 PM. Patient #2’s treatment sheet, dated 08/21/2024, revealed monitoring was not documented for 93 minutes, from 12:04 PM until 1:37 PM. Patient #2’s treatment sheet, dated 09/06/2024, revealed monitoring was not documented for 60 minutes, from 3:06 PM until 4:06 PM. 2. Patient #3’s treatment sheet, dated 08/28/2024, revealed monitoring was not documented for 68 minutes, from 6:53 AM until 8:01 AM. Patient #3’s treatment sheet, dated 09/02/2024, revealed monitoring was not documented for 60 minutes, from 9:31 AM until 10:31 AM. Patient #3’s treatment sheet, dated 09/04/2024, revealed monitoring was not documented for 56 minutes, from 9:35 AM until 10:31 AM. Patient #3’s treatment sheet, dated 09/06/2024, revealed monitoring was not documented for 67 minutes, from 7:30 AM until 8:37 AM, for 55 minutes, from 8:37 AM until 9:32 AM, and for 58 minutes, from 9:32 AM until 10:30 AM. Patient #3’s treatment sheet, dated 09/11/2024, revealed monitoring was not documented for 51 minutes, from 9:01 AM until 9:52 AM. 3. Patient #4’s treatment sheet, dated 08/17/2024, revealed monitoring was not documented for 61 minutes, from 5:31 AM until 6:32 AM, and for 68 minutes, from 7:01 AM until 8:09 AM. Patient #4’s treatment sheet, dated 08/24/2024, revealed monitoring was not documented for 54 minutes, from 5:39 AM until 6:33 AM. During an interview on 09/12/2024 at 8:20 AM, the Facility Administrator stated staff were trained and expected to monitor patients per the facility’s policy. During an interview on 09/13/2024 at 9:14 AM, Registered Nurse #3 stated staff were trained and expected to monitor patients every “30 minutes.” During an interview on 09/13/2024 at 10:00 AM, the Medical Director confirmed staff were trained and expected to monitor patients every 30 minutes according to the facility’s policy.”

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure staff followed the facility procedure for cannulation of a dialysis access site during 3 of 3 observations of cannulation. The findings included: A facility policy titled, “Access Assessment and Cannulation,” dated 05/06/2024, revealed, “Perform skin antisepsis on one site at a time, allow to dry and then (sic.) cannulate. Do note touch cannulation sites after skin disinfection.” During an observation on 09/10/2024 at 12:00 PM, Certified Clinical Hemodialysis Technician (CCHT) #9 initiated dialysis at treatment station #5. CCHT #9 applied antiseptic then palpated the access and inserted the cannulation needle. CCHT #9 touched the cannulation sites after disinfection. During an observation on 09/11/2024 at 10:15 AM, CCHT #8 initiated dialysis at treatment station #15. CCHT #8 auscultated the access, applied antiseptic, performed hand hygiene, changed gloves, applied a tourniquet, palpated the access, and inserted the cannulation needle. CCHT #8 then palpated the access and inserted the second cannulation needle. CCHT #8 touched the cannulation sites after disinfection. During an observation on 09/11/2024 at 11:00 AM, CCHT #8 initiated dialysis at treatment station #14. CCHT #8 auscultated the access, applied antiseptic, performed hand hygiene, changed gloves, applied a tourniquet, palpated the access, and inserted the cannulation needle. CCHT #8 then palpated the access and inserted the second cannulation needle. CCHT #8 touched the cannulation sites after disinfection. During an interview on 09/11/2024 at 1:00 PM, CCHT #9 stated she was trained to clean off the access for 30 seconds, use a tourniquet if the access was not a graft, palpate the access, and cannulate. During an interview on 09/11/2024 at 4:00 PM, the Facility Administrator stated staff were expected to follow facility policy while performing cannulation. During an interview on 09/12/2024 at 2:10 PM, CCHT #8 stated she was trained to not touch the access after cleaning it when performing cannulation. CHHT #8 stated, “I know I should have wiped it again.” During an interview on 09/13/2024 at 9:51 AM, the Medical Director stated staff were expected to follow facility policy when performing cannulation.”