Fmc East Springfield Dialysis (Bma of Massachusetts)

“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: 44223 Based on observation, staff interview, and facility policy review, the facility failed to 1.) ensure that 2 of 2 staff members (Certified Clinical Hemodialysis Technician [CCHT] #4 and Registered Nurse [RN] #4), adequately cleaned and disinfected contaminated surfaces within the dialysis station, during 2 of 2 observations of disinfection of the stations; and 2.) ensure blood pressure (BP) cuffs were free from lint and debris to allow for proper disinfection to reduce the risk of the spread of infection. Findings Include: Review of the facility policy entitled, Cleaning and Disinfecting the Dialysis Station, version 14, dated 9/5/23, indicated the following: *Dialysis Station: Area including the dialysis machine, chair/bed and other reusable equipment or supplied utilized during dialysis treatment, patient training, and/or patient clinic visits include (but is not limited to) the following: dialysis machine/cycler and attachments such as IV pole, BP (blood pressure) cuff and hand sanitizer/holder, organizer, chair/bed, pureflow SL, individual television and remote. *Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment. *All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make surface glistening wet and let air dry unless other wise specified by the manufacturer. 1a. On 12/5/23 at 12:45 P.M., the surveyor observed CCHT #4 cleaning the dialysis machine/treatment area at station 12, for the next patient. She was observed disinfecting the hemodialysis machine with 1:100 bleached soaked pads. CCHT #4 failed to disinfect the sharps container, on the right side of the machine, and the bottom section of the hemodialysis machine. She failed to disinfect the hand sanitizer bottle, sitting in the holder on the right side of the machine, and failed to clean the basket that the BP cuff sits in. During disinfection of the hemodialysis chair, CCHT #4 failed to disinfect the outside of the right side of the chair, under the tray table. During an interview on 12/5/23 at 1:00 P.M., CCHT #4 said that those areas should be cleaned during the disinfection process. She said she thought she had cleaned them, but must of missed them. 10249 1b. On 12/5/23 at 9:50 A.M., the surveyor observed RN #4 cleaning and disinfecting the dialysis machine/treatment area at station 4, for the next patient. RN #4 was observed disinfecting the hemodialysis machine with 1:100 bleached soaked pads. RN #4 failed to disinfect all arms of the intravenous (IV) pole, and the right side of the dialysis machine including the hand sanitizer bottle and holder, the basket that holds the BP cuff, and the sharps container. She failed to lower the tray tables on the right and left side of the dialysis chair, therefore not disinfecting in the crevasses between the trays and below the armrests. RN #4 was observed cleaning the call bell and BP cuff, then placed them on the dirty counter behind the dialysis chair. RN #4 failed to clean the counter. During an interview on 12/5/23 at 12:50 P.M., RN #4 said she was not aware that she missed the areas identified by the surveyor, and also said she did not know she needed to wipe the sharps container. 2. On 12/5/23 and 12/6/23, during several observations of the treatment area, the surveyor observed the BP cuffs at 7 of 16 stations (station 2, 3, 4, 6, 8, 11, and 14). They were observed to be laden with lint embedded in the Velcro portion of the BP cuffs, making it difficult to adequately disinfect them between patients. During an interview on 12/7/23 at 11:30 A.M., the Facility Administrator said she had just noticed that day the lint filled BP cuffs, and said staff can’t clean them properly with the lint there.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 44223 Based on observations, and staff interviews, the facility failed to provide dialysis patients and staff a functional and comfortable treatment environment. Findings Include: On 12/5/23 at 9:05 A.M., during the initial tour of the water treatment room, the surveyor observed the following: Acid/Bicarbonate (bicarb) Area: * Shelving with a large build up of debris with dust and dirt on each shelf under the storage boxes. * Dirty floor with acid build up in the corners and around the acid storage tanks. * Built up of dust and debris on the piping throughout the water treatment room with heavy debris around piping in the acid tank area. * The floor surrounding the front and back of the bicarb tank was laden with white bicarb residue. * White bicarb residue was observed on piping and motors behind and beside the bicarb tank. * A red hoist machine was observed in the middle of the water treatment room, and it had white bicarb residue on it. * The chlorine testing cart was observed in the middle of the water treatment room with white bicarb residue on it. During further observation of the water treatment room, the surveyor observed 3 cardboard boxes sitting up on top of piping against the wall next to the hot water tank. During an interview on 12/6/23 at 2:25 P.M., the Biomedical Facility Manager said the boxes should not be stored up on the pipe but that they are extra motor parts for the motor located below the boxes. He said he will have to find a better place to store them. He also said that he is not responsible for the cleaning of the water treatment room, but the clinical staff is responsible for cleaning up after the day is complete. During an interview on 12/6/23 at 2:45 P.M., the Facility Administrator said there is no process for the cleaning of the water room. She said it is usually the clinical staff that clean the water room, but there is no real process or schedule for cleaning.”

“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: 44223 Based on staff interview and record review, the facility failed to ensure the dialysis treatment was delivered as prescribed, relative to Blood Flow Rate (BFR) (measured in milliliters per minute (ml/min) in which the patient’s blood is pushed through dialyzer and back to the body) during the process of dialysis, for 2 patients (Patient #5, and #7), out of a total sample of 7 patients. Findings include: 1. For Patient #5, the facility failed to ensure that the dialysis prescription was delivered as prescribed relative to BFR. Patient #5 was admitted to the facility in November 2021 with a diagnosis of End Stage Renal Disease, requiring dialysis treatment. Review of the current dialysis treatment order, dated 11/21/23, indicated the BFR was to be delivered at a rate of 325. Review of 9 treatment records, dated 11/8/23 through 12/2/23, indicated the BFR was not delivered as prescribed for 5 of 9 treatments, including the following: *11/23/23 - the BFR was delivered at a rate of 400, not the 325 as prescribed, with no documented reason as to why. *11/25/23 - the BFR was delivered at 400, not the 325 as prescribed, with no documented reason as to why. *11/28/23 - the BFR was delivered at 400, not the 325 as prescribed, with no documented reason as to why. *11/30/23 - the BFR was delivered at 400, not the 325 as prescribed, with no documented reason as to why. *12/2/23 - the BFR was delivered at 400, not the 325 as prescribed, with no documented reason as to why. During an interview on 12/7/23 at 9:00 A.M., the Facility Administrator (FA) said the order was changed by the physician and the nurse told the staff, but failed to change the order in the computer. 2. For Patient #7, the facility failed to ensure the dialysis prescription was delivered as prescribed relative to the BFR. Patient #7 was admitted to the facility in June 2020 with a diagnosis of End Stage Renal Disease requiring dialysis treatment. Review of the current dialysis treatment orders, dated 12/4/23 and previous order dated 11/17/23, indicated the BFR was to be delivered at a rate of 450. Review of 9 treatment records, dated 11/15/23-12/4/23, indicated the BFR was not delivered as prescribed for 2 of 9 treatments, including the following: *11/19/23 - the BFR was delivered at a rate of 360-400, not the 450 as prescribed, with no documented reason as to why. *11/27/23 - the BFR was delivered at a rate of 400, not the 450 as prescribed, with no documented reason as to why. During an interview on 12/7/23 at 9:00 A.M., the FA said she was not sure why the BFR was not run at the prescribed rate per the physician’s order. She said it should have been run based on the order.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 10249 Based on record review, interview, and policy review, the facility failed to ensure the care plan for 1 of 7 applicable patients (#1), out of a total sample of 7 patients, was signed by the patient or the patient’s designee, or if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided, to ensure the patient had involvement with his/her plan of care. Findings Include: Review of the facility’s policy entitled, Comprehensive Interdisciplinary Assessment and Plan of Care, published 7/3/23, indicated the following, but not limited to: *The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan of care. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record. For Patient #1, the facility failed to ensure the patient involvement in his/her plan of care occurred by signing the Patient Approval Signature section of the plan of care, or if the patient chose not to sign, there was no documentation as to why he/she did not provide a signature. Patient #1 was admitted to the facility in June 2022 with a diagnosis of End Stage Renal Disease, requiring dialysis. During clinical record review, the plan of care dated 11/15/23, included a signature section which included the electronic signatures of the Interdisciplinary team (IDT). The signature section did not include Patient #1’s signature, and there was no documented evidence that the patient refused to sign, or that the plan of care was reviewed with the patient. During an interview on 12/5/23 at 3:00 P.M., the Facility Administrator (FA) said the patient has not signed it because it has not been reviewed with him/her. The FA said Patient #1 did not attend the care plan meeting by choice, however the nurse should reviewed the plan of care with him/her at chairside. She could not explain why it had not been done up to this point; 20 days after the care plan meeting. The FA said the system is for the receptionist to print out a copy of the plan of care, and place it in a folder on the nurse’s desk. The nurse would then take it and review with the patient chairside. After the plan of care was reviewed with the patient, then the nurse would have the patient sign and date the plan of care.”

“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: 31240 Based on record review, interview, and policy review, the Medical Director failed to 1.) ensure staff administered a heparin (blood thinning medication) intravenous (IV) infusion as ordered by the physician, for 1 of 7 applicable (#2) patients, and 2.) ensure staff waited 3-5 minutes after the administration of a heparin bolus and/or failed to administer a heparin bolus before the initiation of hemodialysis treatment (removes excess waste products and water from the blood) for 3 of 7 applicable (#6, #7, and #1) patients, out of a total sample of 7 patients. Findings include: 1. For Patient #2, the Medical Director failed to ensure that staff followed the heparin IV infusion physician’s order during dialysis treatments and comply with the facility’s heparin infusion policy. Review of the facility’s policy, Use of Heparin Pump for Continuous Infusion, dated 11/1/21, indicated, but not limited to, the following: * Heparin administration must be monitored and documented along with blood pressure and safety checks at regular intervals during the treatment per policy, and as determined by the physician. * Set infusion rate in “RX Parameters” screen. * Unclamp heparin line after unclamping arterial and venous clamps. * The heparin pump begins automatically with treatment. * The heparin pump will turn off automatically according to the settings in “RX Parameters” screen. * Document the amount of heparin administered during the treatment on the hemodialysis treatment record. Patient # 2 was admitted to the facility in September 2023 with a diagnosis of End Stage Renal Disease (ESRD), requiring hemodialysis treatments three times a week. Review of the clinical record indicated Patient #2 had a physician’s order for an IV heparin infusion, 1000 units per hour during treatment with pump turned off 60 minutes prior to the end of treatment, three times a week. Review of 9 treatment sheets, dated 11/16/23 through 12/2/23, indicated that for 5 of 9 treatments the heparin IV infusion policy, and the physician’s orders were not implemented, including the following: *Review of a treatment sheet, dated 11/22/23, indicated that the patient’s dialysis treatment began at 9:50 A.M. and ended at 1:51 P.M., and the 1000 units/hour IV heparin infusion was documented as administered from 9:35 A.M. to 12:34 P.M. The heparin was not stopped 60 minutes before the end of treatment as ordered. *Review of a treatment sheet, dated 11/25/23, indicated the patient’s dialysis treatment began at 9:55 A.M. and ended at 1:55 P.M., and the 1000 units/hour IV heparin infusion was documented as administered from 9:46 A.M. to 1:48 P.M. The heparin was not stopped 60 minutes before the end of treatment as ordered. *Review of a treatment sheet, dated 11/28/23, indicated that the patient’s dialysis treatment began at 9:17 A.M. and ended at 1:18 P.M., and the 1000 units/hour IV heparin infusion was documented as administered from 9:08 A.M. to 1:10 P.M. The heparin was not stopped 60 minutes before the end of treatment as ordered. *Review of a treatment sheet, dated 11/30/23, indicated that the patient’s dialysis treatment began at 10:16 A.M. and ended at 12:20 P.M., and the 1000 units/hour IV heparin infusion was documented as administered from 10:11 A.M. to 2:13 P.M. The heparin was not stopped 60 minutes before the end of treatment as ordered. *Review of a treatment sheet, dated 12/22/23, indicated that the patient’s dialysis treatment began at 9:50 A.M. and ended at 1:52 P.M., and the 1000 units/hour IV heparin infusion was documented as administered from 9:38 A.M. to 2:17 P.M. The heparin was not stopped 60 minutes before the end of treatment as ordered. During an interview on 12/6/23 at 12:15 P.M., the Facility Administrator (FA) said the staff should have set the IV heparin fusion pump to end 60 minutes prior to the end of treatment as ordered, for Patient #2. She also said the IV heparin infusion should have been documented when the dialysis treatment started. She said the documentation for each of the 5 treatments did not reflect that staff followed the physician’s order for heparin administration, as ordered, nor followed the facility’s policy for heparin infusion. 37700 2. Review of the facility’s policy titled, Heparin Bolus Administration, published 11/1/21, included the following, but not limited to: *Allow heparin to circulate within the bloodstream for a minimum of three (3) to five (5) minutes before initiating treatment to prevent blood from clotting in the dialysis circuit. A. For Patient #6, the Medical Director failed to ensure the staff adhered to the heparin bolus administration policy, and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #6 had a physician’s order to administer heparin 3000 units intravenously push (IVP), three times a week. Review of 9 treatment sheets, dated 11/14/23 through 12/5/23, indicated for 6 of 9 treatments, the staff failed to wait 3-5 minutes after administration of heparin to initiate treatment including the following: *On 11/14/23 the treatment started at 7:22 A.M., heparin was documented as administered at 9:00 A.M., one hour and 38 minutes after the initiation of treatment, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/16/23 the treatment started at 7:37 A.M., heparin was documented as administered at 8:07 A.M., 30 minutes after the initiation of treatment, and staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/18/23 the treatment started at 7:38 A.M., heparin was documented as administered at 8:46 A.M., one hour and eight minutes after the initiation of treatment, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/20/23 the treatment started at 7:24 A.M., heparin was documented as administered at 11:53 A.M., four hours and 29 minutes after the initiation of treatment, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/22/23 the treatment started at 8:52 A.M., heparin was documented as administered at 11:36 A.M., two hours and 44 minutes after the initiation of treatment, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/25/22 the treatment started at 7:24 A.M., heparin was documented as administered at 8:28 A.M., one hour and four minutes after the initiation of treatment, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 12/7/23 at 9:00 A.M., the FA said the heparin was most likely given as ordered, but based on documentation she could not determine for sure if staff administered the heparin prior to treatment and were waiting the 3-5 minutes before initiating treatment. 44223 B. For Patient #7, the Medical Director failed to ensure the staff adhered to the heparin administration policy, and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #7 had a physician’s order to administer heparin bolus 4000 units intravenously (IV) every dialysis treatment. Review of 9 treatment sheets, dated 11/15/23 through 12/4/23, indicated for 2 of 9 treatments staff failed to wait 3-5 minutes after administration of heparin to initiate treatment including the following: *On 11/29/23 the treatment started at 8:03 A.M., heparin was documented as administered at 9:00 A.M., staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 12/1/23 the treatment started at 8:12 A.M., heparin was documented as administered at 8:12 A.M., staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 12/6/23 at 12:30 P.M., the FA said the expectation is the staff should follow the facility policy, and document at the appropriate time of the heparin administration. 10249 C. For Patient #1, the Medical Director failed to ensure the staff adhered to the heparin administration policy, and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #1 had a physician’s order to administer heparin bolus 4000 units intravenously (IV) every dialysis treatment. Review of 9 treatment sheets, dated 11/10/23 through 12/4/23, indicated for 1 of 9 treatments, staff failed to wait 3-5 minutes after administration of heparin to initiate treatment including the following: *On 11/29/23 the treatment started at 1:19 P.M., heparin was documented as administered at 2:02 P.M., 43 minutes after the treatment had started, staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 12/6/23 at 12:30 P.M., the FA said the expectation is the staff should follow the facility policy, and document at the appropriate time of the heparin administration.”