Fmc Peabody Dialysis Center

“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: 37700 Based on observation, interview, and policy review, the facility failed to ensure that 1 staff member (Registered Nurse [RN] #1) observed performed adequate infection control practices related to proper glove use during an initiation of a dialysis treatment for an arterio-venous fistula (AVF) for 1 of 2 patients (#12), in a total sample of 12 patients. Findings Include: Review of the facility policy titled, Access Assessment and Canulation, published 7/5/22, indicated the following: *Assessment of Vascular Access: *Wash hands and don Personal Protective Equipment (PPE): gloves, gown/apron, safety glasses and mask, or full-face shield. *Note and report any unusual findings to the nurse in charge or home therapies staff before proceeding with needle insertion. *Remove gloves and perform hand hygiene. Don new gloves. During an observation of the treatment area (station 3) on 3/5/24 at 9:21 A.M., the surveyor observed RN #1 initiate access for an AVF for Patient #12. She performed hand hygiene and donned gloves. She performed the cleansing and cannulation of the AVF site with the same gloves. She failed to doff her gloves, perform hand hygiene and don new gloves before cannulation of the AVF site. During an interview on 3/5/24 at 1:20 P.M., RN #1 said she should have doffed her gloves after cleansing the AVF site, perform hand hygiene and don a new pair of gloves before cannulating the AVF site, as required.”

“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: 37700 Based on observation, interview and policy review, the facility failed to ensure 1 of 3 staff observed (Registered Nurse [RN] #9), provided adequate infection control measures regarding cleaning and disinfecting of 1 of 3 dialysis stations observed. Findings include: Review of the facility policy titled, Cleaning and Disinfecting the Dialysis Station, published 9/5/23, included the following: *Use a cloth wetted with 1:100 bleach solution or Environmental Protection Agency (EPA)-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, Intravenous (IV) pole, blood pressure cuff, hand sanitizer dispenser and holder, chaise wall behind chair). Place the chair in Tenderloin (supine) position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. On 3/5/24 at 10:30 A.M., during the observation of the treatment floor, the surveyor observed RN #9 as she cleaned and disinfected Station 7 after a patient’s treatment in preparation for the next patient. RN #9 used 1:100 bleach soaked wipes to clean the station. RN #9 did not clean the sharps container, that was attached to the lower right side of the machine, from below the lid to the bottom of the container. She did not clean the front base of the dialysis machine. During an interview on 3/5/24 at 11:00 A.M., RN #9 said she did not realize she missed cleaning the sharps container and the base of the dialysis machine as these areas must also be cleaned.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 37700 Based on observation, policy review and interview, the facility failed to ensure 1 of 2 staff (Registered Nurse [RN] #1) observed provided adequate infection control measures regarding an arterio-venous fistula (AVF) cannulation, and failed to ensure the access site was cleansed and not touched after disinfection and prior to needle insertion for 1 of 2 patients (#12), out of a total sample of 12 patients. Findings include: Review of the facility policy titled, Access Assessment and Cannulation, published 7/5/22, included the following: *Skin Disinfection: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating. *Perform skin antisepsis on one site at a time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection. Note: This method minimizes the risk of contaminating the second site while cannulating the first site. For Patient #12, RN #1 failed to ensure one fistula site was cleansed for the required timeframe and the site was not touched after disinfection prior to cannulation. On 3/5/24 at 9:21 A.M., the surveyor observed RN #1 access Patient #12’s AVF in the left lower arm. RN#1 placed a tourniquet on Patient #12 left upper arm. RN #1 used a 70 % isopropyl alcohol pad and cleansed one cannulation site for 20 seconds using gentle friction and in a circular motion. Upon completion of the cleansing of the site, she did not change her gloves but palpated the site with her gloved hand and performed cannulation of the site. During an interview on 3/5/24 at 1:20 P.M., RN #1 said she should have cleansed one site for the required 30 seconds and not palpated the site after cleansing, as required.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 30889 Based on observation, staff interview, and policy review, the facility failed to ensure that 1 of 3 staff observed (Registered Nurse [RN] #9) followed its policy and procedure for Intravenous (IV) Drug administration to ensure IV medications are prepared according to acceptable infection control standards to prevent the risk of contamination. Findings include: Review of the facility’s policy entitled, Medication Preparation and Administration Procedure, Addendum: Drawing Saline Flushes during a Pre-filled Syringe Shortage, published 1/11/22, included the following: Drawing a Saline Flush: 3. Wipe the rubber stopper of the saline bag with an alcohol prep pad. 4. Withdraw 10 milliliters (ml) of normal saline into the syringe. 5. Continue to follow steps 3-4 with up to 4 needles and syringes as needed. On 3/5/24 at 11:10 A.M., the surveyor observed RN #9 as she was preparing normal saline for intravenous use during initiation of dialysis for a patient with a central venous catheter (CVC). RN #9 brought 4 needles/syringes and one alcohol wipe to station 7. RN #9 disinfected the IV injection port of the normal saline bag, that was connected to the patient’s hemodialysis, with an alcohol wipe. RN #9 inserted the needle/syringe into the normal saline bag and withdrew approximately 10 ml of normal saline. RN #9 placed the needle/syringe down on the patient’s tray table. RN #9 then proceeded to insert 3 more needle/syringes into the same normal saline solution bag, and withdrew approximately 10 ml of normal saline into each syringe to be used to flush the patient’s CVC, without disinfecting the IV injection port each time. During an interview on 3/5/24 at 12:20 P.M., RN #9 said she didn’t realize she needed to use a new alcohol wipe each time she entered the injection port of the IV normal saline solution bag, she said that it makes sense to do so.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 10249 Based on document review, Manufacturer’s Operation Manual, facility policy, and interviews, the facility failed to conduct daily equipment calibration for 1 of 2 Myron meters used to test the pH of dialysate solution to ensure the meters were accurate in their measurements. Findings include: Review of the Manufacturer’s Operation Manual entitled, Digital Dialysate Meter Myron L Company” dated February 16, 2018, indicated the following: *Note: if you are using the Dialysate meter to check dialysate concentration, you should check the calibration in the pH and conductivity function at the beginning and end of each work day, or more often if required by the clinic’s internal procedures. Review of the facility policy entitled, Myron Meter Maintenance Procedure, published 9/1/22, indicated the following: Documentation: *Daily verification will be documented on Myron L D-6 daily Verification Form. *Calibrations will be documented on Myron L D6 Calibration Forms. Review of the facility’s Myron D-6 Meter (D60528) (used in the Isolation Room) verification log indicated the following: *Review of the January 2024 Myron D-6 meter indicated the pH and conductivity calibration was not conducted for 27 of 27 applicable days. *Review of the February 2024 Myron D-6 meter indicated the pH and conductivity calibration was not conducted for 23 of 25 applicable days. *Review of the March 2024 Myron D6 meter indicated the pH and conductivity calibration was not conducted for 5 of 5 applicable days. During an interview on 3/7/24 at 7:50 A.M., Registered Nurse (RN) #5 said whoever is caring for the patient in the isolation room that day needs to calibrate the meter prior to treating the patient. During an interview on 3/7/24 at 8:00 A.M., The Regional Biomedical Director said the Myron meter should be calibrated daily, and also said the staff did not document if they calibrated the meter for the isolation room for January and February 2024. During an interview on 3/7/24 at 11:30 A.M., the Clinic Manager said whoever does the opening in the morning is responsible to calibrate the two Myron meters for the day. She also said the documentation sheet for the Myron meter, in the isolation room, was not easily accessible in the computer.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 44223 Based on record review, staff interviews, and policy review, the facility failed to ensure staff conducted Pre-Dialysis Nursing Assessments within one (1) hour of dialysis treatment for 3 of 10 applicable patients (#10, #6, #3) reviewed, out of a total sample of 12 patients. Findings Include: Review of the facility policy entitled, Nursing Supervision and Delegation, dated 5/1/23, indicated the following: Policy: The registered nurse must evaluate each patient preferably within an hour or according to state regulations to: *Confirm identity. *Review the patient’s condition. *Review accuracy and completeness of treatment and patient data. *Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. *Confirm that the correct vascular access is being used, and that the access is visible. *Observe patient’s response to treatment. *Verify machine safety checks have been completed. *Talk to the patient to elicit information such as changes in condition, response to treatment, new injuries, information/education needs or complaints, and satisfaction with care. 1. For Patient #10, the facility failed to conduct the Dialysis Nursing Assessment within the first hour of dialysis treatment, per the facility policy. Patient #10 was admitted to the facility in August 2021 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of 9 treatment sheets, dated 2/16/24 through 3/4/24, indicated that for 6 of 9 treatments, the nursing assessment was not completed within the first hour of treatment including the following: *On 2/16/24, the patient’s dialysis treatment began at 5:16 P.M., the nursing assessment was not completed until 7:28 P.M., exceeding the one (1) hour requirement. *On 2/20/24, the patient’s dialysis treatment began at 12:20 P.M., the nursing assessment was not completed until 1:56 P.M., exceeding the one (1) hour requirement. *On 2/21/23, the patient’s dialysis treatment began at 5:20 P.M., the nursing assessment was not completed until 8:53 P.M., exceeding the one (1) hour requirement. *On 2/26/24, the patient’s dialysis treatment began at 5:15 P.M., the nursing assessment was not completed until 8:25 P.M., exceeding the one (1) hour requirement. *On 2/28/24, the patient’s dialysis treatment began at 5:18 P.M., the nursing assessment was not completed until 9:06 P.M., exceeding the one (1) hour requirement. *On 3/4/24, the patient’s dialysis treatment began at 5:24 P.M., the nursing assessment was not completed until 10:21 P.M., exceeding the one (1) hour requirement. During an interview on 3/6/24 at 9:30 A.M., the Clinic Manager said that it is preferable that assessments be completed within one hour, but it does get busy. She said if it was documented late, then she has no other documentation to provide to say otherwise. 2. For Patient #6, the facility failed to conduct the Dialysis Nursing Assessment within the first hour of dialysis treatment, per the facility policy. Patient #6 was admitted to the facility in February 2019 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of 9 treatment records, dated 2/13/24 through 3/5/24, indicated that for 3 of 9 treatments, the nursing assessment was not completed within the first hour of treatment including the following: *On 2/17/24, the patient’s dialysis treatment began at 7:14 A.M., the nursing assessment was not completed until 1:07 PM., exceeding the one (1) hour requirement. *On 2/29/24, the patient’s dialysis treatment began at 7:05 A.M., the nursing assessment was not completed until 8:40 A.M., exceeding the one (1) hour requirement. *On 3/2/24, the patient’s dialysis treatment began at 7:05 A.M., the nursing assessment was not completed until 8:29 A.M., exceeding the one (1) hour requirement. During an interview on 3/6/24 at 9:30 A.M., the Clinic Manager said that it is preferable that assessments be completed within one hour, but it does get busy. She said if it was documented late, then she has no other documentation to provide to say otherwise. 10249 3. For Patient #3, the facility failed to conduct the Dialysis Nursing Assessment within the first hour of dialysis treatment, per facility policy. Patient #3 was admitted to the facility in January 2019 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of 9 dialysis treatment sheets, dated 2/19/24 through 3/4/24, indicated 5 of 9 treatments the nursing assessment was not completed within the first hour including the following: *On 2/21/24, the patient’s dialysis treatment began at 4:06 P.M., the nursing assessment was not completed until 6:26 P.M., exceeding the one hour requirement. *On 2/24/24, the patient’s dialysis treatment began at 4:07 P.M., the nursing assessment was not completed until 9:04 P.M., exceeding the one hour requirement. *On 3/1/24, the patient’s dialysis treatment began at 4:38 P.M., the nursing assessment was not completed until 7:20 P.M., exceeding the one hour requirement, *On 3/2/24, the patient’s dialysis treatment began at 4:06 P.M., the nursing assessment was not completed until 5:48 P.M., exceeding the one hour requirement. *On 3/4/24, the patient’s dialysis treatment began at 4:37 P.M., the nursing assessment was not completed until 6:09 P.M., exceeding the one hour requirement. During an interview on 3/6/24 at 12:45 P.M., the Clinic Manager said staff are busy, but it is preferable to complete the nursing assessment within the first hour.”

“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 record review and staff interview, the facility failed to ensure the dialysis treatment order was delivered as prescribed relative to Blood Flow Rate ([BFR] measured in millimeters 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 of 10 applicable patients (#6, #1) records reviewed, out of a total sample of 12 patients. Findings Include: 1. For Patient #6, the facility failed to ensure the dialysis prescription was delivered as prescribed relative to BFR. Patient#6 was admitted to the facility in February 2019 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of the current dialysis treatment orders, dated 10/14/23, indicated the BFR was to be delivered at a rate of 450. Review of treatment sheets, dated 2/13/24 through 3/5/24, indicated the BFR was not delivered as prescribed for 7 of 9 treatments, including the following: *2/13/24 - there was no BFR documented between 9:00 A.M. and 10:30 A.M., with no documented reason as to why. *2/15/24 - BFR ran between 350-430, not the 450 as prescribed, with no documented reason as to why. *2/20/24 - BFR ran at 425, not the 450 as prescribed, with no documented reason as to why. *2/22/24 - BFR ran at 400, not the 450 as prescribed, with no documented reason as to why. *2/24/24 - BFR ran at 400, not the 450 as prescribed, with no documented reason as to why. *2/27/24 - BFR ran at 400, not the 450 as prescribed, with no documented reason as to why. *2/29/24 - there was no BFR documented between 9:00 A.M. and 10:52 A.M., with no documented reason as to why. During an interview on 3/6/24 at 9:20 A.M., the Clinic Manager said if the BFR is not documented it could be an Internet issue and the information was not documented manually by staff. She also said if the BFR ran at a different rate, then staff should document the reason why. 31240 2. For Patient #1, the facility failed to ensure the dialysate treatment order was delivered as prescribed relative to the BFR. Patient #1 was admitted to the facility in January 2024 with a diagnosis of End Stage Renal Disease, requiring hemodialysis. Review of a Physician’s order, dated 2/5/24, indicated the BFR was to be delivered at a rate of 400. Review of 9 treatment records, dated 2/9/24 through 3/4/24, indicated the BFR was not delivered as prescribed on 2 of 9 hemodialysis flowsheets as follows: *2/19/24 - The BFR was delivered at the rate of 350, not 400 as ordered and there was no documentation to indicate why the physician’s order was not followed. * 2/26/24 - The BFR was delivered at the rate of 350 at the start of treatment and decreased to 320 for the remainder of the treatment. The BFR was not delivered at the rate of 400 as ordered and there was no documentation to indicate why the physician’s order was not followed. During an interview on 3/6/24 at 9:30 A.M., the Clinic Manager said that staff should document why the BFR was not delivered as ordered, and it was not done for this patient on 2/19/24 and 2/26/24.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 44223 Based on observation, interview, and policy review, the facility failed to ensure that 1 of 2 staff members (Certified Clinical Hemodialysis Technician [CCHT] #1) observed, evaluated functionality by listening for the bruit the length of the access (swooshing sound heard with the stethoscope placed over the access) for 1 of 2 patients (#11) with arteriovenous fistula/graft (AVF/G) access sites, out of a total sample of 12 patients. Findings Include: Review of the facility policy titled, Access Assessment and Cannulation, dated 7/5/2022, indicated the following but is not limited to: Policy: Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis sessions. Assessment of a vascular access: *Listen: Bruit high pitch/whistle. *Note: Staff/patients/care partners who have been trained to auscultate vascular accesses should listen to the entire length of the access for changes in the sound of the bruit - a normal low-pitched bruit should be present. *Clean stethoscope after assessing patient. For Patient #11, CCHT #1 failed to evaluate the vascular access site to ensure functionality by way of auscultation (listening) for a bruit for initiation of dialysis treatment. On 3/5/24 at 9:00 A.M., the surveyor observed CCHT #1 as she was preparing Patient #11 for his/her dialysis treatment via AVF. CCHT #1 palpated the arteriovenous access with her fingertips for the presence of a thrill (pulsation felt with fingertips as blood is forced through the vasculature). She applied a tourniquet and then proceeded to disinfect the access sites. She inserted the needle into the lower access, and then the upper access. CCHT #1 did not auscultate the site to assess for the presence of a bruit. During an interview on 3/5/24 at 9:15 A.M., CCHT #1 said she should have listened for a bruit using a stethoscope, and would have if she had a stethoscope with her.”

“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 interview, record review, and policy review, the Medical Director failed to ensure that staff followed the policy related to reversal of Central Venous Catheter (CVC) lines for 2 patients (#1 and #2), out of total sample of 12 patients. Findings include: Review of the facility’s policy entitled, Reversal of Central Venous Catheter Lines, dated 2/5/24, indicated the following: *Following Registered Nurse (RN) evaluation and recommendation and with a provider’s order, the patient and/or care partner may be instructed by the RN to initiate treatment by reversing the lines if clinically indicated. *Reversal of CVC lines requires the following documentation in the patient’s medical record: -Provider order with frequency entered in the medical record. -Reason for line reversal. -Action of line reversal in the treatment record. -Evaluation of catheter function and future need for vascular referral. 1. For Patient #1, the Medical Director failed to ensure that staff followed the policy relative to notifying the physician and obtaining an order when reversing treatment lines. Patient #1 was admitted to the facility in January 2024 with a diagnosis of End Stage Renal Disease (ESRD), requiring hemodialysis via a CVC. Review of the treatment flowsheets, dated 2/9/24 through 3/4/24, indicated that for 4 of 9 treatments the CVC lines were reversed, including 2/16/24, 2/26/24, 3/1/24 and 3/4/24. There was no documentation indicating that nursing had notified the physician and obtained an order to reverse the lines. During an interview on 3/6/24 at 12:30 P.M., the Clinic Manager (CM) said nursing staff should notify the physician if the CVC lines need to be reversed, then document the reason why, and the physician’s order. 37700 2. For Patient #2, the Medical Director failed to ensure that staff followed the policy relative to notifying the physician and obtaining an order when reversing treatment lines. Patient #2 was admitted to the facility in April 2022 with a diagnosis of ESRD, requiring dialysis via a CVC. Review of treatment flowsheets, dated 2/5/24 through 3/4/24, indicated for 2 of 9 treatments, the CVC lines were reversed, including 2/12/24 and 2/26/24. There was no documentation indicating that nursing had notified the physician and obtained an order to reverse the lines. During an interview on 3/6/24 at 9:35 A.M., the CM said that nursing staff should notify the physician if the CVC lines need to be reversed, then document the reason why, and the physician’s order. She further said she could not find any documentation the physician had been notified when Patient #2’s lines were reversed, and the reason they were reversed on 2/12/24 and 2/26/24, as required.”