Springfield Dialysis Center

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 31240 Based on observation, interview, and policy review, the facility failed to ensure proper infection control practices were maintained relative to the separation of clean and dirty areas. Specifically, the facility failed to ensure potentially contaminated, dirty equipment, and unused portion intravenous (IV) normal saline (NS), used during treatment, were not discarded in the clean sink after use. Findings include: Review of the facility’s policy entitled, Infection Control, last revised 11/29/22, included the following: * Each center will maintain and clearly label separate “clean” and “dirty” work areas. * Contaminated items, such as lab samples, are to be stored in the designated “dirty” areas. * “Dirty” areas are those areas where contamination with blood or other biohazardous substances would be expected. Depending on center layout and configuration, clean and dirty areas will be designated in a manner that decreases the risk of cross-contamination. During an observation on 12/13/23 between 9:31 A.M. and 9:47 A.M., the surveyor observed Certified Clinical Hemodialysis Technician (CCHT) #6 providing care for Patient #1 in the isolation room. CCHT #6 applied a fistula clamp, over a clean gauze pad, to Patient #1’s access site. Seven minutes later, CCHT #6 removed the clamp from the patient’s arm, placed the clamp in a clear bucket labeled “Isolation”, and then placed the contaminated bucket in the clean sink. CCHT #6 then removed the contaminated bucket from the clean sink and placing it on the countertop next to the sink in the clean area, contaminating the clean countertop. She then discarded the remaining NS into the clean sink. CCHT #6 was then observed removing her personnel protective equipment (PPE) and washing her hands in the clean sink, before exiting the isolation room. During an interview on 12/13/23 at 9:50 A.M., CCHT#6 said she got her clean and dirty sides mixed up and should not have placed potentially contaminated items into the clean sink. She said she should not have washed her hands in the sink. During an interview on 12/13/23 at 9:52 A.M., Registered Nurse #1 said anything used for Patient #1 had the potential for blood contamination, and should not have been discarded in the clean sink. During an interview on 12/13/23 at 11:10 A.M., the Manager of Clinical and Regulatory Processes said that the dirty equipment and remaining IV bag of NS should not have been put into the clean sink due to the risk of cross-contamination. During an interview on 12/14/23 at 1:30 P.M., the Clinical Manager said the clean sink in the isolation room should only be used for handwashing. She said the dirty sink should have been used for the bucket of clamps, and to discard the unused portion of the IV NS.”

“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: 31240 Based on observations, interview, and policy review, the facility failed to 1.) ensure 3 of 3 staff members observed(Certified Clinical Hemodialysis Technician (CCHT) #6, Registered Nurse (RN) #4, and RN #5), adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens, and 2.) ensure 12 of 21 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’s policy entitled, Cleaning and Disinfection of Equipment, Supplies and Treatment Area, revised 11/15/23, included the following: * Unless equipment manufacturers specify use of another agent, equipment, treatment area and work surfaces will be disinfected using 1:100 bleach/water solution using 5.25%-6% bleach. * All routinely touched reusable equipment and surfaces in each patient’s treatment area must be disinfected after each patient’s treatment. Caregivers will ensure that cracks/crevices come in contact with the bleach solution. This includes, but not limited to: -Dialysis machine -Chair, including the top and bottom of the chair-side table(s) -Bedside tables -Television (TV), phone -Counters and wall boxes. * Dialysis chairs will be reclined, and all areas inspected and disinfected where blood could accumulate and not readily noticed. * Reusable supplies contaminated with visible blood must be cleaned per this policy and then disinfected, using the bleach/water solution specified in this policy. * Some reusable supplies must be disinfected after each patient use by soaking for a minimum of 10 minutes in the bleach/water solution defined by this policy. Care must be taken to ensure all surfaces of all items are fully covered by the bleach. This includes but not limited to fistula clamps and bicarb cartridge port caps, if applicable. 1. The facility failed to ensure 3 of 3 staff members (Certified Clinical Hemodialysis Technician (CCHT) #6, Registered Nurse (RN) #4 and RN #5) observed, adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens A. The facility failed to ensure CCHT #6 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the isolation dialysis station, increasing the risk for cross contamination of blood borne pathogens Review of the facility’s policy entitled, Hepatitis B Control and Management, revised 7/21/22, included the following: *Any durable equipment used for the patients being treated under Hepatitis B isolation procedures that cannot be disinfected must be disposed of at the end of each treatment. *After each patient treatment in the Hepatitis isolation room or area, patient care associates must thoroughly disinfect surfaces of all equipment, durable supplies, and work surfaces per the company procedures for disinfection of the treatment area between patients. This includes but is not limited to regular disinfection of: -Counter tops -All chairs and table surfaces -Exterior of dialysate and bicarbonate concentration containers -Sink and area use for lab functions -BP cuffs, TV surfaces, telephones surfaces, etc. -Any item that is visibly contaminated with blood. On 12/13/23 at 11:18 A.M., the surveyor observed CCHT #6 cleaning the dialysis machine/treatment area in the isolation room after treatment for a patient who was known to have a Hepatitis B infection She cleaned and disinfected the prime waste bucket with 1:100 bleach soaked pads. CCHT #6 failed to disinfect the left side of the hemodialysis machine before placing the clean prime waste bucket back onto the machine, therefore recontaminating the prime waste bucket. She also failed to clean the metal bin on the right side of the machine before placing the clean BP cuff into it, therefore recontaminating the blood pressure cuffs. She failed to clean the chair which a visitor sat on during the patient’s treatment, and failed to clean a large blue storage bag stored on the window sill behind the dialysis treatment chair and machine. During an interview on 12/13/23 at 11:50 A.M., CCHT #6 said she that she missed disinfecting the left side of the dialysis machine before placing the prime waste bucket back on it, and missed disinfecting the BP cuff holder, the chair, and the blue bag. She said all of them should have been disinfected. During an interview on 12/14/23 at 1:30 P.M., the Clinical Manager said all equipment in the isolation room should have been disinfected per the facility policy, because of the potential to spread infection to staff and other patients. 37700 B. The facility failed to ensure RN #4 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the isolation dialysis station, increasing the risk for cross contamination of blood borne pathogens On 12/12/23 at 9:16 A.M., the surveyor observed RN #4 as she cleaned and disinfected Station #19 after a patient’s treatment in preparation for the next patient. RN #4 failed to disinfect the right side and the back of the dialysis machine. She did not clean and disinfect the basket attached to the right side of the machine, and the biohazard box located on the bottom of the right side of the machine. During an interview on 12/12/23 at 9:16 A.M., RN #4 said the basket and red biohazard box should have also been cleaned and disinfected. 10249 C. The facility failed to ensure RN #5 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the isolation dialysis station, increasing the risk for cross contamination of blood borne pathogens. On 12/12/23 at 9:10 A.M., the surveyor observed RN #5 cleaning and disinfecting the dialysis machine/treatment area at station 8, for the next patient. RN #5 was observed disinfecting the hemodialysis machine with 1:100 bleached soaked pads. RN #5 failed to clean the entire back of the dialysis machine, and failed to lower the right and left tray tables to adequately clean the crevasses between the trays and below the armrests. During an interview on 12/12/23 at 9:20 A.M., RN #5 said she did not clean the back of the dialysis machine, and did not know she had to. She also said they lower the tray tables at the end of the day to clean between the arms of the chair and the tray table. 44223 2. The facility failed to ensure blood pressure (BP) cuffs were free from lint and debris, to allow for proper disinfection, to reduce the risk of spread of infection. On 12/12/23 at 9:00 A.M., during observations of the treatment floor, the surveyor observed the BP cuffs at 12 of the 21 stations (station 3, 8, 10 , 11, 12, 13, 14, 15, 17, 19, 20, and 21) were 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 12/13/23 at 11:45 A.M., the Clinic Manager (CM) said that it would be difficult to clean the BP cuffs with embedded lint and that the clinic should be replacing the cuffs when they notice they are covered with lint.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 38141 Based on observation, staff interview, and policy review, the facility failed to 1.) provide evidence that the Isolation Room had dedicated equipment for use only for Hepatitis B positive patients; and 2.) ensure that 1 staff member (Certified Clinical Hemodialysis Technician [CCHT} #6), utilized proper personal protective equipment (PPE) while in the isolation room. Findings include: 1. The facility failed to ensure equipment used in the isolation room was labeled for isolation use only. Review of the Facility Policy entitled, “Hepatitis B: Control and Management” revised 7/21/22, included the following: *All supplies, including durable ones, will be clearly labeled as “isolation”, for use in the Hepatitis B isolation room or area only, and will not be removed for use in other areas without disinfection per the applicable procedure. On 12/12/23 at 1:10 P.M., the surveyor observed the following items that failed to be labeled for isolation room use only: *Stethoscope *Blood Pressure cuff *Dialysis chair *Guest/Visitor chair *Oxygen concentrator *One fistula pressure clamp *Three plastic scissor clamps During an interview on 12/13/23 at 9:50 A.M., CCHT #6 said that everything should be labeled “isolation” in the isolation room. During an interview on 12/13/23 at 1:30 P.M., the Clinic Manager said that all equipment in the isolation room should have “isolation” labels/marked on it. 31240 2. The facility failed to ensure that CCHT #6 wore gloves when touching surfaces in the isolation room. Review of the facility’s policy entitled, Hepatitis B Control and Management, revised 7/21/22, included the following: *Gloves and fluid resistant/impermeable gowns must be worn constantly whenever any caregiver is in the Hepatitis B isolation room or area, regardless of whether a patient is currently receiving treatment or not. Face shields or masks and goggles will be worn any time there is potential for spraying or splashing of blood or body fluids. On 12/13/23 at 11:18 A.M., the surveyor observed CCHT #6 disinfecting the isolation room. CCHT #6 removed her dirty gloves, and then used an ungloved finger to close a cabinet door above the dirty sink, then put on new gloves and resumed cleaning. During an interview on 12/13/23 at 11:50 A.M., CCHT #6 said she should never touch anything with bare hands in the isolation room, to minimize the risk of infection. During an interview on 12/14/23 at 1:30 P.M., the Clinical Manager said staff should wear PPE while in the isolation room and not use bare hands to touch anything.”

“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: 38141 Based on observation, policy review, and staff interview, the facility failed to ensure that 2 of 2 facility staff (Certified Clinical Hemodialysis Technician) (CCHT) #10, and CCHT #7) provided adequate infection control measures during arteriovenous fistula and graft cannulation (AVF-AVG) for 2 of 2 patients (#11 and #10) with an AVF/G observed, out of a total sample of 11 patients. Findings include: Review of the facility’s policy/procedure entitled, “AVF-AVG cannulation, treatment initiation and termination”, revised 11/15/23, included the following: -The access will be washed with antibacterial soap or skin antiseptic wipe, prior to preparing the site for cannulation. -Each needle insertion site is then disinfected according to manufacturer’s instruction with one of the following products: *2% chlorhexidine with alcohol *> 70% alcohol *> 10% povidone-iodine 1. For Patient #11, the facility failed to ensure CCHT #10 washed the access site with antibacterial soap and water or skin antiseptic wipes prior to preparing the site for cannulation. On 12/12/23 the surveyor observed Patient #11 enter the treatment area via ambulance stretcher and be transferred into the dialysis chair at station #13. During an observation on 12/12/23 at 10:15 A.M., the surveyor observed CCHT #10 as he prepared patient #11 for dialysis treatment. CCHT #10 removed a plastic like dressing that was wrapped over the left AV graft access and prepared the patient for cannulation. CCHT #10 observed palpated patient #11’s access area, then proceeded to disinfect the area using alcohol prep pad by wiping the area vigorously for 5 seconds and then inserted the needle into the lower access. CCHT #10 did not wash patient #11’s access site with antibacterial soap and water or skin antiseptic wipe before cannulation of the access site. During an interview on 12/12/23 at 10:35 A.M., CCHT #10 said that he did not wash patient #11’s access site with antibacterial soap and water or skin antiseptic wipes prior to preparing the site for cannulation. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager said that the skin over the access site should be washed with soap and water or antibacterial wipes prior to cannulation. 44223 2. For Patient #10, the facility failed to ensure CCHT #7 washed the access site with antibacterial soap and water or skin antiseptic wipes prior to preparing the site for cannulation and failed to follow the manufacturers recommendations for use when disinfecting the site with alcohol prep pads. Review of the manufacturer’s directions for use printed on the alcohol prep pads indicates to wipe the injection site vigorously and then discard. On 12/12/23 the surveyor observed Patient #10 enter the treatment area via ambulance stretcher and be transferred into the dialysis chair at station #19. CCHT #7 proceeded to prepare Patient #10 for dialysis treatment. CCHT #7 prepared the patient for cannulation of a left AV fistula. CCHT #7 palpated the patient’s access area, then proceeded to disinfect the area. She opened an alcohol prep pad and wiped the lower access area for 3 seconds in a slow circular motion. CCHT #7 then cannulated the lower access site. CCHT #7 continued with disinfection of the upper access area and wiped the area with a second alcohol prep pad for 5 seconds in a slow circular motion. CCHT #7 did not wipe the areas vigorously with the alcohol prep pad per the manufacturer’s guidelines. CCHT #7 did not wash Patient #10’s hands with soap and water or antiseptic wipe prior to initiation of treatment, nor did she wash the access site with soap and water or antimicrobial wipe before cannulation of the access sites. During an interview on 12/12/23 at 10:15 A.M. CCHT #7 said she does not wash the access site with soap and water because she uses the alcohol prep pads which disinfect the area. She said sometimes she will give the patient a wipe to wash their hands but did not do that this time. CCHT #7 said she disinfects the access site for 3-5 seconds per the facility policy. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager (CM) said the AV fistula should be washed with soap and water or antimicrobial wipe prior to cannulation. She said alcohol prep pads should not be used for cleansing the area. The CM also said the access site should be disinfected with an alcohol prep pads per the manufacturer’s guidelines.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44223 Based on observations, interviews, and facility policy review, the facility failed to ensure that 1 of 2 staff (Registered Nurse [RN] #5) observed adequate infection control practices to minimize the risk of infection during exit site care for 1 of 2 applicable patients (#9), with a central venous catheter (CVC), out of a total sample of 11 patients. Findings Include: Review of the facility policy, titled “CVC Initiation and Discontinuation of Treatment”, revised 9/1/23, included the following: * Prior to treatment initiation, CVC (central venous catheter) exit site must be inspected. * Mask self, patient, and anyone else observing or assisting. * Masks prevent germs exhaled from nose/mouth from landing on the CVC exit site. For Patient #9, the facility failed to ensure that RN #5 observed adequate infection control practices to minimize the risk of infection during exit site care. On 12/12/23 at 11:00 A.M., during an observation on the treatment floor, the surveyor observed RN #5 in station #10 initiate exit site care for Patient #9. RN #5 failed to encourage Patient #5 to adjust their mask to cover their nose and mouth. While RN #5 was performing exit site care, including disinfection of the area around the catheter, Patient #9 wore a mask below his/her nose, only covering their mouth. During an interview on 12/12/23 at 11:10 A.M., RN #5 said she should have made sure that Patient #9’s mask was covering their nose and mouth. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager said staff and patient should both be wearing a mask that covers their mouth and nose during exit site care.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 44223 Based on observation, interview, and manufacturer’s guideline review, the facility failed to ensure that for 3 of 4 observations, staff (Registered Nurse [RN] #5, Certified Clinical Hemodialysis Technician [CCHT] #10, and CCHT #7) used the independent conductivity meter per the manufacturer’s recommendation for use. Review of the Digital Dialysate Meter Operations Manual for the Myron L meter, dated 2/18/16, included the following: A. Measuring Conductivity & Total Dissolved Solids (TDS) 1. Rinse cell cup 3 times with sample to be measured. (This conditions the temperature compensation network and prepares the cell.) 2. Refill cell cup with sample. 3. Press COND or TDS . 4. Take reading. A display of [- - - -] indicates an overrange cond. C. Measuring pH 1. Remove protective cap by grasping its sides and pulling up. 2. Rinse pH/ORP sensor well and conductivity cell 3 times with sample to be measured. Shake out each sample to remove any residual liquid. 3. Refill pH/ORP sensor well and conductivity cell with sample. 4. Press pH. 5. Note value displayed. 1. During an observation on 12/12/23 at 9:50 A.M., the surveyor observed CCHT #7 as she was checking the pH and conductivity of the dialysate for station #19. CCHT #7 obtained a sample from the dialysate machine in station #19 and brought the sample to the meter station. CCHT #7 poured out the reverse osmosis (RO) water from the cell cup and sensor well in the meter into the sink and then placed the dialysate sample in the cell cup and sensor well and obtained the reading. CCHT #7 did not rinse the cell cup and sensor well in the meter with the dialysate sample to be tested 3 times per the manufacturer’s guidelines. During an interview on 12/12/23 at 9:55 A.M., CCHT #7 said she pours out the RO water and then checks her sample. During an interview on 12/12/23 at 12:25 P.M. the Clinic Manager (CM) said that staff should follow the manufacture’s guidelines and should rinse the meter 3 times prior to obtaining a reading. 38141 2. During an observation on 12/12 23 at 9:45 A.M., the surveyor observed RN #5 as she was checking the pH and conductivity of the dialysate for station #9. RN #5 obtained the sample from the dialysis machine in station #9 and carried the sample to the meter station. RN #5, dumped the reverse osmosis (RO) water from the cell cup and sensor well in the meter into the dirty sink and then placed the dialysate sample in the cell cup and sensor well and then obtained the reading. RN #5 did not rinse the cell cup and sensor well in the meter with the dialysate sample to be tested at least 3 times per the manufacturer’s guidelines. During an interview on 12/12/23 at 9:50 A.M., RN #5 said that she empties the RO water from the meter, fills the cell with her sample and obtains the reading. She did not rinse the cell 3 times. 3. During an observation on 12/12/23 at 10:00 A.M., the surveyor observed CCHT #10 as he was checking the pH and conductivity of the dialysate for station #13. CCHT #10 obtained the sample from the dialysis machine in station #13 and carried the sample to the meter station. CCHT #10 emptied the RO from the cell cup and sensor well in the meter, filled the cell cup and sensor well with the sample and obtained the reading. CCHT #10 did not rinse the cell cup and sensor well in the meter with the dialysate sample to be tested 3 times. During an interview on 12/12/23 at 10:35 A.M., CCHT #10 said that he was not sure how many times he needs to rinse the meter prior to testing. He said that he has to look at the facility policy. During an interview on 12/12/23 at 12:25 P.M., the Clinic Manager said that staff should follow the manufacturer’s guidelines and should rinse the meter 3 times prior to obtaining a reading.”

“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: 38141 Based on observation, record review, interview, and review of facility policy, the facility failed to 1.) ensure for 2 of 2 staff members observed (Certified Clinical Hemodialysis Technicians [CCHT] #10 and CCHT #7) evaluated the arteriovenous fistula (AVF) access to ensure functionality by way of listening for a bruit the length of the access (swooshing sound heard with a stethoscope placed over the access), or a thrill (pulsation felt with fingertips as blood is forced through the vasculature) prior to initiation of dialysis treatment, 2.) ensure staff evaluated a maturing AVF/G for 1 of 1 applicable patient (#6) during record review, with a maturing arteriovenous fistula/graft (AVF/G) access site, and 3.) ensure staff administered a heparin (blood thinner) infusion order as prescribed for 1 of 1 applicable patients (#6), out of a total sample of 11 patients. Findings include: Review of the facility policy entitled, Patient Assessment: Pre and Post Dialysis, revised 9/1/23, included the following: * Pre and Post dialysis assessment will include, but not limited to, assessment of the above data and physical assessment including: * Access: patency, signs of infection, access care provided. Review of the facility policy entitled, AVF-AVG Cannulation, Treatment, Initiation, and Termination, revised 11/15/23, included the following: * The access is palpated for thrill and auscultated for bruit. * The thrill and bruit must be present to verify patency of the access. Palpation of the fistula or graft is done to locate the access, establish patency and help the caregiver avoid areas that may be tender or difficult to cannulate. 1. The facility failed to ensure for 2 of 2 staff members observed (Certified Clinical Hemodialysis Technician [CCHT] #10 and CCHT #7) evaluated the arteriovenous fistula (AVF) access to ensure functionality by way of listening for a bruit the length of the access (swooshing sound heard with a stethoscope placed over the access), or a thrill (pulsation felt with fingertips as blood is forced through the vasculature) prior to initiation of dialysis treatment. A. For Patient #11, Certified Clinical Hemodialysis Technician (CCHT) #10 failed to evaluate the vascular access to ensure functionality by way of auscultating (listening) for a bruit prior to initiation of dialysis treatment. On 12/12/23 at 10:15 A.M., the surveyor observed CCHT #10 as he was preparing Patient #11 for his/her dialysis treatment via arteriovenous graft. CCHT #10 palpated the arteriovenous access with his fingertips for the presence of thrill, he disinfected the graft sites, and inserted the needle into the lower access, and then the upper access. CCHT #10 did not auscultate the site to assess Patient #11’s arteriovenous graft access for the presence of bruit. During an interview on 12/12/23 at 10:35 A.M., CCHT #10 said he assumed the Registered Nurse assessed for bruit and thrill during the pretreatment assessment. CCHT #10 said he should have still assessed for presence of bruit during access of the arteriovenous graft. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager said staff should assess for bruit and thrill during access of AV fistula or AV graft. 44223 B. For Patient #10, Certified Clinical Hemodialysis Technician (CCHT) #7 failed to evaluate the vascular access to ensure functionality by way of auscultating for a bruit prior to initiation of dialysis treatment. On 12/12/23 at 10:00 A.M., the surveyor observed CCHT #7 as she was preparing Patient #10 for his/her dialysis treatment via an AVF. CCHT #7 palpated the area, disinfected the sites with alcohol swabs, applied a tourniquet, and inserted the lower access site, and then the upper access site. CCHT #7 did not auscultate the patient’s AVF access for the presence of a bruit prior to disinfection or insertion of the hemodialysis access site. During an interview on 12/12/23 at 10:15 A.M., CCHT #7 said she only listens if she doesn’t feel anything when she palpates the area. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager said the AV access site should always be palpated and auscultated to check for a bruit and thrill before initiating treatment. 10249 2. For Patient #6, admitted to the facility in April 2023 with end stage renal disease, and used a central venous catheter (CVC) for hemodialysis, nursing staff failed to ensure the patient’s maturing AVF had been evaluated for a bruit and thrill to ensure it was functioning. Review of Patient #6’s progress notes indicated that Patient #6 had an AVF surgically created on 10/25/23 to his/her lower left forearm. Review of the Hemodialysis Treatment Flowsheets indicated that 9 of 9 treatment sheets (11/22/23, 11/25/23, 11/28/23, 11/30/23, 12/2/23, 12/5/23, 12/7/23, 12/9/23 and 12/12/23) did not include an assessment of Patient #6’s maturing fistula. During an interview on 12/13/23 at 11:00 A.M., the Clinical Manager (CM) said all staff should be assessing both the CVC and the maturing fistula, and document on the flowsheets with each treatment. The CM also said the software program only allows staff to check one of the patient’s access site on the flowsheet, but staff should be documenting on both access sites with every treatment. 3. For Patient #6, admitted to the facility in April 2023 with end stage renal disease, and used a central venous catheter (CVC) for hemodialysis, nursing staff failed to administer a heparin infusion order as prescribed to prevent increased risk of clotting of the CVC during dialysis treatment. Review of Patient #6’s physician’s orders, included an order, dated 11/28/23, for heparin pump, 2000 units per hour, for three hours, for a total of 6000 units per treatment. Review of the Hemodialysis Treatment Flowsheets indicated that 2 of 9 treatments, dated from 11/30/23 to 12/7/23, Patient #6 did not receive the prescribed dose of infusion heparin, including the following: *On 11/30/23, the dialysis treatment was initiated at 5:58 A.M., and the heparin was infused from 6:29 A.M. through 9:00 A.M., for a total of 3000 units. *On 12/7/23, the dialysis treatment was initiated at 5:25 A.M., and the heparin was infused from 7:15 A.M., through 8:42 A.M., for a total of 4000 units. During an interview on 12/13/23 at 2:00 P.M., the Clinical Manager said she reviewed the flowsheets for Patient #6 and was unable to identify why the heparin infusions on 11/30/23 and 12/7/23 were not administered as ordered. She said the expectation is that staff document why the patient did not receive the prescribed dose of heparin.”

“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: 37349 Based on staff interview, clinical record review, and policy review, the Medical Director failed to ensure that 1.) 1 of 2 staff members (Registered Nurse [RN] #1) followed the policy for the administration of Venofer (iron supplement) for 1 of 2 patients (#8) observed receiving intravenous (IV) medications; and 2.) staff waited 3-5 minutes after the administration of a heparin (blood thinning medication) bolus to begin the dialysis treatment for 2 of 7 applicable patients (#2, #5), out of a total sample of 11 patients. Findings include: 1. The Medical Director failed to ensure that RN #1 followed the policy for the administration of Venofer to Patient #8. Review of the facility policy, Venofer, revised 2/4/15, included the following: *Inject medication slowly (100 mg over 2-5 minutes) Patient #8 was admitted to the facility in May 2023 with a diagnosis of end stage renal disease, requiring dialysis. Review of the Dialysis Order Report for Patient #8 included an active order for Venofer 100 mg intravenous push (IVP) on the 1st, 2nd and 3rd treatment of the week. On 12/13/23 at 12:05 P.M., the surveyor observed RN #1 prepare 100 mg of Venofer using aseptic technique. RN #1 proceeded to bring the Venofer to the patients station, she disinfected the medication port on the dialysis machine and administered the Venofer to Patient #8 over 1 minute, not 2-5 per the facility policy. During an interview on 12/13/23 at 12:15 P.M., RN #1 said Venofer should be administered over 1-2 minutes, not 2-5 per the facility policy. During an interview on 12/13/23 at 12:30 P.M., the Clinic Manager said that Venofer should be administered slowly over 2-5 minutes, not 1 minute as the surveyor observed. 37700 2. The Medical Director failed to ensure that staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the policy entitled, Central Venous Catheter (CVC): Initiation and Discontinuation of Treatment, revised 9/1/23, included the following: *After patency of both lumens is verified, administer the patient’s heparin bolus as prescribed via the venous lumen. Allow the heparin to circulate systemically for three (3) to five (5) minutes before initiating the hemodialysis treatment. A. For Patient #2, the Medical Director failed to ensure that staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Patient #2 was admitted to the facility in October 2023 with a diagnosis of End Stage Renal Disease requiring dialysis. Review of the clinical record indicated Patient #2 had a physician’s order, dated 11/21/23, to administer a heparin bolus of 2000 units via intravenous push (IVP) every dialysis treatment. Review of nine (9) treatment sheets, dated 11/21/23 through 12/11/23, indicated that for 4 of 9 treatments, staff failed to wait 3-5 minutes after administration of heparin to initiate treatment. Including the following: *On 11/27/23 treatment started at 5:33 A.M., heparin was documented as administered at 6:04 A.M., 31 minutes after the initiation of treatment, not the required 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 12/1/23 treatment started at 5:57 A.M., heparin was documented as administered at 6:12 A.M., 15 minutes after the initiation of treatment, not the required 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 12/6/23 treatment started at 5:45 A.M., heparin was documented as administered at 8:33 A.M., 2 hours and 48 minutes after the initiation of treatment, not the required 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 12/8/23 treatment started at 5:40 A.M., heparin was documented as administered at 6:05 A.M., 25 minutes after the initiation of treatment, not the required 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 12/13/23 at 1:15 P.M., the CM said that the heparin was most likely given as ordered but based on the documentation she could not determine for sure if staff were waiting the 3-5 minutes before initiating treatment. 44223 B. For Patient #5 the Medical Director failed to ensure that staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #5 had a physician order dated 11/21/23, to administer heparin bolus 2000 units intravenously (IV) every dialysis treatment. Review of 9 treatment sheets, dated 11/21/23 through 12/8/23, indicated 2 of 9 treatments staff failed to wait 3-5 minutes prior to initiation of dialysis per the facility policy including: *On 11/24/23 the treatment started at 11:29 A.M., heparin was documented as administered at 3:54 P.M., 4 hours and 24 minutes after the initiation of dialysis treatment, not the 3-5 minutes prior to initiation of dialysis per facility policy. *On 11/27/23 the treatment started at 11:03 A.M., heparin was documented as administered at 11:17 A.M., 14 minutes after the initiation of dialysis treatment, not the the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 12/13/23 at 11:45 A.M., the Clinic Manager said heparin was not documented appropriately within the time frame for when the heparin was actually given, and there is no way to identify if the heparin was given at the appropriate time.”