Taunton Regional 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: 44223 Based on observation and staff interview, the facility failed to ensure that proper infection control practices were followed when personal protective equipment (PPE) came in contact with both clean and dirty areas on the dialysis treatment floor. Findings include: 1. During an observation of the treatment floor on 6/16/25 at 9:20 A.M., the surveyor observed 2 baskets along the wall when entering the treatment floor from the staff area. There were 10 face shields in the first basket stacked on top of each other and 6 face shields and 1 pair of goggles in the second basket stacked on top of each other, causing concern for potential cross contamination. 2. During an observation of the treatment floor on 6/16/25 at 9:30 A.M., the surveyor observed a row of hooks along the wall when exiting the treatment floor into the staff area. There were 3 gowns hung on the hooks. The 3 gowns were hanging from separate wall hooks, however they were touching each other, causing concern for potential cross contamination. 3. During an observation of the treatment floor on 6/16/25 at 12:30 P.M., the surveyor observed a row of hooks along the wall when exiting the treatment floor into the staff area. There were four gowns hung on the hooks. The 4 gowns were touching each other and 1 of the 4 gowns was hung over a face shield causing concern for potential cross contamination. During an interview on 6/17/25 at 1:30 P.M., the Clinic Manager said she would look at finding a better way to store the gowns and face shields since stacking them does cause a concern for cross contamination.”

“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: 10249 Based on observation, staff interview, and policy review, the facility failed to ensure 1 of 2 staff members (Certified Clinical Hemodialysis Technician [CCHT] #9) observed, adequately disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk of cross contamination with blood borne pathogens. Findings Include: Review of the facility’s policy titled, Cleaning and Disinfection of Equipment, Supplies and Treatment Area, revised 6/20/24, indicated the following: *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 is not limited to: -Dialysis machine. -Chair, including the top and bottom of the chair-side table(s). -Bedside table. -Television, phone. -Counters and wall boxes. The facility failed to ensure that CCHT #9 adequately cleaned and disinfected the station for the next patient. On 6/16/25 at 9:00 A.M., the surveyor observed CCHT #9 disinfect station 16 for the next patient. She was observed to disinfect the hemodialysis machine and hemodialysis chair using 1:100 bleach soaked pads. CCHT #9 failed to disinfect the intravenous (IV) pole and the stethoscope that was hanging from the IV pole, as well as the basket attached to the right side of the dialysis machine. CCHT #9 also failed to disinfect the counter, wall, and wall box located behind the dialysis chair, as well as the TV and TV arm. During an interview on 6/16/25 at 9:06 A.M., CCHT #9 said she should have cleaned those items including the IV pole and stethoscope, but was rushing to get the chair ready for the next patient who was coming early.”

“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: 10249 Based on observation, interview, and policy review, the facility failed to ensure 2 of 2 staff observed (Certified Clinical Hemodialysis Technician [CCHT] #1 and CCHT #12 ) implemented adequate infection control measures during termination of treatment and exit site care for 2 of 2 patients (#9 and #10) with a Central Venous Catheter (CVC), out of a total sample of 10 patients. Finding include: Review of the facility’s policy titled, CVC: Initiation and Discontinuation of Treatment, last revised 6/11/2025, included but was not limited to the following: *At end of treatment, wash hands and don PPE. Mask self, patient and anyone assisting or observing. *Masks prevent germs exhaled from the nose/mouth from landing on the CVC exit site. *Disinfect according to manufacturer’s instructions with one of the following products; 2% Chlorhexidine with alcohol. *The manufacturer’s instructions indicate to use gentle repeated back-and-forth strokes for approximately 30 seconds. 1. The facility failed to ensure that Patient #9 wore a facemask over his/her nose during the termination of dialysis. During an observation of the treatment floor on 6/16/25 at 3:15 P.M., the surveyor observed CCHT #1 terminate the dialysis treatment for Patient #9, who had a CVC for dialysis access. Patient #9 wore a mask below his/her nose, only covering his/her mouth, throughout the whole process of termination of dialysis treatment. CCHT #1 failed to encourage Patient #9 to adjust his/her face mask to cover his/her nose and mouth while she performed termination of dialysis treatment with CVC, including disconnecting the blood lines. During an interview on 6/16/25 at 3:30 P.M., CCHT #1 said your right, I should have put the mask over his/her nose. 27189 2. The facility failed to ensure that CCHT #12 disinfected the CVC exit site of Patient #10 for the required amount of time. Patient #10 was admitted to the facility with a diagnosis of ESRD and was receiving hemodialysis treatments 3 times a week, with a CVC in place for access. During an observation on 6/16/25 at 10:30 A.M., CCHT #12 initiated CVC exit site care for Patient #10. She removed the old dressing, changed her gloves (sanitizing her hands before donning a new pair of gloves) and began disinfecting the exit site with a swab of 2% Chlorhexidine with alcohol. She swabbed the site for 5 seconds, discarded the swab and used a second swab to finish disinfecting the site. She swabbed the area with the second swab for 15 seconds, for a total disinfection time of 20 seconds and not for the 30 seconds as per the manufacturers’ instructions. During an interview on 6/16/25 at 4:30 P.M., CCHT #12 said that she thought she disinfected the site for 30 seconds but did not.”

“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: 27189 Based on observation and interview, the facility failed to ensure equipment solutions were maintained according to manufacturer’s expiration date. Findings include: On 6/16/25 at 8:05 A.M., during the flash tour of the dialysis water treatment area, the surveyor observed that 1 of 3 bottles of solutions required for calibration of the Myron meter (provides fast, accurate, on-the-spot measurements of Total Dissolved Solids(TDS) or conductivity) had expired according to the manufacturer’s expiration date: TDS-Conductivity solution 442-15 had a manufacturer’s expiration date of 6/10/25. During an interview on 6/16/25 at 1:30 P.M., the Bio-med Technician said that the solution had expired according to the manufacturer’s expiration date and he would discard and replace the solution.”

“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: 27189 Based on observation, record review and interview, the facility failed to ensure the dialysis treatment order was delivered as prescribed, relative to the dialysate (a balanced solution used during hemodialysis that contains various electrolytes and a buffer, such as bicarbonate, to help maintain the body’s electrolyte balance) for 1 of 4 patient prescriptions observed (#9) out of total sample of 10 patients. 1. For Patient #9, the facility failed to ensure the dialysis prescription was delivered as prescribed relative to the dialysate. Patient #9 was admitted to the facility with a diagnosis of End Stage Renal Disease (ESRD), requiring hemodialysis treatments 3 times a week. During an observation on the treatment floor on 6/16/25 at 9:52 A.M., the surveyor observed Patient #9 receiving dialysis treatment. The dialysis machine was attached (via tubing) to the wall box (this dispenses the dialysate from the water treatment room to the wall box), which indicated Patient #9 was receiving the dialysate of 2.0 K+ 2.5 Ca+. During an interview on 6/16/25 at 9:59 A.M., Registered Nurse (RN) #9 and the surveyor verified the patient’s prescription and RN #9 said the dialysate should be 3.0 K+ 2.5 Ca+, and not the 2.0 K+ 2.5 Ca+ that Patient #9 was currently receiving. Review of the Dialysis order report indicated that Patient #9’s dialysate should have been 3.0 K+ 2.5 Ca+, according to the physician’s order dated 6/10/25. During an interview on 6/16/25 at 10:12 A.M., the Clinical Manager said that the dialysate should have been 3.0 K+ 2.5 Ca+, (as ordered by the physician) and not the 2.0 K+ 2.5 Ca+ that Patient #9 was currently receiving.”

“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 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 for 1 of 7 applicable patients (#5), out a total sample of 10 patients. Findings Include: Review of the facility’s policy titled, Assessment, Plan of Care (CAPOC), last revised 6/11/25, indicated the following: *The patient will be an integral part of the planning process and will be a part of the interdisciplinary meeting whenever possible. The patient or patient representative will be invited to attend the Care Plan meeting. If the patient is not able or chooses not to attend the meeting, the plan of care will be discussed with him/her by a member of the health care team and the patient’s signature obtained on the care acknowledge form. * The Interdisciplinary team (IDT) must make efforts to involve the patient and/or patient representative (if desired by the patient) in the plan of care process. The team must document all efforts to include the patient in the process and the patient’s response to those efforts in the patient’s electronic medical record. *If the patient chooses not to sign the plan of care, this choice must be documented on the plan of care acknowledgement form along with the reason the signature was not provided. For Patient #5, the facility failed to ensure that Patient #5 signed the Care Plan Acknowledgement form indicating that the plan of care was reviewed with the patient, or documentation that the patient refused to provide a signature. Patient #5 was admitted to the facility in June 2024 with a diagnosis of ESRD, requiring hemodialysis treatments 3 times a week. Review of the Care Plan Meeting Acknowledgement form, dated 9/30/24, indicated that the patient signed the form on 9/30/25 indicating he/she would not be attending the care plan meeting on 10/25/24. Review of the clinical record indicated the 90 day Comprehensive assessment and plan of care were initiated on October 24, 2024. Review of the IDT Approval Signature section of the POC included the electronic signatures of the nurse, dietitian, social worker, and physician, indicating they signed the care plan review on October 25, 2024. Further review of the signature page failed to indicate whether the patient participated in the care plan meeting or any documented evidence that the plan of care was reviewed with Patient #5. During an interview on 6/16/25 at 3:35 P.M., the Clinical Regulatory Manager said she was unable to locate a signature page or documentation that the plan of care was reviewed with the patient, or that he/she failed to sign and why.”