Bma - Leonardtown

“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: 47759 Based on observations, staff interviews and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the appropriate catheter care techniques and procedures the facility put in place to prevent intravascular catheter-related infections. This failure placed patients at potential risk of infection. Findings Include: On 06/07/2024 at 03:00 p.m., review of the facility’s policy titled “Initiation of Treatment Using a Central Venous Catheter (reference number: 45651)” page 3 number 9 states “Put mask on the patient. “Page 4, step numbers 3 to 4 then states “Using a sterile alcohol pad scrub the sides and end of the hub thoroughly with friction...using the same sterile alcohol pad applying friction to remove any blood or residue, move from the hub at least several centimeters towards the body of the catheter (Steps 3 and 4 should take 10-15 seconds). “ Policy titled “Central Venous Catheter (CVC) Dressing Change (Reference Number: 47516)” page 4 step 2 of cleaning the catheter site states “If using 2% Chlorhexidine and 70% alcohol: Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds.” On 06/04/2024, during clinical observations of the treatment floor, the surveyor observed the following: 1. At 11:41 a.m., the surveyor (a) observed Staff #1 disinfect the exit site of [patient sitting in station #11] for 17 seconds and (b) observed Staff #1 scrub the arterial hub of the [patient sitting in station #11] for 2 seconds and the venous hub for 12 seconds. 2. At 12:20 p.m., the surveyor (a) observed the [patient sitting in station #13] without a mask on during dressing change and/or without education on infection control performed, (b) observed Staff #2 disinfect the exit site of [patient sitting in station #13] for 18 seconds, and (c) observed Staff #2 scrub the arterial hub of the [patient sitting in station #13] for 7 seconds and the venous hub for 4 seconds 3. At 12:30 p.m., the surveyor observed Staff #5 disinfect the exit site of [patient sitting in station #7] for 13 seconds. On 06/07/2024, Staff #5 corroborated that the staff members mentioned did not abide by the facility policy.”

“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: 47759 Based on observations and interviews with the staff members, the governing body failed to ensure an environment free from defects or hazards in order to maintain safety and functionality. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings included: According to the Centers for Medicare and Medicaid Services (CMS), “All buildings and building systems must be maintained free from defects and/or hazards to ensure safety and functionality. Integrity of all surfaces, (e.g., countertops, floors, walls) must be intact, clean and free from damage. Intact surface integrity allows for effective cleaning and limits the potential for microbial growth on a porous surface.” On 06/04/2024 between 11:30 a.m. -12:15 p.m., during physical inspection of the facility, the surveyor observed the following: 1. During inspection of the laboratory area, the surveyor observed a.) stained countertop with brown and white color b.) peeling linoleum at the back corner and c.) sink with red and brown color surrounding the sides 2. During inspection of the water room area, the surveyor observed a.) uncovered electrical panel and b.) missing ceiling tiles above the electrical area 3. During inspection of the floor and walls of the treatment floor, the surveyor observed a.) a hole on the drywall near Station #17 b.) a separated linoleum tiles located between station #13 and #14 causing uneven flooring. 4. During inspection of the items on the treatment floor, the surveyor observed a.) a chair that had a rip in the middle located in station #9, b.) missing hazard container lid located in station #18, c.) a keyboard cover that is no longer intact located in station #18 5. During inspection of the storage room a pulley in front of the electrical panel with a cardboard leaning on the electrical panel where it states “do not place any items in front of the electrical panel” 6. During inspection of the employee bathroom near the conference room, the surveyor observed an unstable toilet. Per an anonymous staff member, the problem is due to uneven flooring. On 06/07/2024, the Clinical Manager agreed to the surveyor’s findings and acted as witness to the observations.”

“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: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access prior to cannulation and practiced the correct infection control protocol. This failure placed the safety and wellbeing of the patients at potential risk of harm in maintaining their vascular access. Findings Included: On 06/06/2024 at 03:00 p.m., review of the facility’s policy titled “Access Assessment and Cannulation (reference number 45178)”, page 2 step 6 states, “Staff/patients/care partners who have been trained to auscultate vascular access should listen to the entire length of the access for changes in the sound of the bruit-A low pitched bruit should be present.” Page 4 step 1 “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 it to dry before cannulating.” Step 2 “Do not touch cannulation sites after skin disinfection. On 06/04/2024 during clinical observations of the treatment floor, the surveyor observed the following: 1. At 11:50 a.m., Staff #5 disinfected the access site of the [patient sitting in Station #15] for 11 seconds total. 2. At 12:11 p.m., Staff #1 disinfected the access site of the [patient sitting in Station #7] for 18 seconds total. On 06/05/2024, during during clinical observations of the treatment floor, the surveyor observed the following: 1. At 10:55 a.m., Staff #6 did not use the stethoscope to auscultate the [patient sitting in Station #12]’s access site. Staff #6 then proceeded to disinfect the access site of the [patient sitting in Station #12]’s access site for 11 seconds total as well as palpated the access site prior to cannulation. 2. At 11:08 a.m., Staff #6 did not use the stethoscope to auscultate the [patient sitting in Station #7]’s access site. Staff #6 then proceeded to disinfect the access site of the [patient sitting in Station #7]’s access site for 10 seconds total as well as palpated the access site prior to cannulation.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 47759 Based on review of Quality Assessment and Performance Improvement (QAPI) meeting minutes and interviews with staff, the facility’s governing body failed to (1) analyze the incorporated mortality data to identify potential problems and opportunities for improving care and (2) ensure staff members are documenting adverse event per facility policy. This failure placed patients at potential risk of harm by failing to utilize the data gathered to identify potential problems in the facility resulting in delay in interventions aimed at improvement. Findings Included: On 06/06/2024 at 03:00 p.m., during review of the mortality review guide worksheet provided to the surveyor, it states “the required entries for the monthly mortality analysis workbook must include the following:...make sure to select and enter the primary cause of death for the patient from the drop down box.” Based on the facility’s policy titled “Patient Safety Event Reporting and Documentation (Reference Number 61085)” page 3 states, “Any bleeding involving a patient’s dialysis access, regardless of where the event occurred, should be considered a Safety or Serious Safety Event.” On 06/06/2024 at 12:45 p.m., during review of the facility’s mortality review documentation from July 2023-May 2024. The surveyor observed that 6 out of the 7 patients (85%) did not have a documented “cause of death.” Interviews with the Clinical Manager on 06/06/2024 at 12:50 p.m., corroborated that mortality should have been reviewed, analyzed and discussed during QAPI and will be done so moving forward. On 06/06/2024 at 12:30 p.m. during review of the facility’s adverse event log, the surveyor observed that an adverse event categorized as post treatment bleeding which occurred on 06/04/2024 from 11:00 a.m. -11:37 a.m. was not documented on the adverse event log 2 days after the incident. Interviews with Staff #8 on 06/06/2024 at 12:40 p.m. corroborated that the incident should have been documented per policy.”