Quality Care Dialysis - Southern Maryland

“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: 36839 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene requirements were complied with by the clinical staff. This failure placed all patients at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Findings included: As per the Centers for Disease Control and Prevention (CDC), the primary method to prevent contaminant transmission is through hand washing. The CDC recommends vigorous rubbing of hands together for 15 seconds during hand washing and ensuring complete coverage of hands and fingers with alcohol-based rubs until hands are dry. Even when using gloves, it is crucial to practice hand hygiene after glove removal due to potential contamination from glove defects and the outer surface during removal. Gloves should be worn before interacting with patients at the treatment station and in areas with potentially contaminated surfaces like dialysis machines and environmental surfaces. During observations in the clinical treatment room on 12/15/2023, the patient care technician assigned at station #14 did not perform any hand hygiene in between glove changes. This occurred at 11:30 a.m. and again at 11:33 a.m. This finding was discussed with the facility administrator at the end of the survey day on 12/15/2023.”

“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: 36839 Based on observations and interviews with facility staff, the governing body failed to ensure that clean areas and patient supplies were protected from potential cross contamination (unintentional transfer of bacteria or other contaminants from one surface or substance to another especially because of unsanitary handling procedures). This failure placed the patients at potential risk for exposure to blood-borne pathogens and infectious diseases. Findings included: 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. Cellphones and other personal gadgets can harbor germs and contaminants, and keeping them away from clean medical supplies help maintain a hygienic environment, reducing the risk of cross-contamination. Designating specific areas for the handling of medical supplies and keeping personal items separate, contributes to infection control measures in healthcare settings. During observations on the dialysis treatment floor on 12/15/2023, a clinical staff member’s cellphone was found placed on top of a red-and-black supply cart facing station #12. The cellphone was immediately next to the clean supplies used for dialysis patients which included cannulation needles, blue chux, blue clamps and boxes of gloves. This finding was verified with the charge nurse immediately upon observation on 12/15/2023.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 36839 Based on observations and interviews with facility staff, the facility administrator and medical director failed to ensure that small containers with chemicals or solutions were correctly labeled. This failure placed the patients and staff at potential risk of harm. Findings included: During batch preparation, it is essential to attach a precise label to the container of any solution or mixture. This label should offer clear identification, including the date and time of preparation, the chemical composition or formulation of the concentrate, and the initials of the preparer. The label should stay on the container until the solution is changed or emptied. It is crucial to update labels each time a solution for system use is prepared. During observations in the dialysis treatment room, the following were noted: 1. On 12/15/2023: a. At the “dirty sink” near station #10, a rectangular basin containing blue hemostat clamps soaked in unidentified clear liquid did not have any label of the date and time it was prepared and the initials of the staff member who prepared it. b. On a 2-tier cart facing stations #8 and #9, a rectangular basin containing unidentified clear liquid did not have any label of the date and time it was prepared, and the initials of the staff member who prepared it. 2. On 12/18/2023, on top of a supply cart facing station #18, a rectangular basin with unidentified clear liquid did not have any label of the date and time it was prepared and the initials of the staff member who prepared it. These findings were confirmed by the charge nurse and was discussed with the facility administrator during the exit conference on 12/18/2023.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 36839 Based on observations, the facility’s administration 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 for injury or infection. Findings included: To ensure safety and functionality, it is important to keep all buildings and building systems free from defects and hazards. Surfaces such as countertops, floors, and walls must maintain their integrity, remaining clean, intact, and free from damage. This integrity enables effective cleaning and reduces the risk of microbial growth on porous surfaces. During observations in the clinical treatment floor on 12/18/2023, the following were noted: 1. The drawer handle on the left lower side of the supply cabinet facing station #4 was broken. 2. There was resistance in opening and closing the second left bottom drawer of the supply cabinet. These findings were confirmed by the charge nurse upon observation and discussed with the facility administrator during the exit conference on 12/18/2023.”

“PR-CAN HAVE ADVANCE DIR,TOLD FAC AD P&P CFR(s): 494.70(a)(6) The patient has the right to- (6) Be informed about his or her right to execute advance directives, and the facility ’ s policy regarding advance directives; This Standard is not met as evidenced by: 36839 Based on medical record review, the facility administrator and medical director failed to ensure that all of the facility’s patients had a completed Medical Orders for Life-Sustaining Treatment Form (MOLST) in their patient records. This failure denied the patient’s rights to formulate treatment decisions that served their end-of-life needs. Patients: #1 Findings included: Maryland Code 10.01.21.04B(4)E(1)(2)(3) mandates that, starting July 1, 2013, kidney dialysis centers must accept, update, and complete the Medical Orders for Life-Sustaining Treatment (MOLST) form during patient admission. When completing or updating the MOLST form, health care facilities must offer patients or authorized decision makers the opportunity to participate. If declined, the facility must document the refusal in the medical record, including the date, time, participants, and a summary of the discussion. Patients are to be informed that the MOLST form becomes part of the medical record, accessible through standard record procedures. Upon review of the sampled patients’ charts, it was noted that Patient #1, who was admitted to the facility on 5/23/2023, did not have a completed MOLST form in their records. This finding was confirmed by the clinical coordinator on 12/15/2023.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 36839 Based on patient records review, the medical director and the governing body, failed to ensure that the interdisciplinary team (IDT) members met as a team in order to discuss the patients’ plans of care. This failure placed all affected patients at potential risk of harm and denied patients their rights. Patients: #3, #4, #6, and #7 Findings included: The plan of care (PoC) is developed in order to meet the patient’s needs, outlining the services provided by healthcare professionals, the frequency of care, and expected outcomes. The Interdisciplinary Team (IDT), comprising the patient’s physician, nurse, social worker, and dietitian, collaborates on creating the PoC. Patients are welcome to attend and engage in their plan of care meetings based on their preferences. As stated in the facility’s policy on Comprehensive Interdisciplinary Assessment and Plan of Care (Reference #45283, page 1), “The Comprehensive Interdisciplinary Assessment and Plan of Care (POC) must be completed electronically in the patient’s medical record. The POC must be signed at the time of the interdisciplinary team (IDT) meeting for those attending in person. If unable to sign at the time of the meeting, or if attending remotely, the care plan must be signed by the IDT member within 30 days of the IDT meeting. A review of the sampled patients’ PoCs on 12/15/2023 revealed the following: 1. Patient #3’s PoC was done on 11/9/2023, showed that the social worker’s documentation was not completed. 2. Patient #4’s PoC was done on 12/30/2022, but the social worker’s signature was missing. 3. Patient #6’s PoC was done on 11/28/2022, but the nephrologist’s signature was missing. 4. Patient #7’s PoC was done on 7/19/2023, but the nephrologist’s signature was missing. These findings were verified with the clinical manager upon review of the medical records on 12/15/2023, and again discussed with the facility administrator during the exit conference on 12/18/2023.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36839 Based on medical records reviewed, the governing body failed to ensure that all initial nursing assessments were completed by the assigned registered nurse prior to the patients’ initial dialysis treatment when being admitted to the facility. This failure placed the affected patients at risk for receiving insufficient and ineffective care, and denied the patients their rights. Patients: #2, #3, #5 and #7 Findings included: Before starting dialysis treatment, each patient requires an initial dialysis prescription, care orders, and comprehensive baseline physical and nursing assessments completed and documented at the facility. A nursing assessment covers a range of areas: physical examination, vital signs, vascular access assessment and overall patient condition. It also involves a neurological assessment, subjective complaints, pain, activity, respiratory and cardiac assessments, fluid status, skin condition, temperature and bowel sounds. A review of the sampled patients’ medical records on 12/15/2023 revealed the following: 1. Patient #2 was admitted to the facility on 6/30/23; the patient’s initial nursing assessment was started on 7/12/2023, but remains incomplete as of the day of the survey on 12/15/2023. 2. Patient #3 was admitted to the facility on 10/31/23; the patient’s initial nursing assessment remains incomplete as of the day of the survey on 12/15/2023. 3. Patient #5 was admitted to the facility on 7/5/2023, but the patient’s initial nursing assessment was not completed until 7/28/2023. 4. Patient #7 was admitted to the facility on 6/9/23, but the patient’s initial nursing assessment was not completed until 7/10/2023. These findings were verified by the clinical manager at the time of the medical records review on 12/15/2023 and again discussed with the facility administrator during the exit conference on 12/18/2023.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 36839 Based on observations, the facility’s administration failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access prior to cannulation. This failure placed the safety and well being of the patients at potential risk of harm in maintaining their vascular access. Findings included: Hemodialysis requires access to a patient’s blood vessels. A brief physical examination of the patient’s access should always be performed prior to each dialysis treatment. Healthcare providers use a stethoscope to assess blood flow through the access site, crucial for maintaining an adequate rate during dialysis. Inadequate flow can impact dialysis efficiency that can lead to complications. The physical exam should include, but is not limited to: · Visual inspection: Watch for signs of infection, such as redness, swelling or discharge. · Palpation: Ensure that blood is flowing through the vascular access by feeling for thrill (vibration or a rumbling sensation that you can feel). · Auscultation: Listen for bruit (a rumbling sound of blood moving through the patient’s arm access that you can hear) with the use of a stethoscope. During clinical observations in the hemodialysis treatment room 12/15/2023, the following were noted: 1. At 11:20 a.m., the patient care technician (PCT) assigned at station #9 did not listen to the patient’s access site with a stethoscope prior to cannulation. 2. At 11:28 a.m., the PCT assigned at station #1 did not listen to the patient’s access site with a stethoscope prior to cannulation. 3. On 12/18/2023 at 10:56 a.m., the PCT assigned at station #5 did not listen to the patient’s access site with a stethoscope prior to cannulation. These findings were discussed with the facility administrator during the exit conference on 12/18/2023.”