Idf - Calvert Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 36839 Based on observations, the facility’s administration failed to ensure that all staff members in the clinical area took adequate measures in order to prevent the transmission of infectious organisms and the possibility of exposure from contaminants. This failure to reduce the potential spread of infections by allowing patients and other staff members to be exposed to potential infectious materials and contaminants, placed the welfare and safety of patients and staff at risk of harm. Findings Included: Appropriate PPE should be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment, and environmental surfaces, such as the patient care areas. PPE is to be removed prior to leaving the treatment area and must be placed in a designated area if intended to be reused, such as gowns and face shields. The PPE is considered “contaminated” from areas that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside. 1. On 11/28/2023 at 12:00 p.m. in the clinical treatment unit, a reusable yellow PPE gown was noted hanging on the corner top rail of the laboratory room door. 2. On 11/29/2023 at 11:45 a.m. in the clinical treatment unit, a reusable PPE yellow gown was noted hanging on the workstation on wheels (WOW) located outside the isolation room. These findings were discussed with the nurse educator during the exit conference on 11/29/2023.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 36839 Based on observations, the facility’s governing body failed to implement the recommendations developed by the Centers for Disease Control and Prevention (CDC) on standard infection control precautions. This failure placed the patients at potential risk for exposure to blood-borne pathogens and other infectious diseases. Findings included: According to CDC, nail length is important because even after careful handwashing, healthcare workers often harbor substantial numbers of potential pathogens in the subungual (under the fingernail) spaces. Numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas), corynebacteria, and yeasts. Natural nail tips should be kept to ¼ inch in length. Additionally, the length of the healthworker’s fingernails significantly compromises the integrity of nitrile, vinyl, or latex gloves. Maintaining short fingernails is important in reducing the risk of damaging these gloves and hence maintaining the barrier function of the gloves. During observations in the clinical treatment unit on 11/28/2023, it was noted that 2 dialysis technicians providing patient care and dialysis treatment to the patients had fingernails measuring greater than 1/4 inch in length. This finding was discussed with the facility’s nurse educator during the exit conference on 11/29/2023.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 36839 Based on observations, the facility’s administration failed to ensure that the clinical staff wore their personal protective equipment (PPE) properly on the clinical treatment floor. This failure posed a risk of exposure to infectious diseases to affected patients and staff. Findings included: Dialysis staff should wear suitable PPE based on potential exposure. Ensuring that the face mask properly covers both the mouth and nose (clinical staff and patient) is crucial during the initiation and termination of dialysis of a patient with a central venous catheter (CVC). This practice effectively reduces the risk of respiratory droplet transmission and maintains a sterile environment during the procedure, contributing to the safety of both the patient and the healthcare provider. During clinical observations on 11/29/2023 at 12:20 p.m., it was noted that while initiating dialysis on a patient with a CVC at station #15, the patient care technician (PCT) and the patient were wearing their masks beneath their noses. At 12:30 p.m., the same PCT performed another CVC put on at station #14 where the patient’s mask did not cover the nose. These observations were discussed with the nurse educator during the exit on 11/29/2023.”

“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: 36839 Based on observations, the governing body failed to ensure that the clinical staff followed the standard regulations in the cleaning and disinfection of contaminated surfaces that are used in the facility. This failure placed the patients and staff at potential risk for exposure to blood-borne pathogens (causative agent of disease, such as bacteria or virus, that is transmitted by blood) and infectious diseases. Findings included: As defined by the Centers for Disease Control and Prevention (CDC), dialysis wall boxes are frames recessed into the wall at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of waste products. There are several infection prevention and control issues unique to wall boxes. They can become easily contaminated with microorganisms, which can subsequently be transferred to dialysis patients, a vulnerable group at high risk of infection. Thus, wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). During observations in the clinical treatment unit on 11/28/2023, it was noted that the wall box at station #17 had multiple brownish-red stains around it. It was re-inspected on 11/29/2023 and found to have the same exact stains as the day before indicating that the wall box was not cleaned at the end of the day. This finding was discussed with the nurse educator during the exit on 11/29/2023.”

“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 hazards in order to maintain safety and functionality. This failure placed the patients, staff and visitors at potential risk for injury or even death. Findings include: The Occupational Safety and Health Administration (OSHA) defines an exit route as “a continuous and unobstructed path of exit travel from any point within a workplace to a place of safety.” Emergency exits need to remain unobstructed to ensure a swift and safe evacuation in case of emergencies such as fires or other hazards. Clear exits allow quick access for individuals to leave the building without delays or impediments, potentially preventing injuries or fatalities. During observations in the clinical treatment unit on 11/28/2023, it was noted that the emergency exit located between the isolation room and station #17 was blocked with a rolling cart and a workstation on wheels (WOW). A “Do Not Block Exit” sign was posted at that door. This finding was discussed with the nurse educator during the exit conference on 11/29/2023.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36839 Based on observations and a review of the facility’s policies and procedures, the facility’s governing body failed to ensure that every patient’s vascular access was visible during hemodialysis treatment. This failure placed the patients at potential risk of harm and possible death. Findings included: A staff member must maintain visual access to every patient, including their face, vascular access site, and bloodline connections, throughout the dialysis procedure. Covering these areas might lead to undetected accidental needle dislodgement or line disconnection, which, within minutes, could cause severe blood loss and endanger the patient’s life. Patients can refuse aspects of their treatment plans, but if a patient declines to keep their access uncovered during dialysis, the facility should educate them about the risks, assess their reasons and create a care plan. Simply having a patient sign a waiver does not absolve the facility from monitoring the access site. During observations on the treatment floor on 11/29/2023, it was noted that the patient at station #7 had his dialysis access covered with a blanket from 2:20 p.m. to 2:45 p.m. This finding was discussed with the nurse educator during the exit on 11/29/2023.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 36839 Based on observations, the governing body failed to ensure that the list of patients’ rights was posted at an area in the facility where it can be easily seen and accessed by all of the patients. This failure denied the patients their rights. Findings Included: The Centers for Medicare and Medicaid Services (CMS) requires that all in-center dialysis facilities prominently display a notice of patients’ rights in a common area of the facility where it can be easily seen and accessed by patients. This notice must include a list of patients’ rights, as well as the current contact information for the applicable End-Stage Renal Disease (ESRD) Network and State Survey Agency (SSA) and the current complaint telephone numbers for each. The purpose of this posting is to ensure that patients are aware of their rights and have access to important contact information should they need to file a complaint, or report a concern. However, it is important to note that this posting is meant to supplement, not replace, individual communication with each patient about their rights in a way that they can understand. During an observational tour of the facility on 11/28/2023, it was noted that the list of patients’ rights was not posted anywhere within the patients’ common area. Interviews with 3 randomly-selected patients also revealed that they do not know where to find information about their patients’ rights. This finding was discussed with the nurse educator during the exit conference on 11/29/2023.”

“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 patient at risk for receiving insufficient and ineffective care, and denied the patient his/her rights. Patients: #4 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’ charts on 11/29/2023 revealed that Patient #4 was admitted to the facility on 7/20/2020. No initial nursing assessment was found in the patient’s medical records. This finding was confirmed by the nurse educator on 11/29/2023.”

“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 and a review of the facility’s policies and procedures, the governing body failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access. This failure placed the safety and well being of the patients at potential risk of harm in maintaining their vascular access. Findings included: The facility’s policy and procedure on Preparation of the Central Venous Access (CVC) states: (Page 1, #5) “Loosen or remove CVC site dressing. Check CVC site and surrounding areas for redness, swelling, drainage, missing stitches, pain, warmth and CVC placement.” The facility’s policy on Cannulation of Fistula or Graft states: (Page 2-3, #8) “Once the cannulation sites have been cleansed, do not touch the cannulation site again. If a cannulation site is touched, the area must be cleansed again. During clinical observations on 11/28/2023, the following were noted: 1. At 12:25 p.m., it was noted that the patient care technician (PCT) assigned at station #12 did not loosen or remove the dressing to assess the patient’s CVC access site prior to hemodialysis treatment. 2. At 12:28 p.m., the PCT at station #8 touched the patient’s access site after it had already been cleansed and immediately prior to needle insertion. 3. At 12:30 p.m., the PCT at station #15 touched the patient’s access site after it had already been cleansed and immediately prior to needle insertion. These findings were discussed with the nurse educator during the exit on 11/29/2023.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36839 Based on review of the patients’ plans of care, the governing body failed to ensure that the facility’s interdisciplinary team (IDT) completed the 90-day follow-up comprehensive assessment. This failure placed the affected patient at risk for receiving inadequate health care and denied the patient his/her rights. Patients: #5 Findings included: The IDT should conduct a comprehensive assessment 90 days after establishing the initial Plan of Care (PoC). This assessment evaluates health changes, PoC effectiveness, and identifies new needs. Collaborating with the patient (or designee), a nephrologist, nurse, social worker, and dietitian ensures proper addressing of patient needs and PoC adjustments if health status changes. For experienced dialysis patients moving to a new facility, the receiving IDT must reassess within three months of admission. Upon review of the sampled patients’ medical records on 11/29/2023, it was noted that Patient #5 who was admitted to the facility on 3/11/2022, had an initial PoC completed on 4/25/2022. However, the 90-day PoC was not found. This finding was confirmed by the nurse educator upon reviewing the patient’s medical records.”