Usrc New Carrollton Dialysis

“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: 44367 Based on observations and a review of the facility’s policies and procedures, the governing body failed to ensure that the clinical staff followed the standard regulations in the cleaning and disinfection of contaminated equipment being used in the facility. This failure placed the patients at potential risk for exposure to blood-borne pathogens and infectious diseases. Staff: #1 Findings included: Review on 04/24/2024 of the facility’s policy # C-IC-0080 entitled “Disinfection and Cleaning of Dialysis Machine Equipment” states, “Complete surface disinfection at the end of each dialysis treatment after the patient has vacated the station.” The policy also states, “Clean all external surfaces of the dialysis machine to include top, sides, front, back, blood pressure cuffs and basket: dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole, attached computer monitors and keyboard/mouse.” On 04/24/2024 at 11:10 a.m., the surveyor observed that during the termination process at Station #8 machine #6, Staff #1 did not clean the prime bucket or the items at the top of the hemodialysis machine which consist of two blue clamps, clear bag and a white laminated paper. On 04/26/2024 at 10:15 a.m., at station #12 machine #1, the surveyor noted that the machine was newly assembled and in test mode for the next patient’s treatment while the current patient was holding their vascular access in order to stop the bleeding. Staff #1 did not wait until the station was completely vacated before setting up for a new patient. The Facility Administrator was informed of the findings on 04/24/2024 and 04/26/2024.”

“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: 44367 Based on observations and review of the facility’s policies and procedures, the governing body and the medical director failed to ensure that the clinical staff complied with the appropriate catheter care techniques and procedures. This failure placed patients at potential risk of infection or harm in maintaining their central venous catheter. Staff: #2 Findings include: According to the National Institute of Health (NIH), “A central venous catheter (CVC) is an indwelling device inserted into a large, central vein (most commonly the internal jugular, subclavian, or femoral) and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava, or right atrium [parts of the heart].” Review on 04/25/20204 of the facility’s policy C-TI-0090 entitled “Accessing and De-Accessing the Dialysis Catheter” revealed, “Using aseptic technique, disconnect arterial bloodline from catheter...Disinfect the hub with an alcohol prep pad. Clean the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue (e.g. blood). Allow to dry.” During observation of the clinical treatment area on 04/25/2024 at 11:41 a.m., during treatment termination of a Central Venous Catheter (CVC) patient at station #1 machine #4, Staff #2 did not clean the venous hub immediately after disconnecting the arterial bloodline and before attaching the 10 ml syringe. The Facility Administrator was informed of the findings on 04/25/2024.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 44367 Based on observations and interviews with the facility’s staff, the Facility Administrator and Medical Director failed to ensure the water purification and storage systems was secure at all times. This failure had the potential to place all patients at potential risk of harm. Findings include: During the flash tour of the facility on 04/24/2024 at 10:15 a.m., the surveyor noted the water treatment room did not have a door, gate, or the ability to secure the water treatment system. The water treatment room and the supply room are separated by a wall with an opening which will allow unauthorized individuals, such as delivery personnel access to the water system. The Facility Administrator was asked by the surveyor if all delivery personnel is accompanied by the facility personnel for the duration of the delivery. The Facility Administrator corroborated that the delivery personnel is not supervised for the duration of the delivery. The Facility Administrator and Regional Operations Director were informed of the findings on 04/24/2024.”

“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: 44367 Based on observations and interviews with the facility’s administration, the governing body failed to ensure that the water treatment room and supply room were kept clean at all times. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings included: On 05/24/202 at 10:20 a.m., during the flash tour of the water room and supply room area, the surveyor observed the following: A gross amount of white colored crystallization build up at the base and the black spout of the 2.0 K 2.5 CA and the 3.0 K 2.5 CA holding tanks and gross amount of small in size debris throughout the supply room floor. The Facility Administrator was informed and observed the findings on 04/24/2024.”

“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: 44367 Based on observations and a review of the facility’s policies and procedures, the facility’s governing body failed to ensure that all ancillary equipment checks were performed as required and the facility was free of expired supplies. This failure placed the patients at potential risk of harm. Findings include: On 09/24/2024, observation of the laboratory area revealed, nineteen (19) navy blue Vacuette Tubes blood tubes, lot number B22103HY expired 04/10/2024. Review on 04/25/2024 of the facility’s policy #C-Forms-0401 entitled “Medication and Laboratory Refrigerator Temperature Log” states, “Monitoring frequently: 1) Medication Refrigerator: twice daily.” Inspection of the medication refrigeration logs on 05/25/2024 revealed the refrigerators temperature is to be checked in the morning and the evening. When no documentation is present, it is an indication that the refrigerators temperatures were not monitored on the following days: Refrigerator labeled “Med #1” the section “PM” was blank on 02/02/2024, 02/16/2024, 02/22/2024 and 03/25/2024. Refrigerator labeled “Med #2” the section “PM” was blank on 02/16/2024. On 02/03/2024 and 04/13/2024, both sections labeled “AM” and “PM” were left blank. The Facility Administrator was informed of the findings on 04/25/2024”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 44367 Based on review of the dialysis patients’ treatment flowsheets, the facility’s administration and clinical staff failed to ensure that the dialysis prescriptions were the same as what the patients received. Failure to ensure that the dialysis prescription was implemented according to the Nephrologist’s orders placed the patients at potential risk of harm, injury and denied the patients their rights. Patients: #2 Findings included: In order to have an effective dialysis treatment, the Blood Flow Rate (BFR) and the Dialysate Flow Rate (DFR) must be accurate and reflect the doctor’s prescription. The staff member must verify that the rate on the readout is correct. The BFR and DFR are part of the order for treatment; there could be a “sliding scale” guide or protocol for adjusting the BFR. If not, there would need to be an order for the change. If the staff is not able to achieve the ordered BFR or DFR, the record should address this issue, including the date and time that this problem was communicated to the physician. Review on 04/15/2024 of the facility’s policy #C-Tl-0010 entitled “Initiation of Dialysis Treatment” revealed that “Prior to walking away from patient’s machine, verify all prescribed orders are followed. If unable to follow any part of the patient’s prescription after troubleshooting, notify the charge nurse and document notification. Charge nurse will notify the physician if indicated and document any follow up or new orders.” A review of four (4) selected patients’ treatment flowsheets on 04/24/2024 revealed that one (1) out of the four (4) or 25% of the selected patients did not receive the correct dialysis prescription, as ordered by the Nephrologist. 1. On treatment date 04/15/2024, Patient #2’s BFR was prescribed for 450 ml/min.; however, the BFR was set at 400 ml/min from 10:33 a.m. to 02:24 p.m. There was no documentation found explaining why Patient #2’s BFR was not set on the dialysis machine as prescribed. The Facility Administrator was informed of the findings on 04/24/2024.”