Usrc Creve Coeur Dialysis

“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: 18018 Based on review of patients’ Hemodialysis Flowsheets, policy review and interview, the facility failed to ensure staff followed physician orders for: - Bolus/Initial Heparin (medication used to thin blood and/or prevent blood clot formation) administration for two patients (#3, and #13) out of three patients’ Hemodialysis Flowsheets reviewed for bolus/initial heparin administration. - Hourly/Maintenance Heparin administration for two patients (#3 and #13) out of three patients’ Hemodialysis Flowsheets reviewed for hourly/maintenance heparin infusion administration. The failure to follow the heparin order had the potential for dialysis complications including excessive bleeding or clotting for all patients that received heparin. - Duration of dialysis treatment for two patients (#12 and #13) out of three patients’ Hemodialysis Flowsheets reviewed for duration of dialysis treatment. The failure to follow the prescription time had the potential for dialysis complications due to inadequate treatment time. The In-Center Hemodialysis (Hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 61. Findings included: 1. Review of Patient #3’s Hemodialysis Flowsheets showed: - The ordered bolus/initial heparin was 1000U/mL (Units, millimeters, measurement) to be administered three (3) to five (5) minutes before the start of dialysis treatment. - The ordered hourly/maintenance heparin was 3500U/mL to be administered throughout the dialysis treatment. - On 09/12/25, 09/10/25, 09/05/25, and 09/03/25, the patient’s Hemodialysis Flowsheet showed staff documented they administered the hourly/maintenance heparin, however, patient’s Hemodialysis Flowsheet under Heparin Prime and Hourly showed zero heparin was administered, indicating the patient did not receive the hourly/maintenance heparin infusion from the start of dialysis until the end of the patient’s dialysis treatment. - On 09/10/25, 09/08/25, and 09/03/25, staff documented the bolus/initial heparin was not administered within 3 to 5 minutes before the start of the patient’s dialysis treatment. 2. Review of Patient #12’s Hemodialysis Flowsheets showed: - The ordered duration for the patient’s dialysis treatment was 225 minutes (three hours and 75 minutes). - On 09/12/25 at 8:41 AM, staff documented treatment paused and blood returned due to machine difficulties with 20 minutes remaining in treatment. Review of the patient’s Hemodialysis Flowsheet showed the patient’s Treatment Length was documented at three hours and 27 minutes, which was approximately 28 minutes short of the ordered time. - On 09/10/25, the Treatment Length was documented at three hours and 54 minutes, which was approximately 21 minutes short of the ordered time. - On 09/05/25, the Treatment Length was documented at three hours and 48 minutes, which was approximately 27 minutes short of the ordered time. - On 09/03/25, the Treatment Length was documented at three hours and 46 minutes, which was approximately 29 minutes short of the ordered time. - On 09/01/25, the Treatment Length was documented at three hours and 45 minutes, which was approximately 30 minutes short of the ordered time. Staff failed to document the reason the duration of the patient’s dialysis treatment was short on 09/10/25, 09/05/25, 09/03/25, and 09/01/25. 3. Review of Patient #13’s Hemodialysis Flowsheets showed: - The ordered bolus/initial heparin was 2000U/mL. - The ordered hourly/maintenance heparin was 1000U/mL. - The ordered duration for the patient’s dialysis treatment was 225 minutes (three hours and 75 minutes). - On 09/12/25, the Treatment Length was documented at three hours and 54 minutes, which was approximately 21 minutes short of the ordered time. - On 09/10/25, the Treatment Length was documented at three hours and 49 minutes, which was approximately 26 minutes short of the ordered time. - On 09/08/25, the Treatment Length was documented at three hours and 53 minutes, which was approximately 22 minutes short of the ordered time. - On 09/05/25, the Treatment Length was documented at three hours and 53 minutes, which was approximately 22 minutes short of the ordered time. - On 09/03/25, the Treatment Length was documented at three hours and 51 minutes, which was approximately 24 minutes short of the ordered time. - On 09/01/25, the Treatment Length was documented at three hours and 49 minutes, which was approximately 26 minutes short of the ordered time. - On 09/10/25, 09/05/25, and 09/01/25, staff documented the bolus/initial heparin was not administered within 3 to 5 minutes before the start of the patient’s dialysis treatment. 4. Review of the facility’s policy titled, “Heparinization/Heparin - Free Protocol,” dated 02/2023, showed staff directives: - Ensure safe and appropriate administration of heparin to hemodialysis patients. - Prevent clotting in the extracorporeal circuit and/or dialyzer. - Optimize dialyzer clearance to achieve delivery of adequate dialysis. - Minimize blood loss from clotting or excessive bleeding. - Pre-Treatment (loading/bolus): Administer into the second inserted needle or catheter 3-5 minutes prior to hemodialysis treatment initiation. - During Treatment (maintenance dose): Administer using the heparin infusion line and pump. 5. During interviews conducted on 09/12/25 at 3:00 PM, Staff K, Interim Facility Administrator, acknowledged staff did not always administer bolus/initial heparin 3-5 minutes before the start of patients’ dialysis treatment. At 3:10 PM, Staff L, Training Facility Administrator, stated staff did not always document bolus/initial heparin was administered to patients 3-5 minutes before the start of patients’ dialysis treatments and the hourly/maintenance heparin was not always reflected on patients’ Hemodialysis Flowsheets as being administered throughout patients’ dialysis treatments. Staff L stated the expectation of staff was to administer the bolus/initial heparin within 3-5 minutes prior to the start of patients’ dialysis treatment and to ensure the hourly/maintenance heparin was started and if it was started late to document the infusion was late getting started. Staff L stated staff was expected to follow the facility’s policies, procedures and protocols.”

“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: 17026 Based on observations and staff interview, the facility staff failed to wear gloves when they adjusted the dialysis machine during one observation (station # 17) and failed to change gloves and sanitize their hands when going from one dialysis machine to another dialysis machine during two observations. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 132. Findings included: 1. Observation on 8/12/24 at 12:29 PM showed staff (J) adjusted the dialysis machine at station # 17 without gloves on his hands. 2. Observation on 8/12/24 at 12:40 PM showed Patient Care Technician (F) adjusted the dialysis machine at station # 20 and then adjusted the dialysis machine at station # 18 without changing gloves or sanitizing his hands when going from one dialysis machine to another dialysis machine. 3. Observation on 8/12/24 at 2:05 PM showed PCT (F) adjusted the dialysis machine at station # 17 and then removed his gloves but did not sanitize or wash his hands before assisting the patient at station # 19. 4. During an interview on 8/13/24 at 3:17 PM, the interim facility administrator agreed staff should wear gloves when they adjust the dialysis machines and staff should change gloves and sanitize their hands when going from one dialysis machine to another dialysis machine.”

“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: 17026 Based on observations and staff interview, the facility staff failed to fully disinfect two dialysis stations (station # 13 and # 16) and failed to wait until the patient left the dialysis station before starting station disinfection at one (station # 2) out of 24 dialysis stations. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 132. Findings included: 1. Observation on 8/13/24 at 10:01 AM showed Patient Care Technician (PCT) (F) disinfected the dialysis machine at station # 2 while the patient remained in the dialysis chair at the station. Staff did not wait until the patient left the station to start station disinfection. 2. Observation on 8/12/24 at 12:35 PM showed PCT (I) disinfected station # 16 but did not disinfect the intravenous pole/hooks or the chase wall (wall that houses the water distribution system) behind the station. 3. Observation on 8/12/24 at 2:09 PM showed PCT (I) disinfected station # 13 but did not disinfect the chase wall behind the station. 4. During an interview on 8/13/24 at 3:17 PM, the interim facility administrator agreed staff need to disinfect the entire dialysis station and wait until the patient leaves the dialysis station before starting station disinfection”

“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: 17026 Based on observations and staff interview, the facility staff failed to maintain the cleanliness under two clean sinks in the dialysis treatment area and failed to maintain the cleanliness of one of one cart in the acid mixing room. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 132. Findings included: 1. Observation on 8/12/24 at 11:12 AM of the area under the clean sink at the entrance to the dialysis treatment area showed it contained an approximately two feet by eight inch area of black, brown, and yellow spills and stains. 2. Observation on 8/12/24 at 12:02 PM of the area under the clean sink adjacent to the nurses station in the dialysis treatment area showed an approximately one foot by eight inch area with yellow and brown spills and stains. 3. Observation on 8/12/24 at 11:17 AM of the acid mixing room showed a cart with supplies that had white, yellow, and brown spills and stains on the top and bottom of the cart. 4. During an interview on 8/13/24 at 3:17 PM, the interim facility administrator said she did not know how long the areas under the clean sinks in the treatment area had the spills and stains but staff need to ensure the areas and cart were clean.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete the initial care plan within 30 days for three patients (Patient # 2, # 3, and # 4) out of 13 clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 132. Findings included: 1. Review of the clinical record for Patient # 2 showed the patient started on dialysis on 6/24/24 but staff did not complete the initial care plan yet. 2. Review of the clinical record for Patient # 3 showed the patient started on dialysis on 5/7/24 but staff did not complete initial care plan until 7/17/24. 3. Review of the clinical record for Patient # 4 showed the patient started on dialysis on 5/4/24 but staff did not complete the initial care plan until 7/17/24. 4. During an interview on 8/13/24 at 3:17 PM, the interim facility administrator said staff were behind on some of the initial care plans.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete a monthly care plan for one of one patient (Patient # 1) that staff determined to be unstable due to an extended hospitalization. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 132. Findings included: 1. Review of the clinical record for Patient # 1 showed staff determined the patient to be unstable 4/15/24 due to an extended hospitalization and the patient required a ventilator (machine that assists with breathing). 2. Review of the care plans for the patient showed staff completed an unstable care plan for the patient on 4/17/24 but did not complete the unstable care plan for the patient in May, June, or July of 2024. 3. During an interview on 8/13/24, Registered Nurse (RN) (A) said the patient remained unstable since 4/17/24 since he still required a ventilator, but staff did not complete the unstable care plan for the patient in May, June, or July of 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: 17026 Based on observations and staff interview, the facility staff failed to maintain the water room floor and equipment free of brown stains, rust, and areas of brown and white matter. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 62. Findings included: 1. Observation on 11/14/23 at 11:38 AM of the facility water room showed areas of brown and white matter around the water softener, primary carbon tank, secondary carbon tank, and acid tank. 2. Further observation on 11/14/23 at 11:39 AM of the facility water room showed an approximately two inch by three inch area of black matter on the floor next to the hot water heater, yellow and brown spills on the wall behind the hot water heater and acid tank, and areas of brown rust throughout the water room floor. 3. During an interview on 11/14/23 at 11:40 AM, the biomedical technician said staff need to clean the floor and walls in the water room, and he agreed that the water room floor needed resurfaced.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to check the blood pressure every 30 minutes for one patient (Patient # 2) and failed to follow the physician order for the blood flow rate or dialysate flow rate for two patients (Patient # 1 and # 3) out of three clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 62. Findings included: 1. Review of the treatment flow sheet dated 11/9/23 for Patient # 2 showed staff documented a blood pressure check at 12:30 PM, but did not document another blood pressure check until 1:29 PM for the patient during dialysis treatment. Staff also did not document the setting for the blood flow rate or the dialysate flow rate during the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 11/9/23 for Patient # 1 showed the physician directed staff to set the blood flow rate at 450 and the dialysate flow rate at 500, but staff set the blood flow rate at 400 and the dialysate flow rate at 800 during the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 11/13/23 for Patient # 3 showed the physician directed staff to set the dialysate flow rate at 500, but staff set the dialysate flow rate at 800 during the patient’s dialysis treatment. 4. During an interview on 11/14/23 at 1:33 PM, the facility administrator said staff should check the patients’ blood pressure every 30 minutes during dialysis treatment, and staff should follow the physician order for the blood flow rate and dialysate flow rate.”