Dci Big Sky

“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: 46400 Based on observation and record review, the facility failed to follow standards of hand hygiene and infection control for 1 (#8) of 16 sampled residents. Findings include: During an observation on 10/22/24 at 11:20 a.m., patient #8 was in the process of having dialysis initiated. Staff member K knocked a lab tube off the side table. Staff member K reached down picked the tube off the ground, placed it back on the side table, and connected the dialysis lines to the patients CVC hubs without changing gloves or performing hand hygiene between the clean and dirty areas. Review of the facility policy, Infection Control in the Dialysis Setting, approval date 10/5/17, showed: “4. Change gloves after: ... f. designated dirty areas and before clean areas.””

“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: 44769 Based on observation, interview, and record review, the facility failed to maintain a sanitary environment on the hemodialysis unit. Findings include: During an observation on 10/21/24 at 4:16 p.m., of the dialysis wall boxes, (which contain connections for the dialysis machine to receive acid and base concentrates, treated water, and dispose of waste products) there was a pinkish black buildup observed with a scattered lint appearing substance on station #’s 25 and 26’s water box drain basin. During an observation and interview on 10/23/24 at 11:25 a.m., staff member C stated the water boxes were cleaned once a week, on Saturdays. After staff member C observed the wall box for station #25, she sprayed it with vinegar and scrubbed it with a brush and most of the pinkish black buildup was removed. During an interview on 10/23/24 at 11:48 a.m., staff member C stated drain gel is poured in the water box and the surrounding water box area should be cleaned with vinegar and a scrubbed with a brush after using the drain gel. A review of the drain gel label showed “Bacterial Formulation for Removal of Organic Material from Drain lines and Non-Drain areas.” A review of the drain gel “Instructions for Use,” showed “For Non-Drain Areas Preparation: Remove loose and heavy surface organic material from area. Start Up: Spray [Drain Gel trade name] on area until wet. Repeat application daily as necessary until organic material has been removed, usually 5-7 days.””

“PA-ASSESS HD ADEQ Q MO;PD ADEQ Q 4 MO CFR(s): 494.80(c) The adequacy of the patient’s dialysis prescription, as described in §494.90(a)(1), must be assessed on an ongoing basis as follows: (1) Hemodialysis patients. At least monthly by calculating delivered Kt/V or an equivalent measure. (2) Peritoneal dialysis patients. At least every 4 months by calculating delivered weekly Kt/V or an equivalent measure. This Standard is not met as evidenced by: 46400 Based on interview and record review, the facility failed to ensure the adequacy of peritoneal dialysis patients was assessed on an ongoing basis for 3 (#s 13, 15 & 16) of 20 peritoneal dialysis patients. Findings include: Review of the facility policy and procedure, Adequacy of Peritoneal Dialysis, no date, showed: “ ... Peritoneal dialysis patients’ adequacy must be assessed at least every 4 months ... the patient will receive the prescribed amount of dialysis with a goal of achieving or exceeding the current [facility name] adequacy goal of kt/v 1.7 ... patients who do not meet the current adequacy goals will receive ongoing evaluations of their status, including kinetic modeling and intervention, to ensure an optimal outcome is achieved.” Review of the adequacy labs for all peritoneal dialysis patients for the year of 2024, requested on 10/23/24, showed: Three out of 20 peritoneal dialysis patients did not meet the kt/v 1.7 adequacy goal on their most recent kt/v labs, had no reevaluation of their prescription after the poor lab value, and one patient did not have adequacy labs drawn quarterly. - Patient #16 had an adequacy value of .19 on 7/8/24, not meeting the goal of 1.7. There was no follow up lab draw or previous lab results to determine if the patient was recieving adequate dialysis. - Patient #15 had an adequacy lab drawn 7/8/24 with no result. There was no follow up lab draw or previous lab results to determine if the patient was recieving adequate dialysis. - Patient #13 had an adequacy value of .42 on 4/3/24, not meeting the goal of 1.7. There was no follow up lab draw or previous lab results to determine if the patient was recieving adequate dialysis. During an interview on 10/22/24 at 12:15 p.m., staff member R stated patient #16 had done their adequacy incorrectly in July and then had forgotten to bring a repeat sample in for August, September, and October 2024. During an interview on 10/23/24 at 2:30 p.m., staff member Q stated peritoneal dialysis adequacy was a problem for several reasons. Some patients lived far away and did not want to make the trip to the clinic monthy or bimonthly. Staff member Q stated the PD program needed “quality control” when choosing patients for home dialysis, because there is a level of patient compliance required that was not being followed.”