Dci Libby

“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. This deficient practice has the potential to affect all patients receiving hemodialysis from the facility. Findings include: During an observation on 10/7/24 at 3:15 p.m., of the dialysis wall boxes, (which contain connections for the dialysis machine to receive acid and base concentrates and treated water and dispose of waste products) there was a white crystallized buildup on station #’s 1, 3, 8, and 9. The wall box for station #4 had a black and rust colored buildup around the connectors. During an observation on 10/9/24 at 11:30 a.m., there was a white crystallized buildup on the wall boxes for station #’s 1, 3, 8, and 9. The wall box for station #4 had a black and rust colored buildup around the connectors. During an interview on 10/9/24 at 12:43 p.m., staff member E stated the wall boxes should be sprayed down with vinegar and wiped weekly or as needed. During an observation and interview on 10/9/24 at 12:44 p.m., staff member E, when he observed the wall box for station #4, stated that needs to be cleaned. A review of a facility policy titled, “Routine Disinfection in the Hemodialysis Unit,” with a date issued of May 2023, showed, “Purpose: To provide guidance for routine disinfection of items in the hemodialysis unit. ... Policy ... 12. Chase/water boxes will be cleaned at a scheduled interval per facility protocol. All connectors will be kept free of acid and bicarbonate buildup. ...””

“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: 35356 Based on interview and record review, the facility failed to ensure a Registered Dietitian (RD) was part of the facility’s interdisciplinary team (IDT) professional membership. This deficient practice had the potential to affect all patients being provided nutritional services by the facility. Findings include: A review of the facility’s policy and procedure titled, Care Plans, with a date issued of 5/2023, reflected: - “... 2. The interdisciplinary team must consist of, at a minimum (V501): ... e. Dietitian (RD)...” During an interview on 10/8/24 at 1:15p.m., staff member A stated the facility has not had an RD since the first of the year, and they have not had an RD which has attended the facility’s IDT meetings since the RD left.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure regular reassessment by a Registered Dietitian (RD) of “potentially unstable” patients’ nutritional status for 2 (#s 1 and 3) of 8 sampled patients. This deficient practice has the potential to affect all patients in need of a nutritional assessment. Findings include: 1. Patient #1 was admitted to the facility on 4/8/19, with a diagnosis of hypertensive renal disease. A review of patient #1’s last RD nutritional assessment was a 90-day assessment on 11/14/23. Patient #1 was listed on the facility’s “potentially unstable” patient list. During an interview on 10/8/24 at 1:24 p.m., staff member A stated patient #1 has had difficulty with her nutritional status related to her phosphorus levels being elevated. She stated patient #1 has not had a nutritional assessment which was completed by an RD since January 2024. 2. Patient #3 was admitted to the facility on 6/5/23, with a diagnosis of hypertensive chronic kidney disease. A review of patient #3’s Nutritional Assessments, showed the last nutritional assessment completed by an RD was on 9/18/23. Patient #3 was listed on the facility’s “potentially unstable” patient list. Review of patient #3’s Diet Orders, with a review date of 10/8/24, showed no diet orders for patient #3. During an interview on 10/8/24 at 1:24 p.m., staff member A stated it was the expectation for patients identified as “unstable” to have monthly nutritional assessments by an RD. A review of the facility’s policy and procedure titled, Nutrition Services, with no date, showed: “... 4. The dietitian will review monthly chemistries, participate in patient care conferences either Health Care Team Members, advise the patient of necessary diet changes or modifications, reassess each patient as needed to evaluate his/her response to the dietary regimen and to revise the Patient Care Plan.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to sustain the prescribed dose of dialysis for 1 (#4) of nine sampled patients. This deficient practice resulted in inadequate dialysis. Findings include: A review of patient #4’s flow sheets, dated 9/16/24, 9/18/24, 9/20/24, and 9/23/24, showed a Blood Flow Rate (BFR) order for 450. The BFR was 400 for the entire treatment time on those dates. A review of patient #4’s flow sheets, dated 9/27/24, 9/30/24, and 10/4/24, showed a BFR order for 425. The BFR was 400 for the entire treatment time on those dates. A review of a “Hemodialysis Transfer Form,” dated 10/7/24, for patient #4, showed an average blood flow of 354 for 10 previous treatments with dates ranging from 9/11/24 to 10/7/24. During an interview on 10/8/24 at 3:09 p.m., staff member A stated some of the PCT’s may not know a patient with a CVC can run the BFR above 400. During an interview on 10/9/24 at 8:37 a.m., staff member A stated the PCT may have looked at the wrong dialysis order for patient #4.”

“POC-MANAGE MINERAL METABOLISM CFR(s): 494.90(a)(3) Provide the necessary care to manage mineral metabolism and prevent or treat renal bone disease. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to address therapeutic or nutritional interventions for prevention and maintenance of bone mineral metabolism for a patient’s phosphorus levels for 1 (#1) of 8 sampled patients. This deficient practice has the potential to affect all patients with disturbances in mineral and bone metabolism. Findings include: Review of patient #1’s Care Plan, showed: - Current Care Plan Problem: Phosphorus outside of range 2.6 - 5.5 mg/dl. - Additional Description: 7.9 mg/dl (3/8/23) from 2.1 mg/dl (2/13/23) - Date Identified: 3/8/23 - Target Date: 3/7/25 - Action Steps: Review low phosphorus food options. Review of patient #1’s Care Plan Progress Notes, showed patient #1’s elevated phosphorous levels were addressed by the facility as follows: - 10/16/23: “Phosphorous level is elevated at 9.2, trending up from 7.3...” - 11/15/23: “Phosphorous is just above goal at 5.7, trending down from 9.2. RD [Registered Dietitian] spent visit discussing her IDPN [Intradialytic parenteral nutrition]” - 12/19/23: “Phosphorous is 8.1, trending up from 5.7. RD spend most of visit discussing IDPN and increased oral intake for weight gain.” - 4/30/24: “Phosphorus is up this time. Discussed it with [staff member unknown].” - 6/3/24: “Phosphorous remains high at 7.8.” - 6/30/24: “Discussed the use of Tums with her.” There were no further interventions noted in patient #1’s Care Plan Progress Notes since 6/30/24. A review of patient #1’s laboratory values for phosphorus levels reflected: - on 6/3/24, the level was 7.8 mg/dl, - on 7/8/24, the level was 6.6 mg/dl, - on 8/12/24, the level was 9.0 mg/dl, - on 9/9/24, the level was 14.8 mg/dl. During an interview on 10/8/24 at 12:42 p.m., staff member A stated they had tried different medication modalities for patient #1 without success. She stated she had discussed in person with patient #1 about the elevated levels but it was not updated on her care plan. She stated the dietitian used to manage most of the bone mineral complications, but they have not had a dietitian since January of 2024. During an interview on 10/9/24 at 10:20 a.m., patient #1 states she was aware her phosphorus level was elevated but had not spoken to a dietitian about the levels in months. She stated having a dietitian help manage her phosphorus levels would be helpful. She stated she had not attended a care plan meeting in a while. A review of the facility’s policy and procedure titled, Nutrition Services, with no date, showed: “... 4. The dietitian will review monthly chemistries, participate in patient care conferences either Health Care Team Members, advise the patient of necessary diet changes or modifications, reassess each patient as needed to evaluate his/her response to the dietary regimen and to revise the Patient Care Plan.””