Lexington Dialysis Center

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to follow infection control measures by not ensuring that supplies were not kept in the gown pockets in 4 of 14 observations of staff with supplies stored in their pockets (PCT #1, PCT #2, PCT #3, and PCT #4). Findings included: A review on 04/08/2025 of the facility policy “Infection Control Practices For Hemodialysis” effective 10/2024 revealed, “Purpose: To provide a method of infection control that will avoid cross-contamination, prevent the transmission of bloodborne pathogens, and reduce the transfer of microorganisms among patients and staff. Policy: Staff will utilize appropriate infection control practices and standard precautions when performing patient care... Supply Practices... Supplies may not be carried in pockets...” 1. An observation on 04/08/2025 at 1350 revealed PCT #1 in the treatment area while providing patient care with supplies in the gown pockets. An interview with PCT #1 on 04/08/2025 at 1350 during the observation revealed that the PCT had a calculator, a marker, and a roll of tape in her pockets. The interview confirmed that the staff should not carry supplies in their pockets. The PCT revealed that “it was just a habit.” An interview with the regional nurse administrator on 04/09/2025 at 1315 indicated that the gown pockets should remain empty, as outlined in the policy. 2. An observation on 04/08/2025 at 1400 revealed PCT #2 in the treatment area while providing patient care with supplies in the gown pockets. An interview with PCT #2 on 04/08/2025 at 1400 during the observation revealed that the PCT had pens and a thermometer in her pockets. The interview revealed, “I don’t know if we (the staff) are not allowed to keep supplies in our pockets, but I will find out.” The interview confirmed that the policy was not adhered to. An interview with the regional nurse administrator on 04/09/2025 at 1315 indicated that the gown pockets should remain empty, as outlined in the policy. 3. An observation on 04/08/2025 at 1405 revealed PCT #3 in the treatment area while providing patient care with supplies in the gown pockets. An interview with PCT #3 on 04/08/2025 at 1405 during the observation revealed that the PCT had pens, a thermometer, and gloves in her pockets. The interview revealed, “I thought we were allowed to carry our items such as pens, thermometers, and calculators.” The interview confirmed that the policy was not adhered to. An interview with the regional nurse administrator on 04/09/2025 at 1315 indicated that the gown pockets should remain empty, as outlined in the policy. 4. An observation on 04/09/2025 at 1210 revealed PCT #4 in the treatment area while providing patient care with supplies in the gown pockets. An interview with PCT #4 on 04/09/2025 at 1210 during the observation revealed that the PCT had a calculator in the gown pocket. PCT #4 revealed, “I did not know I could not carry a calculator in my pocket.” The interview confirmed that the policy was not adhered to. An interview with the regional nurse administrator on 04/09/2025 at 1315 indicated that the gown pockets should remain empty, as outlined in the policy.”

“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: 38766 Based on observations and staff interviews, the facility staff failed to promote patient safety by not ensuring patients’ access sites were visible during treatment for 1 of 17 in-center patients observed (Patients #12). Findings included: A review on 04/08/2025 of the facility policy “Initiating, Monitoring, and Discontinuing Hemodialysis Treatments Utilizing AVF / AVG” revised on 06/2023 revealed “...Monitoring During Treatment: ...Access: The patient’s access must be visible throughout the treatment. Patients may not cover the AVF or AVG with a blanket, etc. as it prevents the staff from verifying issues such as infiltrations, needle dislodgement, bleeding, line separations, etc...” An observation on 04/08/2025 between 1300 and 1350 revealed patient #12 in Bay D, Station #48, and on HDM #21 had the access site covered with a blanket. The observation revealed the staff in the bay, including one nurse and three PCTs, were providing patient care. The observation revealed PCT #1 entered Station #48 on multiple occasions for vital signs and documentation. The observation revealed the PCT failed to uncover the access site during the patient’s monitoring until prompted by the surveyor. An interview on 04/08/2025 at 1350 with PCT #1 revealed that patients’ access should not be covered at any time during the treatment. The interview revealed that the patient in Station #48 had AVF in the right arm. The PCT added, “To be honest, I did not notice the access was being covered.” An interview on 04/10/2025 at 1325 with the CN revealed that the patient’s access site should remain visible for safety reasons. The interview revealed that the staff, including the nurses, should pull down the patient’s blanket so their access remained visible. The interview confirmed that the policy was not followed.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 38766 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis per policy before cannulation of 1 of 2 patients Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #47, PCT #5). Findings included: A review on 09/10/2024 of the facility policy titled “Preparation, Cannulation, and Management of an AF Fistula /AV Graft” revised on 07/2024 revealed “...PROCEDURE: ...*If the patient is allergic to chlorhexidine (CHG), (2) betadine -or- (2) alcohol prep pads may be used... POINT OF EMPHASIS: *If using betadine or alcohol, use a new swab for each site...” An observation on 04/09/2025 at 1205 in the patient treatment area revealed PCT #5 entered Station #47 to initiate access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #5 performed hand hygiene and applied clean gloves. PCT #5 cleansed both access sites with one (1) alcohol prep pad. An interview on 04/09/2025 at 1215 with PCT #5 confirmed that both access sites were cleaned using one alcohol prep pad. The PCT reported cleaning one access site and flipped the alcohol prep pad to the other side to clean the second access site. During the interview, the PCT explained, “I figured I could use a different alcohol pad for each site.” The interview corroborated this observation. An interview conducted on 04/09/2025 at 1315 with the Regional Nurse Administrator indicated that the observation was unacceptable. The clinic had adequate supplies, and the staff knew better. NC00229159”