Davita Goldsboro South Dialysis

“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: 26622 Based on policy review, observation and interview, the patient care staff failed to disinfect the Central Venous Catheter (CVC) hubs per facility policy and re-disinfect a CVC catheter exit site after touching with gloved hand and prior to placing sterile dressing in 1 of 2 observed initiation of hemodialysis treatment with a CVC (PCT #2, Station #7); failed to disinfect the CVC hubs per facility policy in 1 of 2 observed discontinuation of hemodialysis treatment with a CVC (PCT #2, Station #11); and failed to disinfect a CVC site with ExSept Plus (hypochlorite) per hospital policy for 1 of 1 observed CVC exit sites disinfected with ExSept Plus (PCT #3, Station #18) Findings include: A. Review on 05/07/2024 of the facility policy titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps” effective October 2023 revealed “ ... 16. Using aseptic technique, remove each cap. One at a time disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried.” Observation on 05/07/2024 at 1020 in the patient treatment area revealed PCT #2 entered Station #7 and initiated access of a Central Venous Catheter (CVC). Observation revealed PCT #2 performed hand hygiene, applied clean gloves. Observation revealed PCT #2 cleansed the arterial and venous catheter limbs. Observation revealed the PCT failed to disinfect the catheter hubs per facility policy. Observation revealed PCT #2 failed to cleanse each catheter hub for 15 seconds per facility policy. Observation revealed the CVC exit site care was completed by PCT #2. PCT #2 made RN #4 aware of swollen area under exit site. RN #4 palpated the area around the CVC exit site with a gloved hand. PCT #2 then placed the sterile dressing over the CVC exit site without re-disinfecting the area. Interview on 05/07/2024 at 1045 with PCT #2 revealed “I thought I cleaned the catheter hubs for 15 seconds.” Interview revealed each CVC hub should be cleansed for 15 seconds. Interview revealed PCT #2 did not disinfect the catheter hubs per facility policy. Interview on 05/07/2024 at 1630 with the Manager of Clinical Services revealed the staff were expected to scrub each catheter hub with an alcohol pad for fifteen (15) seconds per facility policy. Interview revealed the staff failed to follow the facility policy. Interview revealed the staff were expected to re-disinfect the site after touching and prior to placing the clean, sterile dressing. B. Review on 05/07/2024 of the facility policy titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps” effective October 2023 revealed “ ... 33. Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds, making sure to remove any residue, for example blood. Hold the catheter until the antiseptic has dried.” Observation on 05/07/2024 at 1035 in the patient treatment area revealed PCT #2 entered Station #11 and discontinued dialysis treatment access of a Central Venous Catheter (CVC). Observation revealed PCT #2 performed hand hygiene and applied clean gloves. Observation revealed PCT #2 disinfected the arterial and venous catheter limbs with an alcohol pad for less than 15 seconds. Observation revealed PCT #2 failed to disinfect each catheter hub with an alcohol pad for 15 seconds per facility policy. Interview on 05/07/2024 at 1045 with PCT #2 revealed “I thought I cleaned the catheter hubs for 15 seconds.” Interview revealed each CVC hub should be cleansed for 15 seconds. Interview revealed PCT #2 did not disinfect the catheter hubs per facility policy. Interview on 05/07/2024 at 1630 with the Manager of Clinical Services revealed the staff were expected to scrub each catheter hub with an alcohol pad for fifteen (15) seconds per facility policy. Interview revealed the staff failed to follow the facility policy. C. Review on 05/08/2024 of the facility policy titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps” effective October 2023 revealed “... NOTES: ...first choice for CVC care is 2% Chlorhexidine/70% Alcohol swab. If these agents are contraindicated for a patient, the physician will prescribe an agent for the individual patient and individual supplies will be used in place of the CVC kit, per manufacturer’s recommendations.” Review of policy documentation on use of ExSept Plus (Hypochlorite) revealed saturate 2x2 gauze with 3-5 milliliters and use at least two sterile gauze for site for 60 seconds and allow site to dry for 2 minutes. Observation on 05/08/2024 at 1125 in the patient treatment area revealed PCT #3 entered Station #18 and initiated CVC exit site care dialysis treatment with a CVC. PCT #3 cleansed the CVC exit site and area around site with ExSept Plus for 30 seconds and allowed to dry for one (1) minute. Observation revealed that the PCT failed to disinfect the CVC exit site are for 60 second and allow the exit site to dry for two (2) minutes per facility policy. Interview on 05/08/2024 at 1145 with PCT #3 revealed that the technician did not know that when using ExSept Plus, the site had to be disinfected for 60 seconds and allowed to dry for 2 minutes. The interview confirmed that PCT #3 did not follow the hospital policy. Interview on 05/07/2024 at 1630 with the Manager of Clinical Services revealed the staff were expected to disinfect the CVC catheter exit site for 60 seconds and allow to dry for 2 minutes when using ExSept Plus antiseptic per facility policy. Interview revealed the staff failed to follow the facility policy.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 26622 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to ensure machine prescription verifications were performed by a nurse within one hour of initiation of hemodialysis treatment in 6 of 7 (Patients #1, #3, #4, #5, #6, and #7) sampled in-center hemodialysis records reviewed. Findings include: Review on 05/09/2024 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2021 revealed “Policy .... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation ...” 1. Review of the medical record for Patient #1 revealed a 62-year-old female admitted for In-Center Hemodialysis treatments on 02/14/2024. Review of the Treatment Flowsheet dated 04/23/2024 revealed Patient #1’s treatment was initiated at 0731. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0843 (1 hour and 12 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #1’s treatment was initiated at 0725. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0849 (1 hour and 24 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 2. Review of the medical record for Patient #3 revealed a 47-year-old female admitted for In-Center Hemodialysis treatments on 03/31/2020. Review of the Treatment Flowsheet dated 04/23/2024 revealed Patient #3’s treatment was initiated at 0808. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0925 (1 hour and 17 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #3’s treatment was initiated at 0712. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0955 (2 hours and 43 minutes after initiation of treatment). Review of the medical record for Patient #1 revealed a 62-year-old female admitted for In-Center Hemodialysis treatments on 02/14/2024. Review of the Treatment Flowsheet dated 04/23/2024 revealed Patient #1’s treatment was initiated at 0731. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0843 (1 hour and 12 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 05/04/2024 revealed Patient #3’s treatment was initiated at 0704. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0807 (1 hour and 3 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 3. Review of the medical record for Patient #4 revealed a 72-year-old female admitted for In-Center Hemodialysis treatments on 06/08/2022. Review of the Treatment Flowsheet dated 04/29/2024 revealed Patient #4’s treatment was initiated at 1124. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1318 (1 hour and 54 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 05/06/2024 revealed Patient #4’s treatment was initiated at 1129. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1235 (1 hour and 6 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 4. Review of the medical record for Patient #5 revealed a 67-year-old male admitted for In-Center Hemodialysis treatments on 09/25/2021. Review of the Treatment Flowsheet dated 05/01/2024 revealed Patient #5’s treatment was initiated at 0640. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0805 (1 hour and 25 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 5. Review of the medical record for Patient #6 revealed a 41-year-old female admitted for In-Center Hemodialysis treatments on 04/30/2024. Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #6’s treatment was initiated at 1056. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1645 (5 hours and 11 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 05/07/2024 revealed Patient #6’s treatment was initiated at 1141. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1345 (2 hours and 4 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 6. Review of the medical record for Patient #7 revealed a 65-year-old male admitted for In-Center Hemodialysis treatments on 04/07/2023. Review of the Treatment Flowsheet dated 04/29/2024 revealed Patient #7’s treatment was initiated at 0638. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0755 (1 hour and 17 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 05/03/2024 revealed Patient #7’s treatment was initiated at 0623. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0742 (1 hour and 19 minutes after initiation of treatment). Interview on 05/09/2024 at 1300 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy.”

“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: 26622 Based on policy review, medical record review, and staff interview the facility staff failed to follow the adequacy plan of care by failing to dialyze 6 of 7 (Patient #1, #2, #3, #4, #6 and #7) patients at the prescribed BFR and 4 of 7 patients at the prescribed DFR (Patient #1, #2, #4 and #7). Findings included: Review on 05/09/2024 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2021 revealed “INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 9. ... b. At a minimum, obtain and document the following: ... iii. Blood and dialysate flows, arterial and venous pressures ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed.” 1. Review of the medical record for Patient #1 revealed a 62-year-old female admitted for In-Center Hemodialysis treatments on 02/14/2024. Review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 04/23/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0731 and ended at 1106 (209 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 282 and DFR average was 500 with no documentation for the decreased BFR and DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 04/27/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0746 and ended at 1110 (205 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 356 and DFR average was 538 with no documentation for the decreased BFR and DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0725 and ended at 1054 (210 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 291 and DFR average was 773 with no documentation for the decreased BFR and DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/02/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0740 and ended at 1112 (210 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 288 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/04/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0744 and ended at 1116 (210 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 301 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/07/2024 revealed Patient #1’s hemodialysis treatment was initiated at 0714 and ended at 1055 (212 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 295 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 6 of 7 treatments and a decreased DFR in 3 of 7 treatments with no documentation for the decreased BFR/DFR and Registered Nurse notification. 2. Review of the medical record for Patient #2 revealed a 59-year-old female admitted for In-Center Hemodialysis treatments on 10/30/2023. Review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 04/27/2024 revealed Patient #2’s hemodialysis treatment was initiated at 0712 and ended at 0939 (147 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 285 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #2’s hemodialysis treatment was initiated at 0654 and ended at 1109 (243 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 269 and DFR average was 500 with no documentation for the decreased BFR and DFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #2 had a decreased BFR in 2 of 3 treatments and a decreased DFR in 1 of 3 treatment with no documentation for the decreased BFR/DFR and Registered Nurse notification. 3. Review of the medical record for Patient #3 revealed a 47-year-old female admitted for In-Center Hemodialysis treatments on 03/31/2020. Review of the Physician orders revealed Patient #3’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #3’s hemodialysis treatment was initiated at 0712 and ended at 1111 (239 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 377 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #3 had a decreased BFR in 1 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 4. Review of the medical record for Patient #4 revealed a 72-year-old female admitted for In-Center Hemodialysis treatments on 06/08/2022. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 04/26/2024 revealed Patient #4’s hemodialysis treatment was initiated at 1112 and ended at 1357 (170 minutes). Review of the Flowsheet revealed Patient #4’s DFR average was 500 with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 04/29/2024 revealed Patient #4’s hemodialysis treatment was initiated at 1124 and ended at 1354 (150 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 350 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/01/2024 revealed Patient #4’s hemodialysis treatment was initiated at 1120 and ended at 1352 (152 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 325 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/06/2024 revealed Patient #4’s hemodialysis treatment was initiated at 1129 and ended at 1422 (169 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 333 and DFR average was 500 with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #4 had a decreased BFR in 3 of 7 treatments and a decreased DFR in 2 of 7 treatments with no documentation for the decreased BFR/DFR and Registered Nurse notification. 5. Review of the medical record for Patient #6 revealed a 41-year-old female admitted for In-Center Hemodialysis treatments on 04/30/2024. Review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 04/30/2024 revealed Patient #6’s hemodialysis treatment was initiated at 1056 and ended at 1429 (210 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 249 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/02/2024 revealed Patient #6’s hemodialysis treatment was initiated at 0848 and ended at 1244 (218 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 200 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/07/2024 revealed Patient #6’s hemodialysis treatment was initiated at 1141 and ended at 1428 (164 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 249 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #6 had a decreased BFR in 3 of 4 treatments with no documentation for the decreased BFR and Registered Nurse notification. 6. Review of the medical record for Patient #7 revealed a 65-year-old male admitted for In-Center Hemodialysis treatments on 04/07/2023. Review of the Physician orders revealed Patient #7’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 04/24/2024 revealed Patient #7’s hemodialysis treatment was initiated at 0628 and ended at 0959 (211 minutes). Review of the Flowsheet revealed Patient #7’s DFR average was 500 with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 04/26/2024 revealed Patient #7’s hemodialysis treatment was initiated at 0622 and ended at 0947 (206 minutes). Review of the Flowsheet revealed Patient #7’s DFR average was 500 with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/01/2024 revealed Patient #7’s hemodialysis treatment was initiated at 0626 and ended at 0956 (209 minutes). Review of the Flowsheet revealed Patient #7’s BFR average was 283 and DFR average was 500 with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 05/03/2024 revealed Patient #7’s hemodialysis treatment was initiated at 0623 and ended at 0958 (214 minutes). Review of the Flowsheet revealed Patient #7’s BFR average was 355 and DFR average was 500 with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Interview on 05/09/2024 at 1300 with the Manger of Clinical Services and Facility Administrator revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient’s treatment. The interview confirmed the medical record findings that patient #7 had a decreased BFR in 2 of 4 treatments and decreased DFR in 4 of 4 treatments with no documentation for the decreased BFR and Registered Nurse notification.”

“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: 26622 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis per policy before cannulation of 2 of 7 patients Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #24, PCT #2; Station #25, PCT #2). Findings included: Review on 05/09/2024 of the facility policy titled “AV (Arterio-venous) Fistula or Graft Cannulation ...” revised October 2022 revealed “ ... Skin Antiseptic: Povidone Iodine; Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site; Effective Contact Time: 30 seconds; Air Drying Time: 2 minutes ...” 1. Observation on 05/09/2024 at 0615 in the patient treatment area revealed PCT #2 entered Station #24 and initiated access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and applied clean gloves. The PCT #2 cleansed the arterial access site with a Povidone Iodine pad for a total of 15 seconds. PCT #2 cleansed the venous access site with a Povidone Iodine pad for a total of 15 seconds. PCT #2 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #2 failed to disinfect each access site for 30 seconds per the facility policy. Interview on 05/09/2024 at 0715 with PCT #2 revealed she was not sure what the disinfect contact time was per policy. Interview revealed that PCT #2 thought she had cleaned each access site for 30 seconds. Interview revealed PCT #2 failed to cleanse the access sites per facility policy. Interview on 05/09/2024 at 0900 with the Manager of Clinical Services revealed the staff were expected to clean each access site for 30 seconds when using Povidone Iodine pads and allow the site to dry for 2 minutes, prior to cannulating. Interview revealed the staff failed to follow the facility policy. 2. Observation on 05/09/2024 at 0700 in the patient treatment area revealed PCT #2 entered Station #25 and initiated access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and applied clean gloves. The PCT #2 cleansed the arterial access site with a Povidone Iodine pad for a total of 15 seconds. PCT #2 cleansed the venous access site with a Povidone Iodine pad for a total of 15 seconds. PCT #2 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #2 failed to disinfect each access site for 30 seconds per the facility policy. Interview on 05/09/2024 at 0715 with PCT #2 revealed she was not sure what the disinfect contact time was per policy. Interview revealed that PCT #2 thought she had cleaned each access site for 30 seconds. Interview revealed PCT #2 failed to cleanse the access sites per facility policy. Interview on 05/09/2024 at 0900 with the Manager of Clinical Services revealed the staff were expected to clean each access site for 30 seconds when using Povidone Iodine pads and allow the site to dry for 2 minutes, prior to cannulating. Interview revealed the staff failed to follow the facility policy. NC00216181”