Fmc Bma South Gaston 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: 35306 Based on observations, facility policy review and staff interview, the facility staff failed to prevent cross-contamination during CVC exit site care in 2 of 2 observations of CVC exit site care (PCT #4, Patient #9 and PCT #3, Patient #10). Findings included: Observation on 05/07/2024 at 1143 in the patient treatment area revealed PCT #4 performed CVC exit site care for Patient #9. Observation revealed the PCT used a chlorhexidine (antimicrobial agent) swab in a back-and-forth motion, progressing from the exit site to the peripheral area and moved to the bottom of the exit site. Continued observation revealed the PCT failed to turn the swab over and used the same side of the swab that was used to clean the top of the exit site and peripheral area. Observation revealed the PCT failed to prevent cross-contamination when cleaning the CVC exit site by failing to use both sides of the swab per policy. Observation on 05/07/2024 at 1152 in the patient treatment area revealed PCT #3 performed CVC exit site care for Patient #10. Observation revealed the PCT used a chlorhexidine swab and scrubbed the area in an up-and-down motion from the exit site to the peripheral area and moved to the bottom of the exit site. Observation revealed the PCT failed to prevent cross-contamination when cleaning the CVC exit site by returning to the exit site per policy. Review on 05/07/2024 of facility policy, “Central Venous Catheter Dressing Change” (Published 05/06/2024) revealed, “Cleaning the Catheter Site ... Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds.” Interview on 05/07/2024 at 1150, following the observation, with PCT #4 revealed, “I should have turned the swab over and cleaned the exit site with the unused side of the swab.” The interview confirmed the observation finding. Interview on 05/07/2024 at 1554 with PCT #3 revealed, “I just took the CVC initiation class. I did go back to the exit site and I shouldn’t have and I should have.” Interview confirmed the observation findings.”

“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: 35306 Based on policy review, record review and staff and patient interview, the facility staff failed to ensure a patient without documented photosensitivity to light did not wear sunglasses during dialysis per policy for 1 of 1 patients observed wearing sunglasses (Patient #8, Station #14). Findings included: Review on 05/06/2024 of the facility policy “All patients must be under visual observation by clinical staff during treatment ... Ensure each patient’s face is visible and uncovered. Patients may not wear sunglasses or sleeping masks without medical documentation confirming a photosensitivity condition. These products may obscure observation of patient’s eyes. For patients’ safety, staff must ask patients to lift or remove any medically justified eye covering during each 30-minute check in order to visually confirm alertness.” Observation on 05/07/2024 from 1015-1215 (2 hours) revealed Patient #8 dialyzing in Station #14 wearing dark sunglasses. Observation revealed the patient did not remove the sunglasses and that staff did not ask for them to be removed during the 2-hour observation. Observation revealed the facility staff failed to ensure the patient did not wear sunglasses during treatment. Medical record review on 05/08/2024 revealed Patient #8 was admitted for ICHD on 12/27/2022. Medical record review failed to reveal documented photosensitivity to light or an order for the patient to wear sunglasses during treatment. Interview on 05/07/2024 at 1115 with Patient #8 revealed he wore sunglasses during his treatments and that staff “don’t say anything or tell me to take them off” during 30-minute safety checks. Interview on 05/07/2024 at 1200 with PCT #1 revealed that the PCT was assigned to Pod 4 where Patient #8 was being dialyzed. Interview revealed, “We are supposed to ask the patient to remove his sunglasses and document refusals in the medical record, but to be honest we don’t always do that. He [Patient #8] wears them every treatment and we just try not to get into a power struggle.” Interview on 05/08/2024 at 1600 at 1540 with the facility’s Clinic Manager (CM) revealed patients should be asked to remove sunglasses and if refused, staff are expected to document the refusal in the medical record. Staff should also ask the patient to remove the glasses so they can visually see their eyes during every 30-minute assessments per policy. Interview revealed select patients have photosensitivity and wear sunglasses for that reason, but there should be documentation in the medical record indicating such.”

“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: 35306 Based on policy review, record review and staff interview, the facility staff failed to obtain a blood pressure (BP) and pulse rate (PR) for 3 of 7 ICHD patients sampled (Patients #1, #5 and #6), failed to document machine parameters for 3 of 7 ICHD patients sampled, and failed to document safety checks for 4 of 7 ICHD patients sampled (Patients #1, #5, #6, and #7) every 30 minutes or more as but not to exceed 45 minutes during dialysis per policy. Findings included: 1. Review on 05/06/2024 of facility policy “Patient Assessment and Monitoring” (Published: 05/01/203) revealed “During Treatment Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” a. Medical record review on 05/07/2024 for Patient #1 revealed a 57-year-old was admitted for ICHD on 02/04/2023. Review of the treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024 the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review of the treatment sheet revealed no documented BP or PR from 1227 to 1334 (67 minutes). Interview on 05/08/2024 at 1422 with PCT #2 revealed that she was assigned to the patient on 04/26/2024. Interview revealed, “To be honest with you, I can’t remember [specific details about the patient’s care on 04/26/2024] but I am not normally in that section and was probably taking someone else off [when the BP and PR were due to be taken]. Interview revealed, “BP, PR and safety checks are supposed to be done every 30 minutes per policy.” Interview on 05/08/2024 at 1422 with the facility’s Clinic Manager (CM) revealed the patient’s BP and PR should be documented every 30 minutes per policy. b. Medical record review on 05/08/2024 for Patient #5 revealed 53-year-old was admitted for ICHD on 05/13/2014. Review of the treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024 the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review of the treatment sheet revealed no documented BP or PR from 0837 to 0926 (49 minutes). Interview on 05/07/2024 at 1554 with PCT #3 revealed, “We are supposed to document the patient’s BP and PR every 30 minutes.” Interview revealed PCT #3 was assigned to Patient #5 on 05/01/2024 and must have “gotten behind” on documenting the patient’s BP and PR. Interview revealed, “I have to own that, I did not follow our policy.” Concurrent interview on 05/07/2024 at 1554 with the facility’s Clinic Manager (CM) following review of the treatment sheet for 04/26/2024 with PCT #3 during the interview revealed the patient’s BP and PR should be documented every 30 minutes per policy. Interview revealed, “Another BP and PR should have documented at 0907 [30 minutes].” c. Medical record review on 05/08/2024 for Patient #6 revealed a 75-year-old was admitted for ICHD on 06/08/2021. Review of the treatment sheets from 04/22/2024 - 05/03/2024 revealed on 05/01/2024 the patient received ICHD from 0653 to 1055 (4 hours and 2 minutes). Review of the treatment sheet revealed no documented BP or PR from 0903 to 1055 (112 minutes). Interview on 05/07/2024 at 1050 with PCT #4 revealed, “We do vitals (BP and PR) and safety checks on patients every 30 minutes.” Interview on 05/08/2024 at 1422 with the facility’s Clinic Manager (CM) revealed the patient’s BP and PR should be documented every 30 minutes per policy. 2. Review on 05/06/2024 of facility policy “Patient Assessment and Monitoring” (Published: 05/01/203) revealed “Document machine parameters .... every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” a. Medical record review on 05/07/2024 of Patient #1’s treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024 the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review revealed no documented machine parameters (BFR/DFR, AP(-)/VP, or UFR/FLDRMVD) at 1400, 1502, 1530, or 1608. Interview on 05/08/2024 at 1354 with the CM revealed the PCT assigned to Patient #1 on 04/26/2024 (PCT #2) stated, “I’m not falsifying information if I wasn’t in the area at the time the information should have been entered.” Interview revealed the CM stated that PCT #2 was reeducated on where to retrieve the historical data in the Electronic Health Record (EHR) and instructed that the machine parameters, BFR/DFR, AP(-)/VP, and UFR/FLDRMVD were to be manually entered every 30 minutes per policy. Interview on 05/08/2024 at 1422 with PCT #2 revealed that she was assigned to the patient on 04/26/2024. Interview revealed, “I thought that I couldn’t enter that data [(BFR/DFR, AP(-)/VP, and UFR/FLDRMVD] if I was not in that area at that time. It [machine parameters] doesn’t auto [automatically] pull over [data must be entered manually by the PCT] and if I am not in the area at that time, I didn’t want to falsify information.” Interview revealed that after reeducation by the CM, PCT #2 now understands where to pull the data from in the HER and enters the required data every 30 minutes per policy. b. Medical record review on 05/08/2024 of Patient #5’s treatment sheets from 04/22/2024 - 05/03/2024, revealed on 04/26/2024, the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review of the treatment sheet revealed no documented BFR at 0601 and no documented BFR/DFR, AP(-)/VP, or UFR/FLDRMVD at 0800, 0900, or 0926 every 30 minutes per policy. Interview on 05/08/2024 at 1354 with the CM revealed the PCT assigned to Patient #5 on 04/26/2024 (PCT #2) stated, “I’m not falsifying information if I wasn’t in the area at the time the information should have been entered.” Interview revealed the CM stated that PCT #2 was reeducated on where to retrieve the historical data in the Electronic Health Record (EHR) and instructed that the machine parameters, BFR/DFR, AP(-)/VP, and UFR/FLDRMVD were to be manually entered every 30 minutes per policy. Interview on 05/08/2024 at 1422 with PCT #2 revealed that she was assigned to the patient on 04/26/2024. Interview revealed, “I thought that I couldn’t enter that data [(BFR/DFR, AP(-)/VP, and UFR/FLDRMVD] if I was not in that area at that time. It [machine parameters] doesn’t auto [automatically] pull over [data must be entered manually by the PCT] and if I am not in the area at that time, I didn’t want to falsify information.” Interview revealed that after reeducation by the CM, PCT #2 now understands where to pull the data from in the HER and enters the required data every 30 minutes per policy. c. Medical record review on 05/08/2024 of Patient #6’s treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024 the patient received ICHD from 0650 to 1056 (4hours, 6 minutes). Review revealed no documented machine parameters (BFR/DFR, AP(-)/VP, or UFR/FLDRMVD) from 1001-1056 (56 minutes). Interview on 05/08/2024 at 1354 with the CM revealed the PCT assigned to Patient #6 on 04/26/2024 (PCT #2) stated, “I’m not falsifying information if I wasn’t in the area at the time the information should have been entered.” Interview revealed the CM stated that PCT #2 was reeducated on where to retrieve the historical data in the Electronic Health Record (EHR) and instructed that the machine parameters, BFR/DFR, AP(-)/VP, and UFR/FLDRMVD were to be manually entered every 30 minutes per policy. Interview on 05/08/2024 at 1422 with PCT #2 revealed that she was assigned to the patient on 04/26/2024. Interview revealed, “I thought that I couldn’t enter that data [(BFR/DFR, AP(-)/VP, and UFR/FLDRMVD] if I was not in that area at that time. It [machine parameters] doesn’t auto [automatically] pull over [data must be entered manually by the PCT] and if I am not in the area at that time, I didn’t want to falsify information.” Interview revealed that after reeducation by the CM, PCT #2 now understands where to pull the data from in the EHR and enters the required data every 30 minutes per policy. 3. Review on 05/06/2024 of facility policy “Patient Assessment and Monitoring” (Published: 05/01/203) revealed “Document .... safety checks every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” a. Medical record review on 05/07/2024 of Patient #1’s treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024, the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review revealed no documented safety check from 1227 to 1334 (67 minutes). On 05/03/2024, the patient received ICHD from 1158 to 1558 (4 hours). Review of the treatment sheet revealed no documented safety check from 1206 to 1300 (54 minutes). Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #1 on 04/26/2024. Interview revealed safety checks were to be performed every 30 minutes. Interview revealed, “I just overlooked it. I own up to it.” Interview revealed safety checks were not performed per policy. Concurrent interview on 05/07/2024 at 1644 with the CM revealed safety checks were supposed to be completed every 30 minutes. Interview on 05/08/2024 at 1422 with PCT #2 revealed she was assigned to Patient #1 on 04/26/2024. Interview revealed, “Safety checks are supposed to be done every 30 minutes per policy.” Interview revealed, “I was probably taking someone off [discontinuing HD treatment for another patient].” Interview revealed safety checks were not performed per policy. b. Medical record review on 05/08/2024 of Patient #5’s treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/26/2024, the patient received ICHD from 0559 to 0925 (3 hours and 26 minutes). Review revealed no documented safety check from 0837 to 0926 (49 minutes). Interview on 05/07/2024 at 1644 with the CM revealed safety checks were supposed to be completed every 30 minutes. Interview on 05/08/2024 at 1422 with PCT #2 revealed she was assigned to Patient #5 on 04/26/2024. Interview revealed, “Safety checks are supposed to be done every 30 minutes per policy.” Interview revealed, “I was probably taking someone off [discontinuing HD treatment for another patient].” Interview revealed safety checks were not performed per policy. c. Medical record review on 05/08/2024 of Patient #6’s treatment sheets from 04/22/2024 - 05/03/2024 revealed on 05/03/2024, the patient received ICHD from 0641 to 1040 (3 hours, 59 minutes) with no documented safety checks from 0735 to 0834 (59 minutes). Review of the treatment sheet for 05/01/2024 revealed the received ICHD from 0653 to 1055 (4 hours, 2 minutes) with no documented safety checks from 0930-1059 (89 minutes). Review of the treatment sheet for 04/22/2024 revealed the patient received ICHD from 0650 to 1051 (4 hours, 1 minute). Review revealed no documented safety check from 0733 to 0832 (59 minutes) and 0905 to 1002 (57 minutes). Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #6 on 04/22/2024 and 05/03/2024. Interview revealed safety checks were to be performed every 30 minutes. Interview revealed, “I just overlooked it. I own up to it.” Interview revealed safety checks were not performed per policy. Concurrent interview on 05/07/2024 at 1644 with the CM revealed safety checks were supposed to be completed every 30 minutes. d. Medical record review on 05/08/2024 for Patient #7 revealed a 79-year-old was admitted for ICHD on 03/28/2024. Review of the treatment sheets from 04/22/2024 - 05/03/2024 revealed on 04/20/2024 the patient received ICHD from 1158 to 1558 (4 hours). Review revealed no documented safety check from 1247 to 1445 (78 minutes). Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #7 on 05/03/2024. Interview revealed safety checks were to be performed every 30 minutes. Interview revealed, “I just overlooked it. I own up to it.” Interview confirmed safety checks were not performed per policy. Concurrent interview on 05/07/2024 at 1644 with the CM revealed safety checks were supposed to be completed every 30 minutes.”

“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: 35306 Based on facility policy review, clinical record review and staff interview, the facility’s patient care staff failed to ensure a patient’s adequacy plan was implemented by dialyzing a patient at their ordered dialysis prescription BFR and/or DFR for 5 of 7 sampled patients (Patients #1, #2, #4, #6 and #7). Findings included: Review of the facility policy, “Patient Assessment and Monitoring” (Published: 05/01/2026) revealed, “ ... During Treatment ... * Check machine settings and measurements: Check prescribed blow flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. * Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ...” 1. Medical record review on 05/07/2024 for Patient #1 revealed a prescribed BFR of 500 and DFR of 800. Review of the treatment sheet for 04/24/2024 revealed the patient received ICHD from 1158 to 1554 (3 hours, 56 minutes). Review revealed the patient dialyzed from 1232 to 1430 (118 minutes) with a BFR of 450 (50 less than the prescribed rate) with no noted justification for lowering the BFR. Review revealed the patient dialyzed with a DFR of 500 (300 less than the prescribed rate) from 1202 to 1602 (4 hours), the entire treatment, with no noted justification for lowering the DFR. Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #1 on 04/24/2024. Interview revealed, “The BFR and DFR are manually entered at the beginning of treatment.” Interview revealed, “I missed it and didn’t put the right BFR in.” Interview on 05/08/2024 at 1445 with the CM revealed that staff are expected to document justification for making changes to the patient’s prescribed BFR or DFR. Interview revealed, “That’s [ensuring documented justification when patients are unable to dialyze at the prescribed BFR or DFR] something we are working on. I just implemented an Action Plan for our Medical Record audits and we’ve been auditing 3 patients per month but I think I’m going to double that and start looking at them [treatment sheets] in real time.” Interview confirmed that staff failed to document justification for making changes to the patient’s prescribed BFR and DFR per policy. Interview on 05/08/2024 at 1530 with the CM revealed PCT #6 [assigned to the patient on 04/29/2024] was not available for interview. 2. Medical record review on 05/07/2024 for Patient #2 revealed a 56-year-old was admitted for ICHD on 09/22/2020. Review revealed a prescribed DFR of 500. Review revealed the patient dialyzed with a DFR of 800 (300 more than the prescribed rate) from 0528 to 0929 (4 hours, 1 minute), the entire treatment, with no noted justification for increasing the DFR. Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #2 on 04/23/2024. Interview revealed, “The BFR and DFR are manually entered at the beginning of treatment.” Interview revealed, “I missed it and didn’t put the right DFR in.” Interview on 05/08/2024 at 1445 with the CM revealed that staff are expected to document justification for making changes to the patient’s prescribed BFR or DFR. Interview revealed, “That’s [ensuring documented justification when patients are unable to dialyze at the prescribed BFR or DFR] something we are working on. I just implemented an Action Plan for our Medical Record audits and we’ve been auditing 3 patients per month but I think I’m going to double that and start looking at them [treatment sheets] in real time.” Interview confirmed that staff failed to document justification for making changes to the patient’s prescribed BFR and DFR per policy. 3. Medical record review on 05/07/2024 for Patient #4 revealed a 33-year-old was admitted for ICHD on 10/11/2022. Review revealed a prescribed BFR of 500. Review of the treatment sheet for 05/03/2024 revealed the patient received ICHD from 1051 to 1425 (3 hours, 34 minutes). Review revealed the patient dialyzed with a BFR of 465 from 1235 to 1334 (59 minutes) with no noted justification for lowering the BFR. Interview on 05/08/2024 at 1530 with the CM revealed PCT #5 [assigned to the patient on 05/03/2024] was not available for interview. Interview on 05/08/2024 at 1445 with the CM revealed that staff are expected to document justification for making changes to the patient’s prescribed BFR or DFR. Interview revealed, “That’s [ensuring documented justification when patients are unable to dialyze at the prescribed BFR or DFR] something we are working on. I just implemented an Action Plan for our Medical Record audits and we’ve been auditing 3 patients per month but I think I’m going to double that and start looking at them [treatment sheets] in real time.” Interview confirmed that staff failed to document justification for making changes to the patient’s prescribed BFR and DFR per policy. 4. Medical record review on 05/08/2024 for Patient #6 revealed a prescribed BFR of 350. Review of the treatment sheet for 05/03/2024 revealed the patient dialyzed with a BFR of 300 (50 less than the prescribed rate) from 0641 to 1049, the entire treatment, with no justification for decreasing the BFR noted. Interview on 05/08/2024 at 1530 with the CM revealed PCT #4 [assigned to the patient on 05/03/2024] was not available for interview. Interview on 05/08/2024 at 1445 with the CM revealed that staff are expected to document justification for making changes to the patient’s prescribed BFR or DFR. Interview revealed, “That’s [ensuring documented justification when patients are unable to dialyze at the prescribed BFR or DFR] something we are working on. I just implemented an Action Plan for our Medical Record audits and we’ve been auditing 3 patients per month but I think I’m going to double that and start looking at them [treatment sheets] in real time.” Interview confirmed that staff failed to document justification for making changes to the patient’s prescribed BFR and DFR per policy. 5. Medical record review on 05/07/2024 for Patient #7 revealed a prescribed BFR of 350 and DFR of 600. Review revealed the patient dialyzed with a BFR of 300 (50 less than the prescribed rate) from 1209 to 1600 (3 hours, 51 minutes), the entire treatment, with no justification for decreasing the BFR noted. Further review of the treatment sheets revealed on 05/04/2024 the patient dialyzed from 1223 to 1622 (3 hours, 59 minutes) with a DFR of 800 (200 more than the prescribed rate) the entire treatment with no justification for increasing the DFR noted. Interview on 05/07/2024 at 1554 with PCT #3 revealed he was assigned to Patient #7 on 05/04/2024. Interview revealed, “The BFR and DFR are manually entered at the beginning of treatment.” Interview revealed, “I missed it and didn’t put the right DFR in.” Interview on 05/08/2024 at 1445 with the CM revealed that staff are expected to document justification for making changes to the patient’s prescribed BFR or DFR. Interview revealed, “That’s [ensuring documented justification when patients are unable to dialyze at the prescribed BFR or DFR] something we are working on. I just implemented an Action Plan for our Medical Record audits and we’ve been auditing 3 patients per month but I think I’m going to double that and start looking at them [treatment sheets] in real time.” Interview confirmed that staff failed to document justification for making changes to the patient’s prescribed BFR and DFR per policy. Interview on 05/08/2024 at 1530 with the CM revealed PCT #6 [assigned to the patient on 04/27/2024] was not available for interview.”