Box Butte Dialysis Unit

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 48995 Based on observations and staff interviews, the facility failed to have a written policy and procedure to ensure expired supplies were identified and removed from the Emergency Drug Box. This failed practice had the potential to expose all 18 patients on census to expired supplies. Findings are: A. Observation of the Emergency Drug Box on 11/27/23 at 2:45 PM, revealed the following expired supplies: 1. Four 25 gauge (refers to the size of the hole in the needle) needles with an expiration date of January 2021. 2. Four 30 milliliter (ml) sterile syringes with an expiration date of April 2021. 3. Four 21 gauge needles with an expiration date of November 2020. B. During staff interview on 11/27/23 at 2:50 PM, the Nurse Manager in Training (NMT) confirmed a facility policy and procedure did not exist to review the Emergency Drug Box for expired supplies. C. During staff interview on 11/30/23 at 3:00 PM, the NMT confirmed facility staff were not reviewing the expiration dates of supplies in the Emergency Drug Box and confirmed the facility expectation is for all licensed nurse teammates to review the Emergency Drug Box routinely.”

“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: 48995 Based on observations and staff interviews, 5 out of 5 staff members failed to ensure 4 patients with Central Venous Catheters (CVC, an indwelling device inserted into a large, central vein and advanced until the tip resides within the upper portion of the heart) and blood line connections remained visible throughout the patient’s hemodialysis (HD) treatment. This failed practice provided the opportunity for accidental dislodgement, or line disconnection, to go undetected in 4 of 17 patients observed. Patient census was 18. This dislodgement or disconnection could result in exsanguination (the process of losing blood) and patient death within minutes. Findings are: A.Observations of HD treatments, on 11/28/23 from 8:00 AM to 10:00 AM, revealed staff members B, C, D, E and G failed to address and correct staff’s obstructed view of Patient #2 and #3’s CVC and blood line connections, which were covered with a blanket. B. Observations of HD treatments, on 11/29/23 from 6:45 AM to 11:00 AM, revealed staff members B, C, D, E and G failed to address and correct staff’s obstructed view of Patient #6 and #12’s CVC and blood line connections, which were covered with a blanket. C. During staff interview, on 11/30/23 at 11:30 AM, the Nurse Manager in Training (NMT), confirmed a facility policy and procedure did not exist for the visibility of patients CVC site and blood line connections by staff during the patient’s HD treatment. D. During staff interview, on 11/30/23 at 3:00 PM, the Interim Nurse Manager (INM) confirmed the absence of a facility policy and procedure for ensuring patient access sites and blood lines were visualized by a staff member throughout the patient’s HD treatment.The INM confirmed it is the expectation that staff members will remind and educate patients who cover their access sites and blood lines during HD treatment to stop this practice.”

“QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL CFR(s): 494.110 The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. This Standard is not met as evidenced by: 47269 Based on record review and staff interviews, the facility failed to have written policies and procedures for their quality assessment and performance improvement (QAPI) program. Findings are: A. Record review, of the facility monthly QAPI meeting minutes from January 2023 through November 2023 on 11/30/23 at 8:00 AM, revealed the QAPI program records from January 2023 through July 2023 failed to include ongoing tracking and trending of QAPI data and failed to identify which member of the Interdisciplinary Team (IDT, a team minimally consisting of a physician, registered nurse, master prepared social worker, and registered dietician who work together towards meeting the goals of dialysis patients) was responsible for each aspect of the data collection and assessment. B. During staff interview on 11/30/23 at 9:00 AM, the interim nurse manager (INM) confirmed: they were contracted by the facility on 6/28/23; the facility’s QAPI program failed to include ongoing tracking and trending of QAPI data until August 2023; and the facility failed to identify which member of the IDT was responsible for each aspect of the QAPI data collection and assessment. The INM was unable to provide written policies and procedures for the facility’s QAPI program. C. During staff interview on 12/1/23 at 7:00 AM, the INM and Nurse Manager in Training (NMT) both confirmed there were no written policies and procedures for the facility’s QAPI program.”