Cherry County Hospital Dialysis Unit

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 48995 Based on review of policies and procedures, observations, and staff interviews, the facility failed to ensure an opened, undated, multidose vial (a vial of liquid medication intended for injection or infusion that contains more than one dose of the medication) of Lidocaine HCL (a drug used to cause loss of feeling for patients during certain medical procedures) was removed from the medication cabinet. The facility’s medication administration policy failed to provide a process for managing multidose vials to include the date and time the vial was opened and expired. Failure to remove the opened, undated, multidose vial of Lidocaine HCL had the potential to allow the medication, which was unable to be verified as being viable, to be administered to 1 of 5 patients sampled who received Lidocaine HCL during their Hemodialysis (HD) treatments. The facility census was 7. Findings include: A. Review of the facility policy titled Administration of IV [(Intravenous)] Medications During HD, dated 2/15/10, revealed this policy failed to provide a process for managing multidose vials to include the date and time the vial was opened and expired. B. Observation of the medication cabinet, during the Flash Tour on 5/21/24 at 2:30 PM, revealed an opened 200 mg (milligram)/20 mL (milliliter) multidose vial of Lidocaine HCL, which failed to include the date and time the vial was opened and expired. C. Observation of the wall below the medication cabinet, on 5/21/24 at 4:45 PM, revealed signage taped to the wall with the following instructions: REMEMBER TO DOCUMENT DATE/TIME VIALS ARE OPENED: MDV [(multidose vial)]: Epo (21) [(Epoetin, a medication used to treat anemia caused by chronic kidney disease)], Heparin [(a medication used to decrease the clotting ability of the blood)], Lidocaine good for 28 days after opening. D. During staff interview on 5/21/24 at 2:30 PM, the Charge Nurse (CN) confirmed the opened 200 mg/20 mL multidose vial of Lidocaine HCL, identified during the Flash Tour on 5/21/24 at 2:30 PM, failed to have a date and time when the vial was opened and expired. E. During staff interview on 5/21/24 at 4:45 PM, the Nurse Manager (NM) confirmed: 1. the opened 200 mg/20 mL multidose vial of Lidocaine HCL, identified during the Flash Tour on 5/21/24 at 2:30 PM, failed to have facility staff’s date and time when the vial was opened; 2. facility staff are to discard Lidocaine HCL multidose vials 28 days after opening the vial; and 3. the facility failed to have a policy or procedure for managing multidose vials to include the date and time the vial was opened and expired.”

“PR-INFORMED OF EXTERNAL GRIEVANCE PROCESSES CFR(s): 494.70(a)(15) The patient has the right to- (15) Be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State survey agency; This Standard is not met as evidenced by: 48995 Based on review of facility policies, procedures, and forms, and staff interview, the facility failed to provide accurate contact information for the End Stage Renal Disease (ESRD) Network (an external organization with which dialysis patients may file grievances and complaints anonymously) and the State survey agency. This failed practice had the potential to prevent all 7 patients on census from filing an anonymous complaint with the ESRD Network or the State survey agency. Findings are: A. Review of the facility policy titled Patient’s Rights and Responsibilities, dated 2/2009, revealed patients have the right to be informed how to file an external grievance and how to contact the ESRD Network and the State Survey Agency without fear of reprisal or denial of services. B. Review of the facility policy titled Patient Rights/Grievance Procedure, dated 4/20, revealed a grievance may be filed with the ESRD Network and/or State Agency without going through the facility process first. The contact information for the ESRD Network was incorrect and the contact information for the State survey agency was incorrect and did not contain all methods available to file a grievance. C. Review of the facility Grievance Procedure handout (given to patients on admission) revealed contact information for the ESRD Network was incorrect and contact information for the State survey agency was incorrect and did not contain all methods available to file a grievance. D. During staff interview on 5/21/24 at 2:30 PM, the Nurse Manager (NM) confirmed the Patient Rights/Grievance Procedure, and the Grievance Procedure handout, contained incorrect contact information for the ESRD Network and the State survey agency.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 48995 Based on review of facility policies and procedures, record review and staff interviews, the facility: 1. staff failed to follow the policies and procedures for notification of the physician when Blood Pressure (BP) readings were not within the facility policy’s parameters for hypertension (high blood pressure), during hemodialysis (HD) treatments, for 1 of 5 sampled patients (Patient 5); 2. policy titled Hypotension (low blood pressure) failed to include hypotensive BP parameters which require Medical Director (MD) or physician notification and documentation of this notification; and 3. staff failed to follow MD expectations for reporting patients with hypotensive BPs, during HD treatments, for 2 of 5 sampled patients (Patient 1 and 5). These failed practices provided for a lack of intervention by the physician, or MD, to prevent negative patient outcomes associated with high and/or low blood pressure changes during HD. The facility census was 7. Findings include: A. Review of facility policy titled Hypertension, dated 10/20/09, revealed the general guideline for high blood pressure is: Systolic BP > 200 mmg [sic (millimeters)]/Hg [(Mercury)] or Diastolic BP > 100 mmg [sic]/Hg for 2 consecutive BP checks. This policy included a requirement to Document: Physician notification/time of notification. This policy failed to include which staff member is responsible for notifying the physician, documenting the notification, and where and how soon this notification is to be documented. B. Review of facility policy titled Hypotension, dated 10/20/09, revealed this policy included a requirement to Document: Physician notification/time of notification. This policy failed to define low blood pressure which requires physician or MD notification and failed to include which staff member is responsible for notifying the physician or MD, documenting the notification, and where and how soon this notification is to be documented. C. Patient 5’s clinical record failed to include the date and time staff notified the physician or MD when the patient’s BP readings, during HD treatments as shown below, required physician or MD notification by staff. 1. Staff-B on 5/3/24 at 12:47 PM, BP 218/80 and at 1:30 PM, BP 217/81 and at 2:00 PM, BP 212/76 and at 4:00 PM, BP 207/81 2. Staff-B on 5/20/24 at 9:30 AM, BP 87/41 and at 9:44 AM, BP 84/35 D. Patient 1’s clinical record failed to include the date and time staff notified the MD or physician when the patient’s BP readings, during HD treatments as shown below, required MD or physician notification by staff. 1. Staff-B on 5/13/24 at 1:45 PM, BP 83/28 2. Staff-G on 5/17/24 at 2:19 PM, BP 88/39 3. Staff-A on 5/20/24 at 3:40 PM, BP 87/44 and at 3:47 PM, BP 80/40 E. During staff interview on 5/22/24, at 8:30 AM, the Nurse Manager (NM) confirmed: 1. Patient 1’s and Patient 5’s clinical record failed to include the date and time staff notified the physician, or MD, when the patient’s BP readings, during HD treatments as shown above, required physician, or MD, notification by staff; 2. the facility’s Hypertensive and Hypotensive policies failed to include which staff member is responsible for notifying the physician or MD, documenting the notification, and where and how soon this notification is to be documented; and 3. the Hypotensive policy failed to define low blood pressure which requires physician or MD notification. F. During staff interview on 5/22/24, at 3:00 PM, the MD confirmed [gender] expectation of being notified by facility staff when: patient vital signs are outside the facility hypertensive parameters, the patient is symptomatic, and the patient’s systolic BP is below 90. The MD also confirmed recieving communication of changes in patient conditions and when patient vital signs are outside of facility parameters. The MD stated, it is the documentation of the physician notification which is needed.”

“GOV-APPOINT CEO/ADMINISTRATOR CFR(s): 494.180(a) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, This Standard is not met as evidenced by: 48995 Based on review of facility policies and procedures and staff interview, the facility failed to develop a policy which defines the qualifications of the Facility Administrator (FA). This failed practice provided the opportunity for the appointment of an unqualified individual to be designated as the FA. The facility census was 7. A. Review of facility policy titled Governing Body, dated 1-2002, revealed this facility policy failed to include defined educational and practical experience requirements for the individual who serves as the FA. B. During staff interview on 5/23/24, at 3:00 PM, the FA confirmed the facility failed to develop a policy which defined FA qualifications including educational and practical experience requirements.”