Children’s Nebraska

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 48995 Based on review of facility policies and procedures, observations, and staff interviews, the facility failed to ensure staff (RN-O and RN-L) followed the five rights of medication administration, which means getting the right drug to the right recipient, in the right dosage, by the right route, at the right time, to prevent a medication error as defined under Nebraska Title 175 NAC 9-002, when preparing and administering medication to a facility patient (Patient 3). This failed practice had the potential to affect the health and safety of all patients who receive medications administered by the hemodialysis (HD) staff. In-center HD patient census was 3. Findings are: A. Nebraska Title 175 NAC 9-002.05 MEDICATION ERROR. Any variance between the chart order or prescription, the five rights, and administration of the medication. B. Review of the facility policy titled Medication Administration, dated 5/2024, revealed medications will be administered using safe administration practices such as the “six rights” of medication administration. Six rights of drug administration for accuracy included right drug, right dose, right patient, right route, right time, and right documentation. If the medication is prepared at the unit level, a non-bar-coded medication label (including drug name, dose/strength, preparation date and initials of who prepared the medication) will be applied if the medication will be given by another professional or given over a period of time. This facility policy failed to ensure the staff member who prepares the medication is the same staff member who administers the medication to the patient. C. During initiation of Patient (PT)-3’s HD treatment on 5/6/24, the following was observed: 1. At 12:50 PM, Registered Nurse (RN)-O delivered a syringe, containing a clear liquid, to PT-3’s chairside table. The syringe was labeled Heparin (a medication which decreases the clotting ability of the blood) 1000 Units/mL (millimeter). 2. At 12:55 PM, RN-L and RN-O co-checked (the process of having a second healthcare professional independently check the preparation of a medication for administration) the Heparin syringe. RN-L administered the syringe, containing a clear liquid, labeled Heparin 1000 Units/mL into PT-3’s venous access device. D. During staff interview on 5/6/24 at 1:05 PM, RN-L confirmed administering the syringe labeled Heparin 1000 Units/mL to PT-3, but had not prepared the syringe. RN-L further confirmed the syringe had been prepared by RN-O (facility Resource Nurse), as the facility Resource Nurse is tasked with preparing the Heparin medications for the patient treatments, which is then administered by the staff initiating treatment. E. During staff interview on 5/9/24 at 9:30 AM, the Clinical Supervisor confirmed RN-L had followed facility policy, but failed to follow the five rights of medication administration.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48995 Based on review of facility policies and procedures, observations, and staff interview, 3 of 5 staff members (Staff RN-T, RN-O, and PCT-E) failed to follow facility policy and procedure to wear gloves while accessing the hemodialysis (HD) machines. This failed practice provided the opportunity for transmission of infectious diseases among both patients receiving HD treatment during the survey observation. In-center HD patient census was 3. Findings are: A. Review of the facility policy titled Infection Control in the Pediatric Dialysis Unit, with the date of 7/2023, revealed gloves will be worn by staff during any potential exposure to blood, dialysate, or any other potentially infectious substance which includes touching any part of the dialysis machine, tubing, blood lines, or dialyzer during or after a treatment. B. Observation of the provision of patient care revealed: 1. On 5/6/24 at 4:30 PM, RN-T touched the screen on an HD machine without wearing gloves. 2. On 5/6/24 at 5:00 PM, RN-O touched the screen on an HD machine with a glove wrapped around [gender] index finger. RN-O failed to wear gloves when [gender] touched the screen on an HD machine. 3. On 5/8/24 at 11:45 AM and 11:52 AM, PCT-E touched the screen on an HD machine without wearing gloves. C. During staff interview on 5/9/24 at 9:30 AM, the Clinical Supervisor confirmed RN-T, RN-O, and PCT-E did not follow facility policy and procedure for glove use while accessing the dialysis machines throughout the patient treatment area.”

“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, staff members failed to ensure 2 of 3 patient’s (Patients 2 and 3) vascular access sites and blood lines remained visible throughout the patient’s hemodialysis (HD) treatment. Additionally, the facility failed to have policies and procedures for the visualization of patient’s vascular access sites and blood lines during HD treatment. This failed practice provided the opportunity for accidental dislodgement, or line disconnection, to go undetected which could result in exsanguination (the process of losing blood) and patient death within minutes. In-center HD patient census was 3. Findings are: A. Observation of HD treatments, on 5/6/24 from 1:45 PM to 5:00 PM, revealed staff members O, L, F and E failed to address and correct staff’s obstructed view of Patient 2’s vascular access site and blood lines, which were covered by Patient 2’s shirt and blanket. B. Observation of HD treatments, on 5/6/24 from 3:00 PM to 4:00 PM, revealed staff members J, E and O failed to address and correct staff’s obstructed view of Patient 3’s vascular access site and blood lines, which were covered by a blanket. C. Observation of HD treatments, on 5/8/24 from 11:45 AM to 12:15 PM, revealed staff members S, E and G failed to address and correct staff’s obstructed view of Patient 2’s vascular access site and blood lines, which were covered by Patient 2’s shirt and blanket. D. During staff interview on 5/9/24 at 9:30 AM, the Clinical Supervisor: 1. confirmed a facility policy and procedure for the visibility of the patient’s vascular access site and blood line connections, by staff, during the patient’s HD treatment did not exist on 5/8/24, when the policy was requested by the surveyor; and 2. provided a copy of the facility policy titled Hemodialysis Nursing Management, dated 5/2024, with a new requirement that vascular access site, bloodline connections, and face must be visible throughout the treatment. The Clinical Supervisor confirmed this new requirement was added to this policy on 5/8/24, after the surveyor requested the policy.”