Fkc Acc Livingston St Barnabas So Orange Ave

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure all environmental surfaces in each dialysis treatment station (Station 9) are disinfected at the end of each dialysis treatment for 1 of 2 observations of dialysis treatment station disinfection. Findings include: A facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published on 09/05/2023, revealed, “Background The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses.” The policy revealed, “Equipment in the dialysis station may include (but is not limited to) the following: Dialysis machine/cycler and attachments such as IV [intravenous] pole, BP [blood pressure] cuff and hand sanitizer/holder, organizer.” During an observation of the hemodialysis treatment area on 06/04/2024 at 11:50 AM, Certified Clinical Hemodialysis Technician (CHHT) #9 was observed disinfecting Station 9 following a dialysis treatment. CCHT #9 failed to disinfect the blood pressure cuff, prime waste receptacle, and a stethoscope in the treatment station. During an interview on 06/07/2024 at 12:00 PM, the Medical Director confirmed that all equipment and surfaces in the dialysis treatment stations should be disinfected after each dialysis treatment. N.J.A.C. 8:43A-24.4(a)”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure that 3 of 10 oxygen tanks were properly stored. Findings include: A facility policy titled, “Emergency Administration of Oxygen,” published 11/01/2021, revealed, “Oxygen cylinders must be secured in an area where they will not fall.” On 06/03/2024 at 11:12 AM, the surveyor observed three out of 10 oxygen tanks were unsecured and stored in the Clean Utility Room. During an interview on 06/03/2024 at 11:12 AM, the Clinical Manager confirmed the facility’s expectation would be for the oxygen tanks to be secured. During an interview on 06/07/2024 at 12:00 PM, the Medical Director stated oxygen tanks being stored securely is an expectation of the facility. N.J.A.C. 8:43A-24.4(a)”

“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: 50873 Based on record review, interview, and policy review, it was determined that the facility failed to follow the individualized dialysis prescription as determined by the medical provider for 4 (Patients #2, 4, 5, and 6) of 7 sampled patients. Failure to follow the medical provider’s dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 63 patients who received dialysis treatments and/or home therapy oversight at this facility. Findings include: A facility policy titled, “Unable to Achieve Prescribed Blood Flow Rate,” published on 11/01/2021, indicated, “Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders.” 1. Patient #2’s “Hemodialysis Orders” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min). Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/21/2024, revealed the patient’s BFR was documented as 330 mL/min from 4:21 PM until 6:17 PM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/23/2024, revealed the patient’s BFR was documented as 300 mL/min from 4:01 PM until 6:20 PM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/25/2024, revealed the patient’s BFR was documented as 300 mL/min from 5:59 AM until 8:00 AM when it increased to 310 mL/min until 9:11 AM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/28/2024, revealed the patient’s BFR was documented as 300 mL/min from 3:20 PM until 4:30 PM and 4:44 PM until 6:29 PM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/30/2024, revealed the patient’s BFR was documented as 300 mL/min from 3:40 PM until 6:13 PM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 006/01/2024, revealed the patient’s BFR was documented as 300 mL/min from 2:55 PM until 6:08 PM. Patient #2’s “Treatment Sheet for Facility: [Name of Facility],” dated 06/04/2024, revealed the patient’s BFR was documented as 300 mL/min from 3:25 PM until 5:21 PM, 265 mL/min from 5:21 PM until 5:40 PM, and 250 mL/min from 5:40 PM until 6:20 PM. 2. Patient #4’s “Hemodialysis Orders” revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #4’s “Treatment Sheet for Facility: [Name of Facility]” dated 05/24/2024, revealed the patient’s BFR was documented as 350 mL/min from 8:00 AM until 9:58 AM. Patient #4’s “Treatment Sheet for Facility: [Name of Facility]” dated 05/27/2024, revealed the patient’s BFR was documented as 375 mL/min from 4:44 PM until 6:41 PM, 350 mL/min from 5:21 PM until 6:41 PM, and 300 mL/min from 6:41 PM until 6:59 PM. Patient #4’s “Treatment Sheet for Facility: [Name of Facility]” dated 05/29/2024, revealed the patient’s BFR was documented as 350 mL/min from 6:07 AM until 7:03 AM. 3. Patient #5’s “Hemodialysis Orders” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min). Patient #5’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/30/2024, revealed the patient’s BFR was documented as 400 mL/min from 10:03 AM until 1:31 PM. 4. Patient #6’s “Hemodialysis Orders” revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #6’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/27/2024, revealed the patient’s BFR was documented as 400 mL/min from 9:01 AM until 10:01 AM. Patient #6’s “Treatment Sheet for Facility: [Name of Facility],” dated 05/29/2024, revealed the patient’s BFR was documented as 300 mL/min from 6:16 AM until 7:03 AM. During an interview on 06/06/2024 at 11:25 AM, the Clinical Manager confirmed treatment sheets lacked documentation regarding why changes to the patient’s prescribed BFR occurred or notification to the provider of the changes. During an interview on 06/07/2024 at 12:00 PM, the Medical Director stated that the provider should be notified if there were any deviations from the prescribed dialysis treatment and confirmed that the facility’s expectation would be for the patient treatments to be run as ordered. N.J.A.C. 8:43A-24.4(a)”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 50873 Based on observation, record review, policy review, and staff and patient interview, it was determined that the facility failed to adjust the patient’s plan of care to reflect the patient’s current condition for one (Patient #5) of seven sampled patients. Findings include: A facility policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” published on 04/24/2019, indicated that the comprehensive interdisciplinary assessment includes “Evaluation of the patient abilities, interest, preferences and goals.” The following was observed on 06/04/2024: At 11:24 AM, Patient #5 was receiving dialysis treatment in Station 8 and had a cover wrapped around their left forearm and taped near the elbow and wrist, making it so the patient’s arteriovenous (AV) fistula access was not visible. At 11:41 AM, Registered Nurse #7 approached Station 8 and assessed the blood pressure of Patient #5 and elevated the patient’s feet. The patient’s access remained covered. At 11:45 AM, Certified Clinical Hemodialysis Technician (CHHT) #9 approached Station 8 and gave Patient #5 oxygen via nasal cannula. The patient’s access remained covered. At 12:00 PM, 12:08 PM, 12:13 PM, and 12:20 PM, CCHT #9 responded to machine alarms in Station 8, where Patient #5 received dialysis treatment. The patient’s access remained covered during the 56 minute observation period. During an interview on 06/04/2024 at 12:26 PM, CCHT #9 stated Patient #5 insisted on having their access covered because they did not like to see blood. CCHT #9 stated the patient’s access site was visible from next to the machine but not from far away or to any staff members. CCHT #9 reported that the patient had been given education on keeping their dialysis access site uncovered, but the patient continued to insist on covering their access site. During an interview on 06/04/2024 at 12:30 PM, Patient #5 confirmed that they liked to cover their access because they did not like the sight of the needles. Patient #5 stated they had been receiving dialysis treatment at the clinic for two years and had covered their access site for treatments the entire time. Patient #5 stated that in the beginning staff would ask them to keep the access site uncovered but otherwise, no one had challenged them on this matter. Patient #5 stated they had not received any education on why they should keep their access uncovered. During an interview on 06/04/2024 at 12:41 PM, Registered Nurse (RN) stated Patient #5 always covered their access and the staff had educated the patient on having their access uncovered, but the patient continued to refuse. RN #7 confirmed that the access was only visible at the chairside and was currently not visible to any staff member, as no one was at the patient’s chairside at the time. RN #7 confirmed the facility expectation was for all patient accesses to be visible at all times. During an interview on 06/04/2024 at 12:47 PM, RN #8 confirmed Patient #5 always covered their access and that if staff uncovered it, the patient would put the cover back on. RN #8 stated that all patients, including Patient #5 have received education about the dangers of having their access covered, including the possibility of a needle becoming dislodged and possibly leading to passing out or bleeding out. RN #8 was unsure if the interdisciplinary team (IDT) had met to address this issue. During an interview on 06/04/2024 at 1:55 PM, the Clinical Manager (CM) confirmed that the facility expectation was for all patients’ accesses to be visible at all times. The CM stated that the staff had spoken with Patient #5 multiple times regarding keeping their access visible. The CM stated that the IDT had not addressed this issue in care planning for this patient. Patient #5’s plan of care, dated 02/08/2024, revealed no evidence the staff addressed with the patient their behavior of covering their access during dialysis treatment. The “Confirmation of Consent for In-center Hemodialysis Treatment Acknowledgement of Patient Responsibilities,” signed by Patient #5 on 03/26/2022, revealed the patient was presented with information regarding keeping their access uncovered during treatment. During a follow-up interview on 06/07/2024 at 9:00 AM, the CM confirmed that the facility expectation would be that the care team would have recognized the issue of Patient #5 needed to be brought to the IDT (Interdisciplinary Team) and addressed in the patient’s plan of care. During an interview on 06/07/2024 at 12:00 PM, the Medical Director confirmed (MD) that the facility expectation was for all patient accesses to be uncovered during dialysis treatment. The MD stated that the expectation in the case of Patient #5 would be that the problem be brought to the IDT and addressed in the patient’s plan of care. N.J.A.C. 8:43A-24.13(b)”