Fmc Whiting

“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: 48966 Based on one of one observation of the initiation of hemodialysis using a central venous catheter (CVC), review of facility policy, and staff interview, it was determined that the facility failed to ensure the end of the luer lock and body of a CVC are cleaned when initiating hemodialysis. Findings include: On 1/25/24 at 10:48 AM in Station 14, Staff (S) 7, a Registered Nurse (RN), was observed during initiation of dialysis through a CVC. S7 removed the arterial thread cap, scrubbed only the threads for 15 seconds with an alcohol prep pad and did not clean the end of the luer lock or the body of the arterial catheter. S7 then attached a syringe on the end of the arterial limb. S7 proceeded to remove the venous thread cap, scrubbed only the threads for 15 seconds with an alcohol prep pad, and did not clean the end of the luer lock or the body of the venous catheter. S7 then attached a syringe on the end of the venous limb. S7 did not clean from the hub and toward the body of the arterial and venous catheters as required by facility policy. During an interview at 10:58 AM, S7 was asked about the procedure on how to clean the catheter limbs and explained that the catheter limbs needed to be wiped down with alcohol not just the threads of the CVC. Upon interview at 11:04 AM, S8, the Charge Nurse, explained that the RN needed to scrub the body of the catheter and then clean the threads of the CVC with alcohol prior to initiation of hemodialysis. On 1/26/24, S7’s personnel file was reviewed and indicated that an annual skills validation checklist was completed on 12/14/23, which included initiation of dialysis with a CVC and scrub the hub. A review of the facility policy titled, “Initiation of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer,” published 07/06/2021, stated, “... Preparing the Catheter: Disinfection of the Catheter Connections, ... Follow the steps below to disinfect the catheter connections: ... Threads and end of the luer lock (hub) must be scrubbed with 70% [percent] sterile alcohol pad (or other antiseptic such as chlorhexidine, ...) for 10 -15 seconds and any time caps are removed, or blood lines are disconnected (i.e. end of treatment or treatment interruption) to reduced risk of contamination. ... Step 2. Remove cap from clamped arterial limb NOTE: If there are secretions or other visible residue on catheter limb and cap, use 70% sterile alcohol pad(s) (or other antiseptic such as chlorhexidine, ...) to remove any exudate on the limb(s) and/or cap(s) prior to removing the cap. 3. Using a sterile alcohol pad (or other antiseptic such as chlorhexidine, ...) scrub the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue (e.g., blood) ... 4. Using the same sterile alcohol pad (or other antiseptic ...) applying friction to remove any blood or residue, move from the hub at least several centimeters towards the body of the catheter. (Steps 3 and 4 should take 10-15 seconds). ... 5. Hold the limb while allowing the antiseptic to dry. 6. ... Repeat steps 1-6 for venous limb. ...” N.J.A.C. 8:43A-24.8(b)”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 33556 Based on observation and staff interview, it was determined the facility failed to ensure that a defect free environment is maintained at all times. Findings include: During a tour conducted on 1/24/24 at 10:30 AM, it was identified that the integral floor base had separated from the wall throughout the treatment area, especially under the waterbox connections. This detachment produced an uncleanable gap between the wall and floor and was a collection point for dust and debris. This finding was confirmed by Staff (S) 3 upon discovery. N.J.A.C. 8:43A-17.4 (a)15”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 48966 Based on one of one observation, staff interview and a review of facility documents, it was determined that the facility failed to ensure that privacy during the initiation of hemodialysis on a patient with a central venous catheter (CVC) is maintained. Findings include: On 1/25/24 at 10:48 AM in Station 14, Staff (S) 7, a Registered Nurse, initiated hemodialysis via a right CVC on female Patient (P) 10. S7 had one privacy curtain drawn behind him/her. The privacy curtain in front and to the left side of P10 was left open exposing P10 to other patients sitting nearby. S7 opened P10’s shirt exposing the right chest, to access the arterial and venous limbs of the CVC during the initiation of hemodialysis. P10 was visible to patients sitting in Station 15, 16, and 17 and the nurses’ station across from Station 14. During an interview with S7 at 10:58 AM, S7 confirmed that the privacy curtains were supposed to be drawn around the dialysis station during catheter care. During an interview at 11:04 AM, S8, the Charge Nurse, explained that the curtains should be drawn during catheter care. Facility documentation, given to each patient upon admission, titled, “[facility name] Patient Rights,” dated 6/28/18, stated, “ ... Privacy and Confidentiality ... Privacy and confidentiality in all aspects of treatment. This includes ... the right to privacy during activities that may require the exposure of body parts while in the dialysis facility. Privacy screens, curtains, or blankets that do not cover your face or access, may be used to provide privacy...” N.J.A.C. 8:43A-16.2 (a)(10)”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 37656 Based on staff interview, medical record review, and a review of facility documents, it was determined that the facility failed to ensure that the physician worked collaboratively with the interdisciplinary (IDT) team members to address the patient’s needs in one of two medical records reviewed Patient (P) 6. Findings include: A review of P6’s medical record revealed the following: The Interdisciplinary Plan of Care (PoC) meeting was held on 11/10/23. The physician’s comprehensive note was written on 11/27/23, 17 days after the PoC meeting. The plan of care Team Approval Signatures, stated, “... Approved by RN (Registered Nurse) (Attended remotely) and the Social Worker (SW) (Attended remotely) and signed on 11/13/23, and the RD, Registered Dietitian (Attended remotely), signed on 11/14/23. The physician, (Attended remotely) approved and signed the Plan of Care on 12/19/23,” 39 days after the Plan of Care meeting. A review of the facility policy titled, Comprehensive Interdisciplinary Assessment and Plan of Care, published 7/03/23, stated, “... The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting. ...” N.J.A.C. 8:43A-24.13 (b)”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 37656 Based on staff interview, review of five of ten medical records (P (Patient) 1, P2, P4, P5, and P6) and a review of facility documents, it was determined that the facility failed to ensure that post hemodialysis treatment assessments are completed on all patients. Findings include: On 1/25/24, a review P1’s hemodialysis treatment flowsheets revealed the following: The pre-treatment “Nursing Evaluation” on 1/2/24 at 10:30 AM stated, “... Lungs Decreased breath sounds, Ankle - Severity 1+: 2 mm (millimeter) or less, disappears rapidly Edema Ankle - Location Bilateral, Lungs - Sound Location Bilateral ...” The post-treatment “Nursing Evaluation” on 1/2/24 at 2:37 PM did not contain documentation of a re-assessment of the patient’s lungs sounds and bilateral ankle edema. The pre-treatment “Nursing Evaluation” on 1/4/24 at 10:33 AM stated, “... Lungs Decreased breath sounds, Ankle - Severity 1+: 2 mm or less, disappears rapidly Edema Ankle - Location Bilateral, Lungs - Sound Location Bilateral ...” The post-treatment “Nursing Evaluation” on 1/4/24 at 2:27 PM did not contain documentation of a re-assessment of the patient’s lungs sounds and bilateral ankle edema. The pre-treatment “Nursing Evaluation” on 1/13/24 at 10:35 AM stated, “... Lungs Decreased breath sounds, Ankle - Severity 1+: 2 mm or less, disappears rapidly Edema Ankle - Location Bilateral, Lungs - Sound Location Bilateral ...” The post-treatment “Nursing Evaluation” on 1/13/24 at 2:41 PM did not contain documentation of a re-assessment of the patient’s lungs sounds and bilateral ankle edema. The pre-treatment “Nursing Evaluation” on 1/18/24 at 10:36 AM stated, “... Lungs Decreased breath sounds ... Lungs - Sound Location Bilateral ...” The post-treatment “Nursing Evaluation” on 1/18/24 at 2:24 PM did not contain documentation of a re-assessment of the patient’s lungs sounds. The pre-treatment “Nursing Evaluation” on 1/20/24 at 10:34 AM stated, “... Lungs Decreased breath sounds ... Lungs - Sound Location Bilateral ...” The post-treatment “Nursing Evaluation” on 1/20/24 at 3:35 PM did not contain documentation of a re-assessment of the patient’s lungs sounds. On 1/25/24, a review of P2’s hemodialysis treatment flowsheets revealed the following: On 1/4/24 at 6:19 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds, ankle swelling, and lower leg swelling. The post-treatment “Nursing Evaluation” at 10:40 AM lacked documented evidence of a re-assessment of lung sounds, ankle swelling and lower leg swelling. On 1/6/24 at 6:07 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds and ankle swelling. The post-treatment “Nursing Evaluation” at 10:26 AM lacked documented evidence of a re-assessment of lung sounds and the ankle swelling. On 1/9/24 at 7:09 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds and ankle swelling. The post-treatment “Nursing Evaluation” at 10:13 AM lacked documented evidence of a re-assessment of lung sounds and the ankle swelling. On 1/13/24 at 6:57 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds, ankle swelling, and lower leg swelling. The post-treatment “Nursing Evaluation” at 10:15 AM lacked documented evidence of a re-assessment of lung sounds, the ankle swelling, and lower leg swelling. On 1/25/24, a review of P4’s hemodialysis treatment flowsheets revealed the following: On 1/2/24 at 11:15 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 1:59 PM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/4/24 at 10:38 AM, a pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 1:50 PM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/20/24 at 11:02 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 2:19 PM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/25/24, a review of P5’s hemodialysis treatment flowsheets revealed the following: On 1/6/24 at 5:35 AM, a pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 9:49 AM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/9/24 at 5:31 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 9:44 AM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/11/24 at 6:55 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 9:14 AM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/13/24 at 5:39 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds. The post-treatment “Nursing Evaluation” at 9:33 AM lacked documented evidence of a re-assessment of the patient’s lung sounds. On 1/25/24, a review of P6’s hemodialysis treatment flow sheets revealed the following: On 1/15/24 at 11:13 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds, ankle swelling, and lower leg swelling. The post-treatment “Nursing Evaluation” at 2:51 PM lacked documented evidence of a re-assessment of lung sounds, the ankle swelling, and lower leg swelling. On 1/17/24 at 11:01 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds, ankle swelling, and lower leg swelling. The post-treatment “Nursing Evaluation” at 12:22 PM lacked documented evidence of a re-assessment of lung sounds, the ankle swelling, and lower leg swelling. On 1/24/24 at 10:55 AM, the pre-treatment “Nursing Evaluation” indicated decreased breath sounds, ankle swelling, and lower leg swelling. The nursing post-treatment evaluation at 3:10 PM lacked documented evidence of a re-assessment of lung sounds, the ankle swelling, and lower leg swelling. During an interview on 1/26/24 at 1:00 PM, Staff (S) 8, the Charge Nurse, stated that if unusual findings are noted in the pre-assessment by the Registered Nurse (RN), then a post treatment re-assessment of the unusual findings should be documented. If the unusual findings are a chronic condition for the patient, then it should be documented as such by the RN. A review of facility policy and procedure titled, “Patient Assessment and Monitoring,” published 5/1/23, stated, “... Post-Treatment Follow the steps below for obtaining post-treatment assessment data: ... 1 ... Lungs sounds, Edema ... The registered nurse will assess/reassess post treatment as indicated. ... 2 Document findings in the patient’s record. ...” 39228 48966”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48966 Based on observation, staff interview, and a review of facility documents, it was determined that the Medical Director failed to implement facility policy to ensure that staff dispose of expired needles and syringes. Findings include: On 1/24/24 at 11:46 AM, during a tour of the Clean Utility/Medication Room, the following was observed: The second top cabinet across from the refrigerator contained six boxes of 25-gauge x 1 inch BD Safety Glide Injection needles. Two of the boxes had an expiration date of 5/31/23, three of the boxes had an expiration date of 8/31/23, and one box had an expiration date of 9/30/23. The third top cabinet across from the refrigerator contained four boxes of 22-gauge x 1 inch BD Safety Glide Injection needles. All four boxes had an expiration date of 11/30/23. The sixth top cabinet labeled “Patient Medication” contained one box of 23-gauge x ¾ inch needle length 12-inch tubing BD Vacutainer Safety-Lok. The box had an expiration date of 8/31/21. The third bottom cabinet below the drawer labeled “Suture Removal Tray” across from the refrigerator contained one box of BD 1 milliliter Tuberculin Syringes. The box had an expiration date of 4/2020. The cabinet also contained four boxes of 22-gauge x 1 ½ inch Sol-Care syringes. Three boxes of the four boxes had an expiration date of 12/2019. One box of the four boxes had an expiration date of 10/2019. During an interview at 12:00 PM, Staff (S) 7, a Registered Nurse, confirmed the above findings and stated the expired needles and syringes should have been discarded. S7 then discarded all sixteen expired items into a sharp’s container. Upon interview at 12:36 PM, S2, the Clinical Manager, explained that S8, the Charge Nurse, S6, a Registered Nurse, and herself check the supplies for expiration dates. S2 stated there is no logbook or documentation for expired supplies. A review of the facility policy titled, “Storage of Supplies,” published on 4/5/21, stated, “ ... Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged .... Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date ...””