Fkc Belleville

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 22676 Based on interview, policy review, and review of the manufacturers direction for use, it was determined that the facility failed to ensure that one of one bottles of Mesa Lab Potential Hydrogen (PH) solution, used to check the pH calibration of the Myron L[sic] D6 meter (a meter used to conduct the conductivity of the dialysis machines), was dated when opened as required. Findings include: During a tour of the Water Room on 11/08/23 at 9:30 AM, one bottle of Mesa Lab pH calibration solution was opened but not dated with the date it was opened. Instructions on the side of the bottle directed that it expired ninety-days from opening. The side of the bottle contained a blank to record the date opened and the date expired. During an interview on 11/08/23 at 9:30 AM, Biomedical Technician 6 confirmed the pH solution was open and not dated and therefore could not determine the last day the solution was to be used. Review of the facility’s policy titled, “Myron L D6 Maintenance Procedure,” indicated, “At the beginning of the day, check conductivity, TDS[sic] (442), and PH solution’s expirations dates. . .” 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: 22676 Based on review of the glucometer logs, interview, facility policy review, it was determined that the facility failed to ensure the glucometers were in the control range for one of two glucometers used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in an inaccurate glucose result that could result in mistreated blood glucose levels and could result in harm. Findings included: Review of the electronic “Blood Glucose Logs” for unit one labeled V2 [sic] ISO (Isolation Room) from 09/01/23 through 10/31/23 revealed the following: On 09/19/23, the recorded acceptable high control range was 301-405, the recorded high control was 529. On 10/07/23, the recorded acceptable high control range was 301-405, the recorded high control was 260. On 10/31/23, the recorded acceptable low control range was 94-126 the recorded low control 132. Interview with the Administrator confirmed the findings on 11/09/23 at 11:45 AM. Both staff confirmed the staff did not repeat the low-level or high-level calibrations as required. During an interview on 11/09/23 at 1:00 PM, the Biomedical Technician 6 confirmed the above log findings. Review of the facility’s policy titled, “Blood Glucose Monitoring Device,” dated 07/05/22, revealed, under the “Policy Training” section, “Calibration of the device per manufactures recommendations, testing of the device using control solutions to assure proper functioning ...” Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision date 09/2020 revealed, “ ...p. eleven, if the “test fall outside the range printed on the test strip vial, repeat the test ...” 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: 22676 Based on record reviews, interview, and review of the facility’s policy, it was determined that the facility failed to follow the individualized dialysis prescription as determined by the medical provider for four of nine sampled in-center patients (Patient (P) 1, P4, P6, and P8). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments. Findings include: 1. Review of P1’s electronic medical record (EMR) revealed a prescribed blood flow rate (BFR) of 350 milliliters per min (ml/min) and a dialysate flow rate (DFR) of 2.0 the BFR, which would be 700 ml/min. Review of one of six “Post Treatment” flowsheets from 10/21/23 through 11/06/23, indicated the following: On 11/06/23, the DFR was documented at 600 ml/min from 2:46 PM through the end of treatment at 6:45 PM. There was no documented rationale for the change to the prescribed DFR. 2. Review of P4s EMR revealed a prescribed BFR of 350 ml/min and a DFR of 600 ml/min. Review of three of six “Post Treatment” flowsheets from 10/25/23 through 11/03/23, indicated the following: On 10/27/23, the BFR was documented at 300 ml/min and the DFR was documented at 500 ml/min from 3:20 PM through 4:31 PM. The BFR was increased to run at 360 ml/min from 4:31 PM and the DFR was left at 500 ml/min until the end of treatment at 6:35 PM. On 10/30/23, the DFR was documented at 500 ml/min from 3:16 PM through the end of treatment at 6:30 PM. On 11/01/23, the BFR was documented at 300 ml/min from 3:59 PM through the end of treatment at 6:36 PM. There was no documented rationale for the change to the prescribed BFR and DFR. 3. Review of P6’s EMR revealed a prescribed DFR of 800 ml/min. Review of one of six “Post Treatment” flowsheets from 10/25/23 through 11/06/23, indicated the following: On 10/27/23, the DFR was documented at 700 ml/min from 11:29 AM through the end of the treatment at 2:15 PM. There was no documented rationale for the change to the prescribed DFR. 4. Review of P8’s EMR revealed a prescribed BFR of 450 ml/min and a DFR of 2.0 the BFR. Review of one of six “Post Treatment” flowsheets from 10/27/23 through 11/08/23, indicated the following: On 11/08/23, the BFR was documented at 300 ml/min and the DFR at 500 ml/min from 5:12 AM until the treatment ended at 9:27 AM. There was no documented rationale for the change to the prescribed BFR and DFR. During an interview on 10/10/32 at 9:46 AM, the Administrator confirmed the above findings and confirmed that staff did not follow the facility’s policy. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, revealed, “Check the prescribed blood flow rate is being achieved or the reason is documented in the medical record if unable to meet prescribed flow rate. Check dialysate flow rate setting is correct, and the correct prescribed flow is being ...” N.J.A.C. 8:43A-24.4(a)”