322501 Santa Fe Dialysis (Fmc)

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 28297 Based on observation, interview and policy review, the facility failed to ensure supplies stored in the crash cart (a cart that contains supplies and equipment needed during an emergency inside the clinic) and ready for use were not expired for one of three days. The failure to remove expired supplies had the potential for staff to use items they were expired, and this could affect 69 in-center patients. Findings include: Observation on 04/18/25 at 1:30 PM found one bag of 1000 milliliters normal saline stored in the bottom of the crash cart and expired 10/2024. During an interview on 04/18/25 at 1:30 PM the Director of Operations and Charge Nurse both confirmed that the normal saline was expired and should have been checked and removed with the monthly checks of the crash cart. Review of the facility’s policy titled, “Emergency Medications, Equipment and Supplies,” revised 02/03/25 indicated, “ ...The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible, and immediately available: ...IV (intravenous) solutions and administration sets ...The medications and supplies outlined in this policy must be maintained and the facility for emergency use. The emergency cart must be: locked when not in use, checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment ...””

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE-refers to wearable equipment used to protect workers, and patients from serious injuries or illnesses) as required during disconnection of dialysis treatment via Central Venous Catheter (CVC) for one of two observations. Personal protective equipment acts as a barrier between infectious materials and the skin, mouth, nose, or eyes (mucous membranes). The failure to wear PPE appropriately had the potential for cross contamination of the CVC and this could affect 26 patients in the facility who receive dialysis via CVC. Findings include: Observation on 04/16/25 at 10:45 AM Registered Nurse (RN) 3 was disconnecting the dialysis treatment via the CVC for Patient (P) 5 at Station 17. RN3 had regular glasses without side protection and the mask was not covering his/her nose as required. During an interview on 04/16/25 at 10:55 AM RN3 confirmed he/she did not have proper eye protection and that the mask was not covering his/her nose as required to prevent possible cross contamination of the CVC. During an interview on 04/18/25 at 1:30 PM the Charge Nurse confirmed staff should wear PPE with full eye covering and mask covering to prevent potential cross contamination of the CVC. Review of the facility’s policy titled, “Initiation and Termination of Treatment Using a Central Venous Catheter (CVC),” revised 11/04/24, indicated, “ ...Infection control: Staff, patients, and care partners must use personal protective equipment (PPE), per policy Personal Protective Equipment. A mask must be worn that covers the nose and mouth by staff, patient, and their care partner for all procedures that require accessing the catheter ...” Review of the facility’s policy titled, “Exposure Categories and Determination,” revised 07/01/24, indicated, “ ...Initiation of Hemodialysis Treatment: Gloves, Full Face Shield or Mask and Goggles, and gown ...””

“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: 28297 Based on observation, interview, and policy review. the facility failed to ensure staff completed Central Venous Catheter (CVC- A hemodialysis central venous catheter is a type of access used for hemodialysis. CVCs are placed under the skin and into a large central vein, preferably the internal jugular veins.) care/inspection prior to accessing the blood lines for one of two observations. The failure to assess the CVC site prior to accessing the blood lines had the potential for missed opportunities to capture access site infections and line dislodgement and this could affect 26 patients who have CVC in the facility. Findings include: Observation on 04/16/25 at 11:05 AM Patient Care Technician (PCT) 2 was at Station 7 initiating the treatment for Patient (P) 4 via the CVC. PCT 2 completed the entire initiation process and started the dialysis treatment without observing the CVC access site as it was covered with a dressing. During an interview on 04/16/25 at 11:20 AM PCT 2 stated he/she was unaware the CVC dressing needed to be removed or changed prior to stating the treatment to assess the insertion site. During an interview on 04/16/25 at 11:20 PM Registered Nurse (RN) 3 confirmed the dressing was not removed or changed prior to stating the treatment but should have to assess the insertion site. RN 3 proceeded to change the dressing for P4 at Station 7. Review of the facility’s policy titled, “Initiation and Termination of Treatment Using a Central Venous Catheter,” revised 11/04/24, indicated, “ ...The catheter exit site must be assessed for signs and symptoms of infection, dislodgement of catheter or other problems, and the catheter exit site care and dressing replacement must be completed prior to accessing the bloodstream per the procedure ...””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 28297 Based on interview, record review, and policy review, the facility failed to ensure four of seven sampled patients (Patient (P) 1,P3, P5, and P6) were monitored every 30 minutes and no more than 45 minutes per policy. The failure to monitor patients every 30 - 45 minutes had the potential not to capture a potential adverse event in a timely manner and could affect all 69 in-center hemodialysis patients. Findings include: 1. Review of the medical record face sheet provided by the facility for P1 revealed the facility admitted the patient on 02/01/25 with a diagnosis including End Stage Renal Disease. Review of six dialysis flow records provided by the facility for P1 from 04/03/25 through 04/15/25 revealed the following: On 04/03/25 the patient’s blood pressure was checked at 1:03 PM with a reading of 121/76 and not again until 2:03 PM with a reading of 126/70, 15 minutes late. On 04/07/25 the patients’ blood pressure was checked at 12:32 PM with a reading of 136/67 pulse 49 and not checked again until 1:35 PM with a reading of 148/77, 18 minutes late. On 04/10/25 the patients’ blood pressure was checked at 2:03 PM with a reading of 138/68 and not checked again until 3:02 PM with a reading of 138/71, 14 minutes late per facility policy. 2. Review of the medical record face sheet provided by the facility for P3 revealed the facility admitted the patient on 04/02/24 with a diagnosis including End Stage Renal Disease. Review of six dialysis flow records provided by the facility for P3 from 04/03/25 through 04/15/25 revealed the following: On 04/12/25 the patient’s blood pressure was checked at 6:32 AM with a reading of 144/68 and not again until 7:41 AM with a reading of 143/66, 24 minutes late. On 04/15/25 the patients’ blood pressure was checked at 9:08 AM with a reading of 164/73 and not checked again until 10:04 with a reading of 167/78, 12 minutes late. 3. Review of the medical record face sheet provided by the facility for P5 revealed the facility admitted the patient on 06/04/18 with a diagnosis including End Stage Renal Disease. Review of six dialysis flow records provided by the facility for P5 from 04/05/25 through 04/16/25 revealed the following: On 04/11/25 the patient’s blood pressure was checked at 1:06 PM with a reading of 153/59 and not again until 2:09 PM with a reading of 140/60, 18 minutes late. On 04/14/25 the patients’ blood pressure was checked at 1:02 PM with a reading of 167/82 and not checked again until 2:32 PM with a reading of 133/34, 45 minutes late. 4. Review of the medical record face sheet provided by the facility for P6 revealed the facility admitted the patient on 04/10/23 with a diagnosis including End Stage Renal Disease. Review of six dialysis flow records provided by the facility for P6 from 04/02/25 through 04/14/25 revealed the following: On 04/02/25 the patient’s blood pressure was checked at 1:04 PM with a reading of 120/65 and not again until 2:03 PM with a reading of 152/64, 14 minutes late. On 04/05/25 the patients’ blood pressure was checked at 11:31 AM with a reading of 132/58 and not checked again until 12:30 PM with a reading of 94/53, 14 minutes late. The nurse was notified of the decrease in blood pressure and fluid removal was stopped. On 04/07/25 the patients’ blood pressure was checked at 10:35 AM with a reading of 140/73 and not again until 12:03, with reading of 149/68, 42 minutes late. During an interview on 04/18/25 at 12:15 PM Patient Care Technician (PCT) 1 stated patients were to be monitored and documented every 30 minutes to ensure they are safe. PCT 1 confirmed the missing blood pressure and monitoring checks for all 4 patients identified. During an interview on 04/18/25 at 12:30 PM the Medical Director stated patients were required to be monitored every 30 minutes to ensure they are safe and tolerating dialysis. During an interview on 04/18/25 at 12:50 PM Registered Nurse (RN) 1 confirmed there were missing blood pressures on all 4 patients identified and that patients were required to be monitored every 30 minutes to ensure they were safe. During an interview on 04/18/25 at 1:30 PM the Charge Nurse and Director of Operations confirmed the missing blood pressure on all four patients identified with 2 patients having extended delays. They both confirmed the policy stated to monitor patients every 30 minutes. Review of the facility’s policy titled, “Patient Monitoring and Safety Checks During Hemodialysis Treatment,” revised 09/05/23 indicated, “ ...Monitor and document every 30 minutes or more often but not to exceed 45 minutes or per state regulation ... Patient monitoring includes Changes in the patients status, blood pressure, pulse, respirations ...confirm each patient and access are uncovered ...””