322513 Espanola Dialysis (Fmc)

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure the timely disposal of expired medications. Failure to remove expired medical supplies had the potential to affect 64 in-center patients receiving dialysis treatments at the facility. Findings include: During an observation of the medication refrigerator on 09/06/24 at 11:10 AM, one vial of Purified Protein Derivative (PPD) testing solution (used to test patients for Tuberculosis, a highly contagious respiratory disease) was opened and undated. A second vial of PPD testing solution was opened and dated 08/01/24, was expired by 7 days. During an interview on 09/06/24 at 11:10 AM, Registered Nurse (RN) 1 confirmed the medications were expired. RN1 stated monthly audits for expired medications were checked, however it was not included on the medication count list. During an interview on 09/06/24 at 1:00 PM, the Clinical Manager stated the medications should be checked monthly and discarded if unlabeled or older than 28 days from opening per facility’s policy. He/she confirmed staff were required to date and initial multidose vials when opened to ensure they were disposed of within 28 days. Review of the facility’s policy title “Medications Preparation and Administration,” revised 02/06/23, indicated “ ...label any open multi-dose vial that is not used immediately and store vial accordingly ...Expiration dates for all stored medications are to be monitored on a monthly basis ...Any open multi dose vials must be discarded 28 days after opening or per manufacture’s expiration date ...””

“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 the patients’ mask was covering his/her nose during the discontinuation of dialysis via a 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. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established.) for one of two observations. The failure to ensure the mask was covering the nose as required had the potential for contamination of the CVC and increase the risk of infections and could affect 22 of 64 in-patients that have CVCs in the facility. In addition, the facility failed to ensure the CVC dressing change was completed prior to initiation of hemodialysis as required for one of two observations. The failure to complete the dressing change prior to initiation had the potential for missed opportunities to identify catheter malfunction or drainage and this could affect 22 of 64 patients. Findings include: 1. Observation on 09/05/24 at 11:00 AM, revealed Registered Nurse (RN) 2 was completing the CVC dressing change for Patient (P) 9. RN2 completed the entire dressing procedure, with the patient wearing his/her mask under the nose the entire time. During an interview on 09/05/24 at 11:05 AM, RN2 confirmed P9’s mask was under the nose and should have been completely covering the nose and mouth to prevent contamination of the CVC access site. 2. Observation on 09/05/24 at 11:10 AM, revealed Certified Clinical Hemodialysis Technician (CCHT) 1 initiating the treatment via the CVC for P8. CCHT1 had removed blood from both lumens of the CVC and flushed both lumens of the CVC with normal saline and connected the dialysis lines to both lumens. When asked if the dressing change had been completed, CCHT1 stated he/she thought it had when RN1 came over to do the assessment. RN1 was asked to come to the Station after it was noted that the dressing change supplies remained on the chairside table. RN1 confirmed that the CVC dressing change had not been completed for P8 prior to initiation of treatment and should have been to assess the access site. During an interview on 09/0/24 at 1:00 PM, the Clinical Manager confirmed that the policy was for patients to wear mask covering the mouth and nose during initiation of the treatment and dressing changes via the CVC to prevent contamination of the CVC exit site. The Clinical Manager also confirmed that CVC dressing changes should be completed prior to initiation of the treatment via the CVC per facility policy to ensure the CVC site was without complications. Review of the facility’s policy “Central Venous Catheter (CVC) Dressing Change,” revised 05/06/2024, revealed the following: “ ...Catheter exit site disinfection and dressing changes are to be completed prior to cap and hub connector disinfection. This provides an opportunity to inspect the exit site for signs of infection or complications and if applicable, notify the Contracted Entity Nurse/Nurse in Charge of the Patient and/or the treating physician prior to initiating treatment ...The patient and Inpatient Services Staff must wear a mask for all procedures that require accessing the catheter to help prevent contamination by airborne nasal bacteria ...Apply a mask to the patient and the Inpatient Service Staff ...””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 28297 Based on interview, record review, and policy review, the facility failed to ensure six of seven sampled patients (Patient (P)1, P2, P4, P5, P6, and P7) were monitored every 30 minutes as required. The failure to monitor patients every 30 minutes had the potential to not capture a potential adverse event in a timely manner and could affect all 64 in-center hemodialysis patients. Findings include: 1. Review of the face sheet found in the medical record for P1 provided by the facility revealed the facility admitted the patient on 06/11/24 with a diagnosis including End Stage Renal Disease (ESRD). Review of six dialysis flow records for P1 from 08/22/24-09/03/24 revealed on 08/27/24 the patient’s blood pressure was checked at 2:04 PM with a reading of 116/48 and was not checked again until 3:00 PM, with a reading of 116/55, 56 minutes later. On 09/03/24, the patient’s blood pressure was checked at 2:33 PM reading 118/51 and not again until 3:25 PM, reading 166/63, 58 minutes later. 2. Review of the face sheet found in the medical record for P2 provided by the facility revealed the facility admitted the patient on 07/10/24 with a diagnosis including ESRD. Review of six dialysis flow records for P2 from 08/09/24- 08/30/24 revealed on 08/26/24 the patient’s blood pressure was checked at 2:32 PM with a reading of 109/55 and was not checked again until 3:25 PM, with a reading of 110/58, 53 minutes later. On 08/30/24, the patient’s blood pressure was checked at 2:31 PM reading 120/75 and not again until 3:29 PM, reading 123/77, 58 minutes later. 3. Review of the face sheet found in the medical record for P4 provided by the facility revealed the facility admitted the patient on 01/10/23 with a diagnosis including ESRD. Review of six dialysis flow records for P4 from 08/23/24-09/04/24 revealed on 08/26/24 the patient’s blood pressure was checked at 1:32 PM with a reading of 125/102 and was not checked again until 2:39 PM, with a reading of 134/72, 1 hour and 7 minutes later. On 08/28/24/24, the patient’s blood pressure was checked at 11:34 AM with a reading of 114/63 and not again until 12:33 PM, reading 113/65, 59 minutes later, and not checked again until 1:33 PM with a reading of 137/68, 1 hour later. On 09/04/24 the patient’s blood pressure was checked at 1:35 PM with a reading of 130/68 and not checked again until 2:34 PM, 59 minutes later. 4. Review of the face sheet found in the medical record for P5 provided by the facility revealed the facility admitted the patient on 04/15/24 with a diagnosis including ESRD. Review of six dialysis flow records for P5 from 08/23/24-09/04/24 revealed on 08/23/24 the patient’s blood pressure was checked at 9:00 AM with a reading of 183/95 and was not checked again until 10:05 AM, with a reading of 173/92, 65 minutes later. 5. Review of the face sheet found in the medical record for P6 provided by the facility revealed the facility admitted the patient on 03/15/18 with a diagnosis including ESRD. Review of six dialysis flow records for P6 from 08/19/24-09/03/24 revealed on 08/21/24 the patient’s blood pressure was checked at 1:00 PM with a reading of 100/66 and was not checked again until 3:07 PM, with a reading of 88/52, two hours and seven minutes later. 6. Review of the face sheet found in the medical record for P7 provided by the facility revealed the facility admitted the patient on 11/11/21 with a diagnosis including ESRD. Review of six dialysis flow records for P7 from 08/22/24-09/03/24 revealed on 08/24/24 the patient’s blood pressure was checked at 8:30 AM with a reading of 139/79 and was not checked again until 9:34 AM, with a reading of 137/81, 56 minutes later. On 08/27/24, the patient’s blood pressure was checked at 9:08 AM reading 157/76 and not again until 10:04 AM, reading 165/82, 56 minutes later. During an interview on 09/06/24 at 9:10 AM, Registered Nurse (RN) 1 stated patients vital signs and machine checks should be checked every 30 minutes and documented to ensure patients were not having any issues with blood pressure. During an interview on 09/06/24 at 11:15 AM, Certified Clinical Hemodialysis Technician (CCHT) 1 stated patients monitoring, and blood pressures were required to be checked and documented every 30 minutes. During an interview on 09/06/24 at 1:00 PM, the Clinical Manager stated staff should be checking the patient’s blood pressure every 30 minutes to ensure the patient’s safety. The Clinical Manager reviewed and confirmed all six patient’s flowsheets that were missing patient monitoring and blood pressure checks. Review of the facility’s policy titled, “Patient Monitoring and Safety Checks During Hemodialysis Treatment,” revised 09/05/23 indicated the following: “ ...Patient Monitoring: Monitor and document every 30 minutes or more frequently as needed but not to exceed 45 minutes or per state regulations in the FKC Treatment Record. Patient Monitoring includes Change in patient’s status, blood pressure, pulse and respirations ...””

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 28297 Based on interview, document review, and facility policy review, the facility failed to ensure staffing assignments and schedules demonstrated a pattern of sufficient staff coverage to ensure safe patient care. The failure to have adequate staff coverage had the potential for patients to not be monitored as required and adverse events not being addressed in a timely manner and this could affect 64 in-center patients. Finding include: Review of seven medical record reviews found that six of seven patients were not monitored every 30 minutes as required. Review of the staffing schedule provided by the Clinical Manager from 08/19/24-09/14/24 revealed seven out of 24 days there were only four staff scheduled for the 17 station unit. Cross Reference to V504. During an interview on 09/04/24 at 2:15 PM, Patient (P) 4 stated the facility did not have enough staff to take care of the patients and that the staff who do work are very stressed. P4 stated sometimes he/she must wait to be taken off the machine when his/her time is up because the staff are helping other patients. During an interview on 09/05/24 at 10:30 AM, the Medical Director stated staffing had been an issue for a while. He/she stated if patients were not being monitored every 30 minutes as required it was reasonable to put pressure on the management staff to increase staffing. During an interview on 09/06/24 at 9:10 AM, Registered Nurse (RN) 1 stated the facility used to have four patients to one staff ratio for Certified Clinical Hemodialysis Technician (CCHT) however it was changed to five to one ratio. During an interview on 09/06/24 at 10:30 AM, the Clinical Manager stated only the CCHT’s were assigned to a section of five to one ratio. He/she stated each RN was assigned to patient 16 and patient 17 of the 17-station unit. The Clinical Manager stated there were usually two nurses working every day, but they were not assigned a section of five to one patients and that only the CCHT’s were assigned a section. He/she stated if there was not good teamwork that could affect adequate staffing. During an interview on 09/06/24 at 10:30 AM, the Clinical Manager stated on those days he/she asked for help, however they had not been included in the document. During an interview on 09/06/24 at 11:15 AM, CCHT 1 stated that he/she worked six days a week and if he/she didn’t the unit would really be short staff. CCHT 1 stated sometimes there were only four staff scheduled (two nurses and two CCHT’s) and the CCHT’s will have eight patients to one CCHT. CCHT 1 stated there was a lot of tension with the nurses and CCHT’s because they work short staffed. Review of the Quality Assessment and Performance Improvement for July 2024 revealed the facility documented they had open positions for three staff. Review of the facility’s policy on Compliance effective 01/01/2007 indicated the following: “General Medical Director Responsibilities Quality of Patient Care: The Medical Director is required to assure adequate supervision of dialysis operations by medical and patient care staff through proper scheduling of medical personal, direct patient care personnel, supervisory personal and emergency coverage ...””

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 28297 Based on interview, document review, and policy review, the facility failed to ensure one of one grievance reported to the facility was investigated and a follow up and or resolution was completed in a timely manner. The failure to investigate grievances and follow up with the patient in a timely manner caused a delay in a resolution for the patient’s reported grievance and could affect 64 in-center patients. Findings include: Review of the “Patient Grievance Report,” provided by the facility revealed Patient (P) 11 completed a formal grievance that listed the Clinical Manager as the “Intake Staff Member” on 08/14/24. The grievance detail documented that “patient complained of 2 other patients being loud and disruptive.” There was no other documentation in the report that the complaint had been investigated or that there was a “Resolution/Corrective Action” as of the date of the survey. During an interview on 09/06/24 at 10:30 AM, the Clinical Manager stated he/she still had not followed up with the patient on the grievance, but had talked with staff. He/she also stated there had not been any discussion with the two patients mentioned in the grievance. The Clinical Manager stated that he/she was not aware of the facility’s policy on timeframes to investigate and follow up with patients for a resolution. Review of the facility’s policy “Patient Grievance,” revised 01/02/2014 indicated the following: “ ...Nurse in Charge or Team Lead Meeting with the patient/representative within 72 hours of being notified of a grievance ...Clinical Manager (CM) Review the Patient Grievance Status Report daily. Meeting with the patient/representative within 5 days to discuss the grievance, resolve it as quickly as possible, and provide periodic updates to the patient ...””