322520 Rio Rancho Dialysis (Dci)

“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 nine patients who have CVCs in the facility. Findings include: Observation on 04/21/25 at 11:45 AM Registered Nurse (RN) 1 was at Station 20 initiating the treatment for Patient (P) 6 via the CVC. RN 1 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 04/21/25 at 12:15 PM RN1 stated he/she forgot to remove the CVC dressing prior to stating the treatment to assess the insertion site however he/she was aware that was required to ensure the CVC was not dislodged or that there were no issues with the CVC insertion site. During an interview on 04/23/25 at 1:10 PM the Nurse Manager confirmed the facility policy was to assess the CVC insertion site prior to accessing the blood lines to ensure there were no complications with the CVC. Review of the facility’s policy titled, “Care of Central Line Catheter with Tego Connections-Initiation and Weekly Change,” indicated, “ ...Remove Dressing and assess catheter site for any signs of infection, the CHT 2 must report and s/sx of infection to the RN prior to treatment initiation ...””

“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: 28297 Based on observations, interview, and facility’s policy, the facility failed to follow the facility’s policy for dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing it through a filter) treatments by not maintaining the arterial drip chambers (a pressure and air monitoring component of the dialysis bloodline tubing) fluid levels at 85-95% full for one of three survey days. Failure to follow the facility policy had the potential to result in equipment malfunction and/or failure and negatively impact the safety and wellbeing of the 41 in-center patients receiving dialysis treatments in this facility. Findings include: Observation of the hemodialysis treatment area on 04/21/25 at 12:10 PM revealed the arterial drip chamber level was less than 25% full at Stations 15, 17, 19, and 22. During an interview on 04/21/25 at 12:20 PM Patient Care Technician (PCT) 2 confirmed the arterial drip chambers were less than 25 % full at Stations 15 and 17, 19 and 22 and should be 75 % full to ensure no air get into the extracorporeal system. During an interview on 04/23/25 at 1:10 PM the Nurse Manager confirmed the arterial drip chambers should be to the line on the tube that is at least 75 % full to ensure no air gets into the extracorporeal system. Review of the facility’s policy titled, “Set-Up Priming and Treatment Initiation with a Single Use Dialyzer Utilizing Fresenius 20008 K, K2 and T Dialysis Delivery Systems with CombiSet Bloodlines,” revised June 19, 2024, indicated, “ ...Fill arterial drip chamber approximately 90% full using level adjust key ...” Review of the Manufacture Directions for USE (DFU) Combiset Blood Tubing ...” indicated, “ ...Prime pre-pump arterial chamber 85% to 95% full ...””

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 28297 Based on interview, record review and policy review the facility failed to ensure staff completed the “SF 36+24 Health Surveys (a generic measure of 8 domains of health-related quality of life (HRQOL), has been widely used to examine HRQOL of end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). The current study synthesizes existing literature to examine which SF-36 domains capture the largest burden in this patient population)” for two of five sampled patients (P) 2 and P3. The failure to complete the “SF 36+24 health survey had to potential for missed opportunities to evaluate a patient’s ability to cope with dialysis and actions that may need to be taken if the score were out of range. This could affect 41 in-center patients.: Findings include: 1. Review of the medical record for P2 revealed the facility admitted the patient on 08/09/24 with Diagnosis end stage renal disease (ESRD). Review of the 90-day assessment dated 04/16/25 revealed the Social Worker met with the patient on 04/16/25 however there was no evidence that the “SF36+24 Heath Survey” was completed. 2. Review of the medical record for P3 revealed the facility admitted the patient on 12/26/24 with Diagnosis end stage renal disease (ESRD). Review of the 90-day assessment dated 12/16/24 revealed the Social Worker met with the patient on 11/14/24 however there was no evidence that the “SF36+24 Heath Survey” was completed. During an interview on 04/23/25 at 10:50 AM the Social Worker confirmed he/she did not get the SF36+24 Health Surveys” completed for P2 and P3 because he/she was not given enough time to see the patients at this clinic. During an interview on 04/23/25 at 12:45 PM the Nurse Manager confirmed the Social Worker was covering two clinics that were an hour and a half apart. He/he state the Social Workers are told the “SF 36+24 Health Surveys” are complete at the 90-day assessment and annually, however the facility policy did not specifically state when the 36+24 Health Surveys were due. Review of the facility’s policy titled, “Comprehensive Care Plan (Universal) revised 06/14/11 indicated, “ ...General Health Status. The Health Status section will pull information from the last three SF 36+24 Health Surveys ....” The policy does not indicate when or who was to complete the SF36+24 Health Survey.”