Usrc Gallup Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure 8 (Certified Hemodialysis Technicians [CHT] #6, #8, #9, #10, #11, and #12, and Registered Nurse [RN] #3 and RN #4) of 8 observed staff performed hand hygiene after removing gloves, before touching patient care equipment (dialysis machine), before touching patient care supplies (medication syringe, medication vials), after touching personal protective equipment (PPE - gown, face shield), and before patient contact. Failure to perform hand hygiene provided a mode of cross contamination with the potential spread of pathogens, which could negatively impact the health and well-being of the 172 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Hand Hygiene,” revised 08/2020, indicated, “Hand Hygiene will be performed: 1. Before and after touching the patient 2. Prior to entering and on exiting station to provide care to patient 3. Prior to contact with vascular access site 4. Prior to adjusting or removing cannulation needles 5. Before medication preparation.” Additional review indicated, “9. After gloves are removed 10. Before and after touching PPE 11. After contact with inanimate objects including medical equipment or environmental surfaces at the patient station, 12. Before entering and on exiting the patient treatment areas.” Observation of the water purification area on 09/24/2024 with the Biomedical Technician and Facility Administrator revealed the following: - At 1:30 PM, CHT #6 was observed performing a water test while wearing a pair of gloves. After performing the water test, CHT #6 removed the pair of gloves and prepared to leave the area. When interviewed immediately after performing the water test, CHT #6 confirmed he was trained and expected to perform hand hygiene after removing gloves. Observations of the dialysis treatment area on 09/25/2024 with the Facility Administrator revealed the following: - At 9:20 AM, RN #3 was observed exiting the nurses’ station. RN #3 obtained and applied a previously used PPE gown and face shield and obtained and applied a pair of gloves. RN #3 picked up an item off the floor and discarded the item with her gloved hands. RN #3 entered Station 21 and touched the dialysis machine with the same pair of gloves. During an interview at 9:40 AM, RN #3 stated she was trained and expected to perform hand hygiene before touching patient care equipment. - At 9:55 AM, CHT #8 was observed exiting Station 21 while wearing a pair of gloves. CHT #8 removed the pair of gloves, touched the computer keyboard, and adjusted her PPE face shield. - At 10:05 AM, CHT #8 was observed in Station 34 while wearing a pair of gloves. CHT #8 touched her face shield and touched the dialysis machine. CHT #8 exited the station, removed a glove from her left hand, and held the glove in her right hand while typing on the computer keyboard near Station 34. CHT #8 removed the glove from her right hand and obtained and applied a new pair of gloves. CHT #8 entered Station 33 and touched the dialysis machine. CHT #8 exited the station, removed the pair of gloves, and obtained and applied a new pair of gloves. CHT #8 then touched Patient #13 while escorting the patient to Station 22. - At 10:27 AM, CHT #8 was observed exiting Station 21 while wearing a pair of gloves. CHT #8 removed the pair of gloves, obtained and applied a new pair of gloves, entered Station 22, and touched the dialysis machine. During an interview at 10:37 AM, CHT #8 confirmed she was trained and expected to perform hand hygiene after removing gloves, after touching PPE, before touching patient care equipment, and before patient contact. - At 10:39 AM, CHT #9 was observed obtaining patient care supplies from a common storage area at the nurses’ station while wearing a pair of gloves. CHT #9 entered Station 36, placed the supplies on the dialysis machine, and touched the dialysis machine with the same gloves. - At 11:14 AM, CHT #10 was observed entering the treatment area. CHT #10 obtained and applied a PPE gown and face shield, entered Station 31, and touched the dialysis machine with her bare hands. CHT #10 obtained and applied a pair of gloves, re-entered Station 31, and touched the dialysis machine. During an interview at 11:15 AM, CHT #10 stated, “I guess so,” when asked if she was trained and expected to perform hand hygiene before touching patient care equipment. - At 1:13 PM, CHT #11 was observed in Station 2 while wearing a pair of gloves. CHT #11 exited the station, obtained and applied a PPE face shield, re-entered Station 2, and touched Patient #S18. During an interview at 1:22 PM, CHT #11 confirmed she was trained and expected to perform hand hygiene before patient contact. - At 1:35 PM, CHT #6 was observed exiting Station 24 while wearing a pair of gloves. CHT #6 removed the pair of gloves, obtained and applied a new pair of gloves, re-entered Station 24, and touched the dialysis machine. - At 1:45 PM, CHT #12 was observed typing on the computer keyboard near Station 20. CHT #12 obtained and applied a pair of gloves, entered Station 20, and touched the dialysis machine. - At 1:47 PM, CHT #12 was observed obtaining and applying a previously used PPE face shield and obtaining and applying a pair of gloves. CHT #12 entered Station 20 and touched Patient #S19. During an interview at 2:10 PM, CHT #12 confirmed she was trained and expected to perform hand hygiene after touching PPE, before touching patient care equipment, and before patient contact. - At 2:35 PM, RN #4 was observed entering the medication preparation area. RN #4 opened the supply storage drawers with her bare hands, obtained and applied a pair of gloves, and touched a syringe and medication vial while preparing the intravenous medication for administration. RN #4 removed the pair of gloves and exited the medication preparation area. During an interview at 2:37 PM, RN #4 confirmed she was trained and expected to perform hand hygiene before touching patient care supplies and after removing gloves. During an interview on 09/25/2024 at 12:05 PM, the Facility Administrator confirmed staff were trained and expected to perform hand hygiene after removing gloves, after touching PPE, before touching patient care equipment and supplies, and before patient contact. During an interview on 09/26/2024 at 8:29 AM, the Medical Director confirmed staff were trained and expected to perform hand hygiene after removing gloves, after touching PPE, before touching patient care equipment and supplies, and before patient contact.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment during 2 of 2 observations. Failure to thoroughly disinfect all environmental surfaces in the dialysis treatment stations had the potential to serve as a vehicle for transmission of infectious disease and negatively impact the safety and wellbeing of the 172 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 07/2023, indicated, “7. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP [blood pressure] cuffs and basket; dialysate connectors and lines; hand sanitizer [bottle] and holder; IV [intravenous] pole, items hanging on pole, attached computer monitors and keyboard/mouse.” Observation of the hemodialysis treatment area on 09/23/2024 revealed the following: - At 10:20 AM, Certified Hemodialysis Technician (CHT) #7 was observed disinfecting Station 31. CHT #7 failed to disinfect the intravenous (IV) pole and prongs. During an interview at 10:22 AM, CHT #7 acknowledged she did not disinfect the IV pole and prongs and confirmed she was trained and expected to disinfect all surfaces in the treatment station. - At 10:30 AM, CHT #8 was observed disinfecting Station 36. CHT #8 failed to disinfect the IV pole and prongs. During an interview at 10:37 AM, CHT #8 acknowledged she did not disinfect the IV pole and prongs and confirmed she was trained and expected to disinfect all surfaces in the treatment station. During an interview on 09/25/2024 at 12:05 PM, the Facility Administrator confirmed staff were trained and expected to disinfect all environmental surfaces in the dialysis treatment stations, including the IV pole and prongs, after each dialysis treatment. During an interview on 09/26/2024 at 8:29 AM, the Medical Director confirmed staff were trained and expected to disinfect all environmental surfaces in the dialysis treatment stations, including the IV pole and prongs, after each dialysis treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 7 (Patients #1, #4, #5, #7, #12, #14, and #15) of 15 sampled patients. Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 172 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Intradialytic Monitoring of Patient,” revised 07/2024, indicated, “3. Blood flow rate: any variance from prescribed order requires documentation of reason. 4. Dialysate flow rate: any variance from prescribed order requires documentation of reason.” 1. Patient #1’s treatment sheet dated 09/10/2024 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #1’s BFR was documented as 360 mL/min from 4:00 PM until 4:55 PM, and 350 mL/min from 5:02 PM until the treatment was terminated at 6:45 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/14/2024 revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as 350 mL/min from 5:50 PM until the treatment was terminated at 6:28 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/21/2024 revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 2. Patient #4’s treatment sheet dated 09/06/2024 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #4’s BFR was documented as 350 mL/min from 3:20 PM until the treatment was terminated at 6:50 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient #4’s treatment sheet dated 09/20/2024 revealed a prescribed BFR of 400 mL/min. Patient #4’s BFR was documented as 350 mL/min from 3:49 PM until 5:19 PM. There was no rationale documented why the prescribed BFR was not achieved. 3. Patient #5’s treatment sheet dated 09/03/2024 revealed a prescribed dialysate flow rate (DFR) of 1.5 times (x) the blood flow rate (BFR) of 400 milliliters per minute (mL/min) (400 x 1.5 = 600). Patient #5’s DFR was documented as 500 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/05/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 480 mL/min and 500 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/07/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/10/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as 500 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/12/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/14/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/19/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 490 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/21/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 490 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #5’s treatment sheet dated 09/24/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #5’s DFR was documented as between 500 mL/min and 530 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. 4. Patient #7’s treatment sheet dated 09/03/2024 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #7’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #7’s treatment sheet dated 09/07/2024 revealed a prescribed BFR of 400 mL/min. Patient #7’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 5. Patient #12’s treatment sheet dated 09/05/2024 revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #12’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 6. Patient #14’s treatment sheet dated 09/04/2024 revealed a prescribed dialysate flow rate (DFR) of 1.5 times the blood flow rate (BFR) of 400 milliliters per minute (mL/min) (400 x 1.5 = 600). Patient #14’s DFR was documented as 500 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/06/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 430 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/09/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/11/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/13/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 490 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/16/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/18/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 490 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/20/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/23/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 500 mL/min and 510 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. Patient #14’s treatment sheet dated 09/25/2024 revealed a prescribed DFR of 1.5 times the BFR of 400 mL/min (400 x 1.5 = 600). Patient #14’s DFR was documented as between 400 mL/min and 500 mL/min during the entire treatment. There was no rationale documented why the prescribed DFR was not achieved. 7. Patient #15’s treatment sheet dated 09/09/2024 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #15’s BFR was documented as 350 mL/min from 5:19 AM until 8:14 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #15’s treatment sheet dated 09/11/2024 revealed a prescribed BFR of 400 mL/min. Patient #15’s BFR was documented as 350 mL/min from 4:55 AM until 8:20 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #15’s treatment sheet dated 09/20/2024 revealed a prescribed BFR of 400 mL/min. Patient #15’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. During an interview on 09/26/2024 at 8:20 AM, the Medical Director stated staff were expected to document a reason when the prescribed BFRs were not achieved. During an interview on 09/26/2024 at 9:40 AM, the Facility Administrator stated staff were trained and expected to follow the physicians’ orders and document reasons when the prescribed BFR and/or DFRs were not achieved. During an interview on 09/26/2024 at 10:14 AM, Certified Hemodialysis Technician #13 stated staff were trained and expected to write a reason for changes to the prescribed BFR and/or DFR. During an interview on 09/26/2024 at11:05 AM, Registered Nurse #5 stated staff were trained and expected to “write a reason” when a patient’s BFR and/or DFR were not as prescribed.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs and/or machine parameters according to their policy for 6 (Patients #1, #3, #5, #7, #9, and #10) of 15 sampled patients. Failure to monitor patients’ vitals and machine parameters according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact the care provided to the 172 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Intradialytic Monitoring of Patient,” revised 07/2024, indicated, “Direct patient care staff will monitor the following parameters during each dialysis treatment: Patient: 1. Must be in direct view of a staff member at all times: if staff leave the treatment area for any reason, report off to another staff member and ensure observation of the assigned patients. 2. Vital Signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters, refer to C-FORMS-0081 Reportable Parameters to CN [charge nurse].” Additional review indicated, “8. Delivery of dialysis prescription: review prescribed treatment orders against actual machine settings.” 1. Patient #1’s treatment sheet dated 09/17/2024 revealed monitoring was not documented for 60 minutes, from 3:43 PM until 4:43 PM. 2. Patient #3’s treatment sheet dated 09/03/2024 revealed monitoring was not documented for 82 minutes, from 3:10 PM until 4:32 PM. Patient #3’s treatment sheet dated 09/14/2024 revealed monitoring was not documented for 52 minutes, from 2:18 PM until 3:10 PM. 3. Patient #5’s treatment sheet dated 09/05/2024 revealed monitoring was not documented for 59 minutes, from 12:18 PM until 1:17 PM. 4. Patient #7’s treatment sheet dated 09/24/2024 revealed monitoring was not documented for 59 minutes, from 2:40 PM until 3:39 PM. 5. Patient #9’s treatment sheet dated 09/10/2024 revealed monitoring was not documented for 74 minutes, from 3:13 PM until 4:27 PM. 6. Patient #10’s treatment sheet dated 09/04/2024 revealed monitoring was not documented for 53 minutes, from 4:33 PM until 5:26 PM. During an interview on 09/26/2024 at 8:29 AM, the Medical Director confirmed staff were trained and expected to monitor patients every 30 minutes according to the facility policy. During an interview on 09/26/2024 at 9:40 AM, the Facility Administrator stated staff were trained and expected to monitor patients “every 30 minutes” per the facility policy. During an interview on 09/26/2024 at 10:14 AM, Certified Hemodialysis Technician #13 stated staff were trained and expected to follow the facility policy for “30 minute” monitoring of patients. During an interview on 09/26/2024 at 11:05 AM, Registered Nurse #5 stated staff were trained and expected to follow the facility policy for monitoring patients every 30 minutes.”