322541 Albuquerque South (Dci)

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 35949 Based on observation, interview, and document review, the facility failed to ensure that 1 (Registered Nurse [RN] #4) of 2 staff members observed performed water chlorine checks were appropriately trained and audited for compliance with facility procedures. Findings included: The undated manufacturer “Instructions for Use,” for the “Ultra-Low Total Chlorine Test Strips, revealed “As an alternative to measuring the water temperature and using the water temperature ranges to determine swish time for the test strip, it is acceptable to use a 60 second swish time to cover a 42 [degrees] F [Fahrenheit] to 93 [degrees] F range of water temperature.” During an environmental tour on 08/19/2024 at 9:19 AM, RN #4 performed a chlorine check of the water. RN #4 took a sample from the port between Carbon Tank #1 and Carbon Tank #2. RN #4 allowed the water to flow for approximately 30 seconds, rinsed the container three times, then collected approximately 100 milliliters (ml) of water and brought the sample to the supply cart. RN #4 opened the test strip and placed the test strip in the sample and swished it back and forth in the sample for 30 seconds and allowed it to develop for 20 seconds. RN #4 utilized a clock to keep track of the time. RN #4 stated that at other facilities he worked at, the time to swish the test strip in the sample was 60 seconds, but here he was told to do 30 seconds. The facility “Water System Log DCI” for the timeframe 08/05/2024 to 08/19/2024, revealed seven treatment days were documented. The log revealed for each treatment day, there were five 4-hour chlorine test and of the 35 total chlorine checks, RN #4 performed 21 of the chlorine checks. In an interview on 08/20/2024 at 11:08 AM, the Nurse Manager confirmed that RN #4 independently performed water checks; however, he had not demonstrated competency in the area of performing water checks. In an interview on 08/21/2024 at 8:45 AM, the Chief Technician (CT) confirmed that employees should have completed their skills sign-off prior to independently performing water testing. The CT confirmed that RN #4 had not completed his skills sign off and should not be performing chlorine testing on his own. The CT stated he did an initial water room education with the RN and instructed the nurse that the test strip must be dipped in the sample for 60 seconds. In an interview on 08/21/2024 at 2:47 PM, the Medical Director (MD) stated the facility expectation would be that all employees be signed off prior to performing any skills, including water testing. The MD stated the facility expectation would be that policy be followed when testing was performed.”

“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 4 (Patient #1, Patient #2, Patient #3, and Patient #5) of 5 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 44 patients who received dialysis treatments at the facility. Findings included: The facility’s policy titled, “Initiation of Dialysis,” revised 09/10/2015, indicated, “Dialysis orders will be entered following the prescription and verified upon initiation of treatment.” Further review indicated, “Start blood pump; initiate treatment, watch for signs of infiltrates, excessive pressures, pain, etc., advance to ordered BFR [blood flow rate] if no problems. Ensure UF [ultrafiltration], Heparin, UF profiles, and Sodium profiling are turned on as prescribed.” 1. Patient #1’s “Hemodialysis Flowsheet,” dated 07/31/2024, revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) and an hourly heparin infusion of 1000 units. Patient #1’s BFR was documented at 300 mL/min during the entire treatment, and no hourly heparin infusion was documented. There was no rationale documented why the prescribed BFR was not achieved, and the hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/02/2024, revealed a prescribed BFR of 350 mL/min and an hourly heparin infusion of 1000 units. Patient #1’s BFR was documented between 250 mL/min and 300 mL/min during the entire treatment, and no hourly heparin infusion was documented. There was no rationale documented why the prescribed BFR was not achieved, and the hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/05/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/07/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/09/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/12/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/14/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/16/2024, revealed a prescribed hourly heparin infusion of 1000 units. A bolus of 3000 units was documented at 3:43 PM, but no hourly heparin infusion was documented. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #1’s “Hemodialysis Flowsheet,” dated 08/19/2024, revealed a prescribed hourly heparin infusion of 1000 units. A bolus of 3400 units was documented at 3:57 PM, but no hourly heparin infusion was documented. There was no rationale documented why the prescribed hourly heparin was not infused. 2. Patient #2’s “Hemodialysis Flowsheet,” dated 08/02/2024, revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #2’s BFR was documented between 330 mL/min and 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 3. Patient #3’s “Hemodialysis Flowsheet,” dated 08/16/2024, revealed a prescribed BFR of 400 mL/min. Patient #3’s BFR was documented between 320 mL/min and 395 mL/min from 6:55 AM until 9:02 AM. There was no rationale documented why the prescribed BFR was not achieved. 4. Patient #5’s “Hemodialysis Flowsheet,” dated 07/31/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/02/2024, revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) and an hourly heparin infusion of 1000 units. Patient #5’s BFR was documented at 300 mL/min from 1:03 PM until 4:01 PM. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed BFR was not achieved, and the hourly heparin not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/05/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/07/2024, revealed a prescribed BFR of 350 mL/min and an hourly heparin infusion of 1000 units. Patient #5’s BFR was documented at 300 mL/min during the entire treatment. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed BFR was not achieved, and the hourly heparin not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/09/2024, revealed a prescribed hourly heparin infusion of 1000 units. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/12/2024, revealed a prescribed hourly heparin infusion of 1000 units. A bolus of 3900 units was documented at 4:00 PM, but no hourly heparin infusion was documented. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/14/2024, revealed a prescribed hourly heparin infusion of 1000 units. A bolus of 3500 units was documented at 3:49 PM, but no hourly heparin infusion was documented. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/16/2024, revealed a prescribed hourly heparin infusion of 1000 units. A bolus of 3900 units was documented at 4:00 PM, but no hourly heparin infusion was documented. There was no rationale documented why the prescribed hourly heparin was not infused. Patient #5’s “Hemodialysis Flowsheet,” dated 08/19/2024, revealed a prescribed dialysate flow rate (DFR) of 600 mL/min and an hourly heparin infusion of 1000 units. Patient #5’s DFR was documented at 800 mL/min during the entire treatment. There was no evidence documented to indicate the hourly heparin infusion. There was no rationale documented why the prescribed DFR was not achieved, and the hourly heparin not infused. During an interview on 08/21/2024 at 11:45 AM, the Nurse Manager (NM) stated the above listed hemodialysis treatments were reviewed and the prescribed BFRs and DFRs were not achieved, and the prescribed hourly heparin infusions were not documented. The NM confirmed no rationales were documented during the above listed hemodialysis treatments. The NM confirmed staff were expected and trained to document a rationale when the prescribed BFRs and DFRs were not achieved. The NM also confirmed the prescribed hourly heparin infusions were not documented as expected. During an interview on 08/21/2024 at 2:30 PM, the Medical Director confirmed the staff were expected to document a rationale when the prescribed BFRs and/or DFRs were not achieved and/or any changes to the dialysis prescription occurred.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to complete an initial comprehensive assessment conducted by all members of the interdisciplinary team (IDT - a registered nurse, a physician treating the patient for end stage renal disease, a social worker, and a dietitian) within 30 calendar days or 13 dialysis treatments after admission, for 1 (Patient #1) of 1 sampled patient new to dialysis and admitted to the facility within the last 90 days. Failure to complete an initial comprehensive assessment performed by all members of the IDT within 30 calendar days or 13 dialysis treatments after admission for patients new to dialysis, provided opportunities for areas of concern to be unidentified and left unaddressed related to the patients’ plan of care, and had the potential to negatively impact the care and well-being of the 44 patients who received dialysis treatments at the facility. Findings included: The facility’s policy titled, “Initial/Annual Patient Assessment,” effective 04/14/2010, indicated, “The nursing assessment will be done on admission, at three months, another at fifteen months and annually thereafter.” The facility’s policy titled, “Comprehensive Care Plan (Universal),” revised 06/14/2011, indicated, “A comprehensive care plan is based on information obtained during the admission process and includes the nursing assessment, social work assessment, dietician assessment and physician (nephrologist) or physician extender history and physical (see samples).” An undated form titled, “DCI [Dialysis Clinic, Incorporated] Modality List,” which indicated the current patients at the facility, revealed Patient #1’s admission date was 06/12/2024. A “Hemodialysis Data” form, printed on 08/20/2024, indicated Patient #1’s first dialysis treatment at the facility occurred on 06/14/2024, and the 13th dialysis treatment occurred on 07/12/2024. During an interview on 08/20/2024 at 9:24 AM, the Nurse Manager confirmed an initial comprehensive assessment for Patient #1, was not completed by the IDT members within 30 days or 13 dialysis treatments. During an interview on 08/21/2024 at 9:56 AM, Registered Nurse #5 confirmed an initial comprehensive assessment was required to be completed within 30 days or 13 dialysis treatments for newly admitted patients. During an interview on 08/21/2024 at 2:30 PM, the Medical Director and physician who treated Patient #1, confirmed an initial comprehensive assessment was required to be completed within 30 days or 13 dialysis treatments for newly admitted patients.”