University of Rochester Strong Memorial Pediatric Esrd

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This Standard is not met as evidenced by: 42572 Based on observation and interview, the facility does not ensure that all means of egress are continuously maintained free of all obstructions to full instant use in case of emergency. Findings include: Observations on 02/18/25 at 02:10 PM and on 02/19/25 at 01:05 PM in the patient treatment area revealed a 32-gallon trash can was placed in front of the emergency exit stairwell door which obstructed access to the stairwell. Interview on 02/19/25 at 01:10 PM with Staff (B), Nurse Manager, verified this finding.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit and 200 feet travel distance is not exceeded. 20.3.4.2, 21.3.4.2, 9.6.2 This Standard is not met as evidenced by: 42572 Based on observation and interview, the facility does not ensure that unobstructed access to each manual fire alarm box is maintained in case of an emergency. Findings include: Observations on 02/18/25 at 11:00 AM, on 02/18/25 at 02:10 PM, and on 02/19/25 at 01:05 PM in the patient treatment area revealed a manual fire alarm box, located next to the emergency exit stairwell door, was obstructed by two 32-gallon trash cans placed in front of the alarm. Interview on 02/19/25 at 01:10 PM with Staff (B), Nurse Manager, verified this finding.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10 This Standard is not met as evidenced by: 42572 Based on observation and interview, the facility does not ensure that unobstructed access to the fire extinguisher is maintained. Findings include: Observations on 02/18/25 at 11:00 AM, on 02/18/25 at 02:10 PM and on 02/19/25 at 01:05 PM in the patient treatment area revealed a cabinet mounted portable fire extinguisher located next to the emergency exit stairwell door, had two 32-gallon trash placed in front of the extinguisher that would obstruct access during an emergency. Interview on 02/19/25 at 01:10 PM with Staff (B), Nurse Manager, verified this finding.”

“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: 22484 Based on policy review, observation, and interview, staff do not wear gowns, face shields/eye ware to protect themselves while performing procedures which spurting or splattering can occur. Findings include: Review of the policy “Treatment Termination and De-accessing of the Hemodialysis Catheter,” effective 04/01/21, indicated in preparation for disconnection from the extracorporeal circuit (bloodlines and dialyzer), staff will perform hand hygiene and apply personal protective equipment (PPE). This policy does not indicate what type of PPE should be worn. Observation on 02/18/25 at 12:20 PM in Station #1 revealed Staff (F), Registered Nurse, began to terminate the treatment for Patient #1. At 12:35, Staff (F) rinsed Patient #1’s blood back without donning a protective gown and eye ware. At 12:55 PM, Staff (F) removed the used bloodlines from the hemodialysis machine for disposal after Patient #1’s treatment without wearing a protective gown and eye ware. Interview with Staff (H), Assistant Director, verified findings.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 22484 Based on policy review, observation, and interview, staff failed to disinfect reusable equipment between patients. Findings include: Review of the policy “Infection Control,” effective 02/19/20, indicated all surfaces and equipment in the treatment station will be disinfected between patient treatments. Review of the policy “Treatment Termination and De-accessing of the Hemodialysis Catheter,” effective 04/01/21, indicated that once the patient is transferred out of the station (post-treatment), staff are to disinfect the station by wiping down all surfaces with bleach wipes and alert environmental services. Observation on 02/18/25 at 12:50 PM in Station #1 revealed Staff (F), Registered Nurse, removed the thermometer hanging on the wall, obtained a temperature reading for Patient #1, and placed the thermometer back in the holder on the wall without disinfecting it. Interview with Staff (H), Assistant Director, verified findings.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 22484 Based on policy review, observation, and interview, the facility does not ensure that sharps containers (bin that hold needles or other sharp objects) are secure and potentially infectious waste is handled and disposed of properly. Findings include: Review of the policy “Disposal of Regulated Medical Biohazard Waste,” effective 01/10/22, indicates needles, syringes, lancets, scalpel blades, vials of blood, and other sharps are disposed of only in hospital approved, rigid, sharps containers. This policy does not indicate sharps containers need to be secure to prevent tipping and/or spillage of contents. Observation on 02/18/25 at 10:45 AM in Station #2 revealed a sharps container was located on the floor, half full, and not secure to prevent tipping and/or spillage. Interview with Staff (G), Assistant Nurse Manager and Staff (H), Assistant Director verified this finding. Review of the policy “Treatment Termination and De-accessing of the Hemodialysis Catheter,” effective 04/01/21, indicated staff are to remove the bloodlines from the patient’s catheter using aseptic technique. The policy does not provide guidance on how to or when to secure the contaminated blood lines while performing termination catheter care. Observation on 02/18/25 at 12:20 PM in Station #1 revealed Staff (F), Registered Nurse, began to terminate the treatment for Patient #1. At 12:40, Staff (F) removed the blood lines from the central venous catheter (CVC-tube inserted into a large vein in the body to provide access for dialysis) and set them on Patient #1’s chest uncapped while securing the CVC lines with tape. Staff (F) capped both blood lines and set the lines back the on the bed. Patient #1 stood up for a blood pressure and the lines fell to the floor. The blood lines remained on the floor while Patient #1 put their shoes and jacket on. Patient #1 accidently stepped on the lines twice. At 12:55 PM, Staff (F) picked the lines up off the floor when removing them from the hemodialysis machine. Interview with Staff (H), Assistant Director, verified these findings.”

“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: 22484 Based on policy review, medical record review, and interview, in three of three medical records review, the facility does not ensure pre-treatment central venous catheter (CVC-tube inserted into a large vein in the body to provide access for dialysis) assessments are documented and/or completed by a registered nurse when treatment was initiated by a licensed practical nurse (Patient #1, Patient #2, and Patient #3). Findings include: Review of the policy “Initiation of Hemodialysis Treatment Using a Hemodialysis Catheter,” effective 02/19/20, indicated prior to accessing the catheter, staff are to assess the catheter insertion site and dressing to examine for signs and symptoms of infection, dislodgement, or other problems. If complications are noted, the nephrology provider will be notified before proceeding. This policy does not indicate a registered nurse must perform the catheter assessment. Review on 02/19/25 of the medical record treatment flowsheets from 01/15/25 to 02/19/25 revealed no evidence that a registered nurse performed an assessment of the CVC when treatment was initiated by a licensed practical nurse for the following patients: - Patient #1: On 01/15/25, 01/18/25, 01/20/25, 01/30/25, 02/01/25, and 02/11/25. - Patient #2: On 01/15/25, 01/20/25, and 01/22/25. - Patient #3: On 02/01/25 and 02/11/25. The CVC assessments were signed off by the licensed practical nurse. Interview on 02/19/25 at 11:10 AM with Staff (B), Nurse Manager, verified these findings.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 22484 Based on policy review, medical record review, and interview, in three of three medical records reviewed, the facility does not ensure pre-treatment & post-treatment assessments are documented and/or completed by a registered nurse when treatment was initiated by a licensed practical nurse (Patient #1, Patient #2, and Patient #3). Findings include: Review of the policy “Initiation of Hemodialysis Treatment Using a Hemodialysis Catheter,” effective 02/19/20, indicated prior to accessing the catheter staff are to: obtain a baseline of vitals, assess the patient, and document in the electronic medical record; enter the treatment prescription into the hemodialysis machine and ensure the machine is connected to the correct acid bath; and complete all pre-treatment documentation in the electronic medical record. This policy does not indicate a registered nurse must perform a pre-treatment assessment of the patient. Review of the policy “Treatment Termination and De-accessing of the Hemodialysis Catheter,” effective 04/01/21, indicated post-treatment, staff are to complete the post treatment documentation and handoff in the electronic medical record. This policy does not indicate a registered nurse must perform a post-treatment assessment of the patient. Review on 02/19/25 of the medical record treatment flowsheets from 01/15/25 to 02/19/25 revealed no documentation that a registered nurse documented and/or completed a pre-treatment & post treatment assessment when treatment was initiated by a licensed practical nurse for the following patients: Patient #1: On 01/15/25, 01/18/25, 01/20/25, 01/30/25, 02/01/25, and 02/11/25. Patient #2: On 01/15/25 (pre-treatment only), 01/20/25, and 01/22/25. Patient #3: On 02/01/25 (pre-treatment only) and 02/11/25 (pre-treatment only). Interview on 02/19/25 at 11:10 AM with Staff (B), Nurse Manager, verified these findings.”

“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: 22484 Based on policy review, medical record review, and interview, in three of three medical records reviewed, the facility does not ensure pre-treatment evaluation of the dialysis prescription, specifically, verification of the prescription/machine settings, are documented and/or completed by a registered nurse when treatment was initiated by a licensed practical nurse (Patient #1, Patient #2, and Patient #3). Findings include: Review of the policy “Initiation of Hemodialysis Treatment Using a Hemodialysis Catheter,” effective 02/19/20, indicated prior to accessing the catheter staff are to: obtain a baseline of vitals, assess the patient, and document in the electronic medical record; enter the treatment prescription into the hemodialysis machine and ensure the machine is connected to the correct acid bath; and complete all pre-treatment documentation in the electronic medical record. This policy does not indicate a registered nurse must verify the machine settings and prescription. Review on 02/19/25 of the medical record treatment flowsheets from 01/15/25 to 02/19/25 revealed no documentation that a registered nurse verified the prescription and machine settings when treatment was initiated by a licensed practical nurse for the following patients: - Patient #1: On 01/15/25, 01/18/25, 01/20/25, 01/30/25, 02/01/25, and 02/11/25. - Patient #2: On 01/15/25, 01/20/25, and 01/22/25. - Patient #3: On 02/01/25 and 02/11/25. There is a “Hemodialysis Pre-procedure Time Out,” section on the flowsheet where a second nurse must sign off on, however, it does not include a review of the hemodialysis prescription or machine settings. Interview on 02/19/25 at 11:10 AM with Staff (B), Nurse Manager, verified these findings.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 22484 Based on policy review, medical record review, and interview, in three of three medical records reviewed, licensed practical nurse (LPN) did not notify the registered nurse (RN) regarding changes in a patient’s condition for two of three patients (Patient #1 and Patient #2). Findings include: Review of the policy “Monitoring Dialysis Patients During Treatment,” effective 11/26/24, indicated changes in the patient’s overall condition will be observed during each vital sign check (every 15-30 minutes). The nurse will respond to changes in status, notify the attending nephrologist or fellow as needed, and follow through with new orders from the provider. All interventions will be documented on the treatment flowsheet. This policy does not indicate that a RN is required to perform patient assessments, Review on 02/19/25 of the medical record treatment flowsheets revealed the LPN did not notify the RN of changes in condition and/or treatment prescriptions for the following patients: - On 01/18/25, Patient #1 experienced an elevated heart rate and decreased blood pressure. At 01:27 PM the LPN notified the physician, but there is no evidence the RN was notified for assessment. The LPN documented that treatment was terminated early due to cramping and Patient #1 not feeling well. There is no documentation the RN was notified and performed an assessment prior to discharge. The post-treatment assessment and note is documented by the LPN. - On 01/20/25, Patient #2 experienced poor catheter flow (100-300ml/min, 400 ml/min is the maximum ordered) throughout treatment; anxiety with thrashing in bed which required notification of the physician twice and the administration of Atarax (decrease anxiety); and the inability to obtain post-treatment blood work. There is no documentation the RN was notified and performed an assessment of Patient #2. The post-treatment assessment and note is documented by the LPN. - On 01/22/25, Patient #2 experienced low blood pressures that required the ultrafiltration rate (rate blood is processed) to be turned off, 150 ml of Normal Saline to be administered, and treatment to be terminated early per physician. There is no documentation the RN was notified and performed an assessment of Patient #2. The post-treatment assessment and note is documented by the LPN. - On 02/11/25, Patient #1 experienced nausea and the treatment was terminated 15 minutes early by the LPN. There is no documentation the RN was notified and performed an assessment prior to discharge. The post-treatment assessment and note is documented by the LPN and does not indicate treatment was terminated early. Interview on 02/19/25 at 11:10 AM with Staff (B), Nurse Manager, verified these findings.”