Fms-South Queens Dialysis Center

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 37913 Based on observation, document review, interviews and policy review, the facility failed to document 50 out of 65 patients’ capabilities for participation in fire and disaster drills. Failure to thoroughly evaluate the patient capabilities for an emergency has the potential to affect 216 in-center patients receiving dialysis treatments at the facility. Findings include: Review of the binder titled “Fire Drills” revealed 50 out of 65 patient forms titled “Patient Participation in Fire and Disaster Drills” were incomplete. The sections labeled 1.) “The patient was able to: Correctly verbalize the Emergency Clamp and Disconnect procedure. Correctly verbalize the location of the designated meeting area for evacuations. Correctly verbalize the Hand-Cranking procedure. Correctly verbalize where to find a copy of the patient emergency meal plan. Correctly verbalize what to do if the facility is closed. Correctly verbalize where to locate the Patient Hotline telephone number. Correctly verbalize what to do if they are unable to get to their regular dialysis treatment during a disaster.”; and 2.) “The patient was unable to correctly verbalize one or more of the above. Verbal re-education and/or patient education hand-outs were provided on the following: (Include name of any patient education hand-outs provided)” were not completed. During an interview on 05/15/24 at 10:00 AM, the Charge Nurse confirmed that the facility staff was not completing all the required sections on the “Patient Participation in Fire and Disaster Drills.” Review of the facility’s policy titled, “Fire Dril,” dated 08/02/17, indicated “. . .Document patient’s participation in the fire and disaster drills on the patient participation in fire and disaster drills form. . .””

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 37913 Based on observation, interview and policy review, the facility failed to ensure that two of two bicarbonate mixing tanks (prepares a bicarbonate dialysate solution for use in hemodialysis patients) were labeled with the date and time that the bicarbonate solution in the tanks were mixed. Failure to properly label the date and time that the bicarbonate solution was mixed has the potential to affect 216 in-center patients receiving dialysis treatments at the facility. Findings include: Observation of the water room on 05/13/24 at 12:30 PM revealed two of two bicarbonate mixing tanks were filled with a liquid. The labels on the tanks were not filled out indicating the date and time that the bicarbonate solution was mixed. During an interview on 05/13/24 at 12:30 PM, the Biomedical Technician (BMT) 1 confirmed that two of two bicarbonate mixing tanks were not labeled. Review of the facility’s policy dated 09/05/23 titled “Concentrate Labeling Requirements” indicated “. . .When a mix tank contains a solution, a label identifying the solution must be conspicuously displayed on the tank and remain until the mix tank is empty. . .Mixed tank labeling must include the date and time of mixing.””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 37913 Based on observation, interview and document review, the facility failed to ensure that the floor under the booster pump in the water room was properly cleaned. Failure to properly clean the water room floor has the potential to affect 216 in-center patients receiving dialysis treatments at the facility. Findings include: During an observation of the water room on 05/13/24 at 12:15 PM, a thick black substance was found under the booster pump. During an interview on 05/13/24 at 12:15 PM, the Bio-medical Technician (BMT) 1 confirmed there was a thick black substance under the booster pump and stated, “I found a small leak in the booster pump that was the cause of the thick black substance.” Durning an interview on 05/14/24 at 2:00 PM, the Clinical Manager revealed he/she was unable to find a specific policy on cleaning the water room floor. Review of the facility’s Audit Report for the month of May, under the section for the cleanliness of the facility’s floors, indicated that there were no issues identified.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 37913 Based on record reviews, interview and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for four of 15 sampled in-center patients (Patient (P) 4, P5, P7 and P9). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for 216 in-center patients receiving dialysis treatments at the facility. Findings include: 1. Review of P4’s medical record revealed a prescribed dialysate flow rate (DFR) of 800 milliliters per minute (mL/min). On 04/29/24 the dialysis treatment started at 6:55 PM with the DFR documented at 800 mL/min. At 7:57 PM the DFR was changed to 700 mL/min and remained at 700 mL/min until 10:24 PM. Review of P4’s medical record revealed a prescribed DFR of 800 mL/min. On 05/01/24 the dialysis treatment started at 6:47 PM with the DFR documented at 500 mL/min. The DFR was continued at 500 mL/min until 8:08 PM and then the DFR was changed to 700 ml/min until end of treatment at 10:46 PM. There was no documented rationale for the change to the prescribed DFR. 2. Review of P5’s medical record revealed a prescribed blood flow rate (BFR) of 250 mL/min. On 04/29/24 the dialysis treatment started at 2:58 PM with the BFR documented at 275 mL/min until the end of treatment at 5:56 PM. Review of P5’s medical record revealed a prescribed BFR of 250 mL/min. On 05/03/24 the dialysis treatment started at 3:05 PM with the BFR documented at 250 mL/min. At 3:27 PM the BFR was changed to 275 mL/min and remained at 275 mL/min until the end of treatment at 6:34 PM. Review of P5’s medical record revealed a prescribed BFR of 250 mL/min. On 05/10/24 the dialysis treatment started at 3:17 PM with the BFR documented at 300 mL/min. At 3:27 PM the BFR was changed to 350 mL/min and remained at 350 ml/min until the end of treatment at 6:53 PM. There was no documented rationale for the change to the prescribed BFR. 3. Review of P7’s medical record revealed a prescribed BFR of 450 mL/min. On 05/01/24 the dialysis treatment started at 6:03 AM with the BFR documented at 400 mL/min. The BFR was continued at 400 ml/min until the end of treatment at 9:02 AM. Review of P7’s medical record revealed a prescribed DFR of 800 mL/min. On 05/08/24 the dialysis treatment started at 5:23 AM with the DFR documented at 500 mL/min. The DFR was continued at 500 mL/min until the end of treatment at 8:53 AM. There was no documented rationale for the change to the prescribed BFR or the DFR. 4. Review of P9’s medical record revealed a prescribed DFR of 600 mL/min. On 05/03/24 the dialysis treatment started at 4:59 AM with the DFR documented at 800 mL/min. The DFR was continued at 800 mL/min until the end of treatment at 8:01 AM. There was no documented rationale for the change to the prescribed DFR. During an interview on 05/14/24 at 2:30 PM, the Clinical Manager confirmed that the treatment sheets were reviewed, and rationales were not documented. Review of the facility’s policy titled, “Nursing Supervision and Delegation,” dated 11/06/23, indicated, “The registered nurse must evaluate each patient preferably with in a hour or according to state requirement to: ... review patient treatment prescription and equipment parameters to verify correct setting and if dialysis prescription is being followed ...””

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 37913 Based on record review, interview and policy reviews, the facility failed to follow the prescribed blood flow rates (BFR’s) for 17-gauge needles that have a maximum BFR of 300 millimeters per minute (mL/min) for one out of 15 (Patient (P) 5) medical records reviewed. Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for 216 in-center patients receiving dialysis treatments at the facility. Finding include: Review of P5’s medical record revealed that on 05/10/24, P5’s BFR was documented at 350 ml/min. Patient P5’s dialysis access was accessed with a 17-gauge needle. During an interview on 05/14/24 at 2:00 PM the Clinical Manager confirmed the maximum BFR for a 17-gauge needle is 300 mL/min and stated that the “facility staff did not follow the prescribed policy for 17-gauge needle.” Review of the facility’s policy titled, “New Access Cannulation Standing Order” dated 08/22/18, indicated, “. . .For 17-guage needle, run BFR less than or equal to 300 ml/min.” Review of the facility’s policy titled, “Nursing Supervision and Delegation” dated 11/06/23, indicated, “. . .Registered nurse must evaluate each patient preferably within an hour or according to the state requirements. . .Review patient treatment prescription and equipment parameter to verify correct setting and if dialysis prescription is being followed. . .””