Usrc Cheektowaga 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: 40430 Based on policy review, observation, and interview, nursing staff do not follow standard infection control practices regarding the use of gloves and hand hygiene. Specifically, staff do not change gloves and/or perform hand hygiene when entering/exiting the dialysis station, when performing safety checks/touching the machine, and when using the computer keyboard while monitoring patients during their dialysis treatment. Findings Include: Review of the policy “Infection Control and Precautions for All Patients,” revised July 2023, indicated staff will perform hand hygiene using soap and water or antibacterial hand sanitizer before/after all patient contact and before applying and removing gloves. Hand hygiene must be performed after contact with the integrated keyboard or chairside computer, regardless of whether contact occurred through gloved or ungloved hands. Staff must remove gloves and perform hand hygiene between each patient or station. Observation on 03/17/25 at 02:38 PM at Station #2 for Patient #17 revealed Staff (K), Registered Nurse, touched the dialysis machine screen and computer keyboard with gloved hands. Without removing gloves and performing hand hygiene, Staff (K) exited Station #2 leaving their gloves on. Staff (K) entered Station #5 for Patient #21, wearing the same gloves, touched the dialysis machine screen to reset an alarm, and type on the computer keyboard. At 2:39 PM, wearing the same gloves, Staff (K) exited Station #5, entered Station #6 for Patient #22, and touched the dialysis machine screen and computer keyboard. At 2:40 PM, wearing the same gloves, Staff (K) exited Station #6, entered Station #8 for Patient #2, and touched the dialysis machine screen and computer keyboard. Staff (K) exited Station #8, removed their gloves, and performed hand hygiene. Interview on 03/19/25 at 01:45 PM with Staff (B), Nurse Manager and Staff (O), Clinical Specialist, verified these 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: 34528 Based on policy review, observation, and interview, the facility does not ensure appropriate disposal of needles and sharps into sharps containers (puncture/leak resistant container) and that the sharps containers are secure to prevent tipping and/or spillage of contents. Findings Include: Review of the policy “Preparation and Administration of IV/Sub Q/IM Medications,” revised February 2023, indicated after drawing up the correct amount of medication from the vial, discard the vial in the appropriate container. Review of the policy “Guidelines for the Handling and Disposal of Infectious Medical Waste,” revised April 2023 indicated contaminated sharps including blades, needles, vacutainers and syringes are considered and treated as infectious and/or special waste materials. Special waste requires special handling and disposal to protect human health or the environment. All needles and sharps will be placed in puncture resistant containers. (The policy did not indicate sharps containers need to be secure to prevent tipping and/or spillage of contents). Observation on 03/17/25 and 03/18/25 from 08:30 AM to 03:40 PM and 03/19/25 from 08:30 AM to 12:00 PM, in the medication storage/preparation area, revealed an empty 10 x 6 x 6-inch cardboard box located on the medication area countertop. There were 10-20 used/empty glass medication vials and one capped one ml syringe (on 03/17/25), no longer in its packaging. Interview on 03/19/25 at 08:40 AM Staff (H), Licensed Practical Nurse, verified this finding and stated the facility does not have a small sharps container for the medication storage/preparation area. The cardboard box was used for sharps disposal. Staff empty the box into a secured sharps container at the end of each night. Observation on 03/19/25 at 01:03 PM in peritoneal dialysis (PD) training area revealed three training rooms that had a sharps container located on the floor, not secured to prevent tipping and/or spillage. Interview 03/19/25 at 01:15 PM with Staff (F), Home Hemodialysis/PD Nurse, and 01:45 PM with Staff (B), Nurse Manager and Staff (O), Clinical Specialist, 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: 40430 Based on policy review, observation, and interview, in four of four patients observed, nursing staff do not use the appropriate infection control measures to prevent infections for central venous catheters (CVC-tube inserted into a large vein in the body to provide access for dialysis). Specifically, staff do not replace the pad under the catheter with a new, clean pad at the completion of the dialysis treatments, prior to disconnecting the blood lines from the CVC ports (Patient #4, Patient #17, Patient #18, and Patient #19). Findings Include: Review of the policy “Accessing and De-Accessing the Dialysis Catheter,” revised June 2024, indicated staff are to replace the under pad beneath the CVC in preparation to disconnect the patient from the blood lines at the completion of their dialysis treatment. Observation on 03/17/25 at 02:24 PM at Station #12 for Patient #4 and at 03:00 PM at Station #2 for Patient #17 revealed Staff (H), Licensed Practical Nurse, did not replace the pad under the CVC with a clean pad at the completion of the dialysis treatments, prior to disconnecting the blood lines from the CVC ports. Observation on 03/18/25 at 10:45 AM at Station #1 for Patient #18 revealed Staff (N), Registered Nurse, did not replace the pad under the CVC with a clean pad at the completion of the dialysis treatments, prior to disconnecting the blood lines from the CVC ports. At 02:35 PM at Station #12 for Patient #19, Staff (M), Registered Nurse, did not replace the pad under the CVC with a clean pad at the completion of the dialysis treatments, prior to disconnecting the blood lines from the CVC ports. Interview on 03/19/25 at 01:45 PM with Staff (B), Nurse Manager, and Staff (O), Clinical Specialist, verified these findings.”

“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: 25545 Based on observation and interview, the facility does not maintain two of two eye washes with tepid water. Findings Include: Observation on 03/18/25 at 11:00 AM revealed that the eye wash station on the treatment floor and the eye wash station in the storage area were plumbed to cold water only. The temperature was measured at both eye wash stations at 41.7 degrees Fahrenheit. According to the American National Standard Institute Z358.1 2014: Emergency Eyewash & Shower Standard (for Emergency Eyewash and Shower Equipment), eyewash stations require tepid water as defined as 60 degrees Fahrenheit (F) to 100 degrees F. Interview on 03/18/25 at 11:00 AM with Staff (E), Biomedical Technician, verified these findings.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 25545 Based on document review and interview, the facility does not document required parameters while the generator (source of emergency power) was running with a load (the electrical demand placed on a generator). Findings Include: Review on 03/19/25 of the “Monthly Generator Log,” dated 01/12/25, 02/09/25, and 03/16/25, revealed the generator was tested under a load. However, neither amps (the unit of measurement for an electrical current, which is the flow of electric current through a conductor) drawn by the load, or the water temperature and oil pressure were not documented. Interview on 03/19/2025 at 10:00 AM with Staff (E), Biomedical Technician, revealed they conducts the monthly generator test with a load, but they did not document either amps, or water temperature and oil pressure according to NFPA 110 Standards for Emergency and Standby Power Systems 2010 edition, which is a referenced publication of NFPA 101 Life Safety Code 2012 edition.”

“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: 40430 Based on policy review, observation, medical record review, and interview, for six of eight patients/medical records reviewed, the registered nurse does not ensure the hemodialysis prescription is implemented and/or maintained for the ultrafiltration profile (UF-amount of fluid removed in a specified time. Profiles allow for the fluid removal at various intervals vs. removing the same amount throughout a treatment), dialysate flow rates (DFR-rate dialysate flows through a dialyzer or artificial kidney, to remove toxins from a patient’s bloodstream), blood flow rates (BFR- rate at which blood is processed during dialysis), and the correct dialyzer (filter used to clean blood) for (Patient # 2, Patient #11, Patient #12, Patient #14, Patient #26, and Patient #27). Findings Include: Review of the policy “Pre-Treatment Assessment of Patient,” revised January 2020, indicated patients will receive hemodialysis treatment and nursing care based on data collected and pre dialysis nursing assessment. The pre-dialysis nursing assessment will occur within the first hour of patient contact or per stricter state regulations. Review of the policy “Initiation of Dialysis Treatment,” revised July 2024, indicated two staff members must verify and document the correct prescription on the treatment flowsheet. Prior to walking away from the patient’s dialysis machine, verify that all prescribed orders are followed. If unable to follow any part of the patient’s prescription, notify the charge nurse and document the notification. Prescription orders and safety measures include verification the dialyzer, DFR, BFR, and fluid removal (UF) goal are programmed correctly. Observation and medical record review on 03/18/25 from 11:25 AM to 12:06 PM revealed the following: - For Patient #11 at Station #5: The hemodialysis machine had an Optiflux 180 dialyzer (filter brand/size) dialyzer in use. The medical record flow sheet indicated the ordered dialyzer was an Optiflux 160 dialyzer. There was no documentation found in the medical record to indicate why a different size dialyzer was utilized. - For Patient #12 at Station #4: The hemodialysis machine was set with a DFR of 500 milliliters per minute (ml/min). The medical record flow sheet indicated the prescribed/ordered DFR was 600 ml/min. There was no documentation found in the medical record to indicate why the DFR was not implemented as ordered. Medical record review on 03/18/25 revealed the following: - For Patient #2: Review of the medical record flowsheets from 02/14/25 to 03/17/25 revealed a prescribed/ordered DFR of 800ml/min and BFR of 350ml/min. On 02/14/25, the DFR was set at 500ml/min. On 02/28/25, the BFR was set at 250-300ml/min. There was no documentation found in the medical record to indicate why the DFR and BFR were not implemented as ordered. - For Patient #14: Review of the medical record flowsheets from 02/19/25 to 03/10/25 revealed a prescribed/ordered DFR of 800ml/min. On 03/07/25, the DFR was reduced to 500ml/min. There was no documentation found in the medical record to indicate why the DFR was reduced and not maintained as ordered. - For Patient #26: Review of the medical record flowsheets from 02/24/25 to 03/17/25 revealed a prescribed/ordered UF profile #1 ( profile- instead of a constant rate profiling adjusts rate of fluid removal throughout treatment to reduce complications during dialysis). On 03/07/25, no UF profile was not set/implemented as ordered. There was no documentation found in the medical record to indicate why the UF profile was not implemented as ordered. - For Patient #27: Review of the medical record flowsheets from 02/22/25 to 03/15/25 revealed a prescribed/ordered BFR of 450ml/min and UF profile #3. On 03/04/25 and 03/06/25, the BFR was set at 200-325ml/min. On 03/13/25, the UF profile was not set/implemented as ordered. There was no documentation found in the medical record to indicate why the BFR and UF profile were not implemented as ordered. Interview on 03/19/25 at 01:45 PM with Staff (B), Nurse Manager, and Staff (O), Clinical Specialist, 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: 40430 Based on policy review, medical record review, and interview, in one of eight medical records reviewed, the licensed practical nurse and/or patient care technician do not notify the registered nurse regarding changes in a patient’s condition (Patient #2). Findings include: Review of the policy “Reportable Parameters to Charge Nurse,” revised January 2020, indicated that intra-dialysis (during dialysis) issues to be reported to the charge nurse are to include a systolic (top value of a blood pressure or “BP” reading that measures the heart pumping rate) blood pressure reading of less than 90. Review on 03/19/25 of the medical record flowsheets for Patient #2, dated from 02/14/25 to 03/17/25, revealed the following: - On 02/17/25 at 01:31 PM, a patient care technician administered 150 milliliters (ml) of NS for a BP of 89/38. There is no documentation in the medical record indicating the registered nurse was notified. - On 02/28/25 at 01:05 PM, a licensed practical nurse administered 200 ml of NS for a BP of 65/36. At 01:09 PM, the licensed practical nurse reduced the ultrafiltration rate (UFR-rate of fluid removal during dialysis). There is no documentation in the medical record indicating the registered nurse was notified. - On 03/07/25 at 01:33 PM, a patient care technician administered 100 ml of NS for a BP of 72/35. There is no documentation in the medical record indicating the registered nurse was notified. - On 03/10/25 at 01:01 PM, a patient care technician administered 100 ml of NS and reduced the UFR for a BP of 89/48. There is no documentation in the medical record indicating the registered nurse was notified. Interview on 03/19/25 at 01:45 PM with Staff (B), Nurse Manager, and Staff (O), Clinical Specialist, verified these findings.”