Center for Dialysis Care, Garfield

“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: 29732 Based on observation, policy review, and staff interview the facility failed to ensure staff changed gloves and used hand hygiene after glove removal. This affected two (Staff D and J) of four staff observed. The census was 61. Findings include: 1. On 03/07/24 at 8:24 AM Staff D was observed to assess the patient in station 6, then touched the dialysis machine (dirty area) then removed gloves and went to the computer (clean area) without practicing hand hygiene. Interview on 03/07/24 at 8:26 AM Staff D confirmed this finding. 2. On 03/07/24 at 8:35 AM Staff J was observed to touch the dialysis machine at station 5 then touched the dialysis machine at station 1 using the same gloves. Interview on 03/07/24 at 8:38 AM Staff J confirmed this finding. Review of facility policy titled, “Personal Protective Equipment,” effective 12/13/13, revealed change gloves when gong from a “dirty” task or area to a “clean” task or area and after touching one patient or their machine and before arriving to care for another patient or touch another patient’s machine. Review of facility policy titled, “Hand Hygiene,” effective 05/04/18, revealed Hand Hygiene includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic hand rub with at least 60% alcohol content. Hand Hygiene must be performed immediately after removing gloves.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 29732 Based on observation, educational power point review, and staff interview, the facility failed to ensure the sinks were marked clean or dirty and failed to ensure staff recognized a dirty sink. This had the potential to affect all patients and staff. The census was 61. Findings include: Review of an educational power point, with no effective date, revealed this facility defines a “clean” area as an area designated only for clean and unused equipment, supplies and medications. Sinks are designated dirty or clean. The countertop adjacent to the dirty sink are dirty. Lab areas with centrifuge and refrigerator are dirty. On 03/06/24 at 8:15 AM three sinks were observed to not be labeled as clean or dirty. Interview on 03/06/24 between 8:16 AM and 9:00 AM Staff I and B both stated the sink located between stations three and four was considered a clean sink. Staff B confirmed this sink had blood tubes and a centrifuge machine on the same counter. Interview on 03/06/24 at 11:00 AM the Vice President of Operations confirmed this sink was considered dirty because of the blood tubes and centrifuge machine and confirmed none of the sinks were labeled as clean or dirty.”

“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: 29732 Based on record review, policy review, and staff interview, the facility failed to ensure the registered nurse was notified if the blood flow rate was not achieved and failed to document in the medical record. This affected two (Patients #12 and #15) of four patients reviewed. The census was 61. Findings include: Review of the facility’s Initial Assessment and Standing Orders, revised 02/20, revealed the Blood Flow Rate (BFR) ordered could be plus/minus 50 milliliters per minute (ml/min). Review of the facility policy titled, “Initiating the Dialysis Treatment with the BBraun Dialog+ Machine,” effective date 12/19/19, revealed if unable to advance the pump speed to the prescribed blood flow rate, notify the registered nurse (RN) and document in the medical record. 1. On 03/07/24 at 8:29 AM, Staff J was observed to answer the dialysis machine alarm for Patient #15. Review of the medical record for Patient #15 and treatment sheet dated 03/07/24 revealed the ordered BFR was 400. At 5:59 AM, the BFR was at 350. At 6:29 AM, Staff J turned the BFR down to 270 until 7:29 AM when Staff J turned the BFR up to 300. At 7:59 AM, Staff J turned the BFR up to 320 then at 8:29 AM, Staff J turned the BFR down to 280. There was no documented evidence the Registered Nurse (RN) was notified Patient #15 was not able to run at the prescribed BFR rate range of 350 to 450 per policy. 2. Review of the medical record for Patient #12 and treatment sheet dated 02/22/24 revealed the ordered BFR was 450. At 9:53 AM, the BFR was 400. At 10:23 AM, Staff G turned the BFR down to 350, then at 10:53 AM, Staff G turned the BFR down to 330. There was no documented evidence the RN was notified Patient #12 was not able to run at the prescribed BFR rate range of 400 to 500 per policy. Further review on 02/24/24 revealed Patient #12’s treatment started at 7:54 AM with a BFR at 150. At 8:23 AM, Staff G turned the BFR up to 370 where the patient ran until end of treatment at 12:01 PM. There was no documented evidence the RN was notified Patient #12 was not able to run at the prescribed BFR rate range of 400 to 500 per policy. Further review of the treatment sheet dated 02/29/24 revealed Patient #12’s BFR at 10:57 AM was 440. At 11:27 AM, Staff F turned down the BFR to 350 until the end of treatment at 11:57 AM. There was no documented evidence the RN was notified Patient #12 was not able to run at the prescribed BFR rate range of 400 to 500 per policy. Interview on 03/07/24 at 2:35 PM the Vice President of Operations confirmed these treatments were not as ordered and there was no documentation the RN was notified when the prescribed BFR was not reached.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 29732 Based on observation, policy review and staff interview the facility failed to ensure all medications were labeled with date, time, and initials on multi-use vials when opened. This had the potential to affect all patients and staff. The census was 61. Findings include: Review of facility policy titled, “Medication Preparation and Administration,” effective 01/22/14 revealed all medications must be labeled with date, time, and initials on multi-use vials when opened. 1. On 03/06/24 at 8:38 AM an opened bottle of Heparin (blood thinner) was observed to not be labeled with the date and time it was opened. Interview on 03/06/24 at 8:43 AM Staff I confirmed the open bottle of Heparin was not labeled per policy and stated, someone opened it today, but didn’t know who or when. 2. On 03/07/24 at 8:42 AM an opened bottle of Zemplar (used to treat overactive parathyroid glands) was observed to not be labeled with the date and time it was opened. Interview on 03/07/24 at 8:46 AM Staff D confirmed this finding.”