Fmcna - Ada Dialysis Ctr

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 34689 Based on observation, interview, and record review, the facility failed to ensure that infection control practices and techniques were followed and maintained to prevent risk to patient health and safety, as evidenced by: Findings included: 1. The facility failed to ensure that A) two of two facility treatment areas (Laboratory area and Nursing Station counter) and B) five of five hemodialysis machines (hemodialysis machines #2, #8, #12, #13, and #18) provided and monitored a sanitary environment to minimize the transmission of infectious agents within and between the units or other public areas. Cross refer to V tag: V 111. 2 The facility failed to ensure that staff, citing 1 of 1 personnel (Personnel #2), wore a gown that covered the front and back of whole body or cover garment which provided an impervious barrier to fluids to protect and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur during provision of care for an isolation patient. Cross refer to V tag: V 115. 3. The facility failed to ensure that staff clearly designated areas, citing one of one facility area (in-center treatment area) for the storage of clean unused supplies and used equipment, in that “clean” unused supplies were stored on dirty storage containers or areas. This practice had the potential for harm to all patients and personnel in the facility with possible cross contamination of clean and contaminated supplies and/or equipment. Cross refer to V tag: V 117. 4. The facility failed to monitor and implement biohazard and infection control policies and activities within the dialysis unit, citing one of one personnel (Personnel #13) inappropriate procedure of disposal of blood soaked blue pad. This practice placed all patients and staff at risk for accidental exposure to cross contamination transmission. Cross refer to V tag: V 121. 5. The facility failed to ensure used syringes with blood and used vacutainer with blood in the isolation room were placed on top of the chairside table, citing one of one facility staff (Personnel #2) in that used syringes with blood and vacutainer were not discarded in the sharps container. Cross refer to V tag: V 130.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 34689 Based on observation, record review, and interview the facility failed to ensure proper maintenance of the physical environment which could impact the safety and health of the patients and staff, as evidenced by: Findings included: The facility failed to implement and maintain a program to ensure that all equipment and/or cleansers used in the facility was used and maintained according to the manufacturer’s instructions for use (IFU) citing one of one cleanser (Steri Fab). This practice placed all patients and staff at risk for harmful inhalation or contact of chemical. Cross refer to V tag: V 403.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 34689 Based on record review and interview, the medical director failed to ensure that all policies and procedures relative to patient care, infection control, and safety were adhered to by all individuals who treat patient in the facility, as evidenced by: Findings included: 1. The facility failed to ensure that emergency equipment was readily available to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing two of two emergency supplies and medications (Evacuation Box and Emergency crash cart) included expired supplies and medications available for use during an emergency in the facility. Cross refer to EP tag: EP 0028. 2. The facility failed to ensure that infection control practices and techniques were followed and maintained to prevent risk to patient health and safety, Cross refer to V tag: V 110. 3. The facility failed to ensure proper maintenance of the physical environment which could impact the safety and health of the patients and staff. Cross refer to V tag: V 400.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure that emergency equipment was readily available to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing two of two emergency supplies and medications (Evacuation Box and Emergency crash cart) included expired supplies and medications available for use during an emergency in the facility. Findings included: A review of the facility’s Storage of Supplies Policy dated 04/05/2021, included, “...Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date...” A review of the facility’s Emergency Medications, Equipment and Supplies dated 05/01/2023, included, “Emergency Cart...the emergency cart must be checked monthly or after use for contents, expiration dates...Emergency Evacuation Box must be checked monthly or after use for contents, expiration dates and cleanliness...” 1. On 12/11/24 at 2:45 PM, the clinic manager (Personnel #1) opened and reviewed the supplies in the evacuation box and included expired supplies such as: Temp dots expired 11/16/24, Island dressing 2/19/24, 7 Povidine Iodine 11/2023, and 12 Chloraprep swabsticks 08/24. On 12/11/24 at 2:55 PM, the clinic manager (Personnel #1) confirmed the above findings. When Personnel #1 was asked if the evacuation box’s content is checked and how often, she stated the evacuation box and contents are checked monthly. 2. On 12/12/24 at 10:55 AM, the clinic manager (Personnel #1) opened the facility’s emergency crash cart and the surveyor reviewed the contents of the emergency crash cart. There was one box (10 vials) of Naloxene (Narcan) with the expiration date of May 2024. On 12/12/24 at 11:00 AM, the clinic manager (Personnel #1) confirmed the above findings. When Personnel #1 was asked if the evacuation box’s content is checked and how often, she stated the evacuation box and contents are checked monthly.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure that A) two of two facility treatment areas (Laboratory area and Nursing Station counter) and B) five of five hemodialysis machines (hemodialysis machines #2, #8, #12, #13, and #18) provided and monitored a sanitary environment to minimize the transmission of infectious agents within and between the units or other public areas. Findings included: A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 11/04/2024, included, “All areas must be kept clean and organized, including but not limited to treatment areas...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff...Clean supplies may not be kept under dirty sinks...detergents germicides and cleaning supplies...all cleaning supplies shall be stored in a designated area...” A review of the facility’s Storage of Supplies Policy dated 04/05/2021, included, “...All supplies must be stored and handled in accordance with manufacturer’s instructions for use...” On 12/11/24 between 12:00 PM - 2:30 PM the surveyor accompanied by the clinic manager (Personnel #1) conducted a tour of the facility’s treatment area and observed the following: A. Treatment area: 1. Laboratory area: 12:15 PM - The wall on the laboratory area had 3 papers posted with clear tape. The wall had several pieces of several grayish residual tapes. - The cabinet under the laboratory sink was dirty with the whole cabinet base covered with sticky dark orange/brownish stain. -There were 7 cabinet doors with paper flyers posted held by grayish colored tape on the edges. - The laboratory counter was dirty stained with tape residues and pieces of tapes. 2. Nursing Station counter: 12:18 PM The nursing station counter at the middle of the dialysis’ facility’s treatment area, included cabinets on the bottom of the counter. There were two Steri Fab gallon jugs on top of the counter of the clean sink across dialysis stations #9, #12, and #13 during patients’ dialysis treatments. The cabinet that stored clean hemodialysis care packs was dirty with gray fuzzy dust and sediments. There were 11 corrugated supply boxes stored in the cabinets below the nursing station. On 12/11/24 at 12:20 PM, the clinic manager (Personnel #1) confirmed the above findings. When Personnel #1 was asked what the Steri Fab gallon jugs were used for, she stated that the Steri Fab spray were used for the recliner after the patient with bed bugs finished with dialysis treatment. At 12:30 PM, the end of the nursing station counter’s cabinet under the designated “clean sink,” was dirty with pieces of wrapped candy and black pieces of sediments. On 12/11/24 at 12:32 PM, the RN (Personnel #2) confirmed the above findings. B. Hemodialysis Machines: On 12/13/24 at 8:10 AM, the surveyor observed Hemodialysis machines #2, #8, #12, #13, and #18 with dark reddish/brownish drip sticky stain from the red acid port to the base of the machine in the front of the dialysis machines during patients’ dialysis treatments. When the Patient Care Technicians (PCT) Personnel #17, Personnel #18, and Personnel #19 were asked to use a bleach rag to see if the stains will come off, the stains on all of the machines came off. On 12/13/24 at 8::20 AM, Patient Care Technicians #17, #18, and #19, confirmed the above findings. A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 11/04/2024, included, “All areas must be kept clean and organized, including but not limited to treatment areas...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff...Clean supplies may not be kept under dirty sinks...detergents germicides and cleaning supplies...all cleaning supplies shall be stored in a designated area...””

“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: 34689 Based on observation, interview, and record review, the facility failed to ensure that staff, citing 1 of 1 personnel (Personnel #2), wore a gown that covered the front and back of whole body or cover garment which provided an impervious barrier to fluids to protect and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur during provision of care for an isolation patient. Findings included: A review of the facility’s Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+) Policy dated 11/06/2023, included, “...Policy: In addition to dialysis precautions, all patients with hepatitis B infection (hepatitis B surface antigen positive HBsAg+) treated in the facility require additional infection control precutions...Background: Caring for HBsAg positive requires adherence to strict guidelines. The Hepatitis B virus is highly infectious becaue the concentration of virus particles in the blood is very high...Hand Hygiene and Personal Protective Equipment (PPE)...Anyone entering the isolation area/room during the patient’s treatment must wear a separate fluid resistant gown at all times...” On 2/11//24 at 2:00 PM, the surveyor observed the Registered Nurse (RN) (Personnel #2) inside the isolation room with Patient #3 on the recliner. The RN’s (Personnel #2) shoulders, front chest, and whole back were not covered with the impervious gown worn by Personnel #2 while setting up for the dialysis treatment and during blood specimen collection from Patient #3’s Central Venous Catheter (CVC). On 12/11/24 at 2:02 PM, the clinic manager (Personnel #1) confirmed the above findings. When Personnel #1 was asked if Personnel #2 wore her impervious gown appropriately while in the isolation room, she stated Personnel #2 should have her back, shoulders, and chest covered with the impervious gown.”

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that staff clearly designated areas, citing one of one facility area (in-center treatment area) for the storage of clean unused supplies and used equipment, in that “clean” unused supplies were stored on dirty storage containers or areas. This practice had the potential for harm to all patients and personnel in the facility with possible cross contamination of clean and contaminated supplies and/or equipment. Findings included: A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 11/04/2024, included, “All areas must be kept clean and organized, including but not limited to treatment areas...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff...Clean supplies may not be kept under dirty sinks...detergents germicides and cleaning supplies...all cleaning supplies shall be stored in a designated area...” On 12/11/24 at 12:30 PM the surveyor observed two plastic containers dirty with dried whitish crusted statn and stored white and blue clamps stored at the end of the nursing station counter, without a label if the clamps were clean or dirty. There were two Intravenous (IV) pumps without a label if the pumps were clean ready for use or if dirty, at the end of the nursing station counter. On 12/11/24 at 12:31 PM, the Registered Nurse (Personnel #2) confirmed the above 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: 34689 Based on observation, interview, and record review, the facility failed to monitor and implement biohazard and infection control policies and activities within the dialysis unit, citing one of one personnel (Personnel #13) inappropriate procedure of disposal of blood soaked blue pad. This practice placed all patients and staff at risk for accidental exposure to cross contamination transmission. Findings included: A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 11/04/2024, included, “...specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling...” On 12/11/24 at 12:10 PM, the surveyor observed Patient #1 bleeding from her upper right arm arteriovenous (AV) site through gauze on the site dripping on the blue pad soaked with red blood where Patient #1 rested her left arm. Blue pad remained soaked with blood. On 12/11/24 at 12:13 PM, the clinic manager (Personnel #1) confirmed above findings.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 34689 Based on observation, interview, and record review, the facility failed to ensure used syringes with blood and used vacutainer with blood in the isolation room were placed on top of the chairside table, citing one of one facility staff (Personnel #2) in that used syringes with blood and vacutainer were not discarded in the sharps container. Findings included: A review of the facility’s Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+) Policy dated 11/06/2023, included, “...Policy: In addition to dialysis precautions, all patients with hepatitis B infection (hepatitis B surface antigen positive HBsAg+) treated in the facility require additional infection control precautions...Background: Caring for HBsAg positive requires adherence to strict guidelines. The Hepatitis B virus is highly infectious because the concentration of virus particles in the blood is very high...Hand Hygiene and Personal Protective Equipment (PPE)...Anyone entering the isolation area/room during the patient’s treatment must wear a separate fluid resistant gown at all times...” On 12/11/24 at 2:00 PM, the surveyor observed the Registered Nurse (RN) (Personnel #2) inside dialysis station #21, isolation room. Personnel #2 accessed Patient #3’s right chest central venous catheter (CVC), aspirated 10 milliliters (ml) of blood from each CVC port, placed the 2 syringes with blood on top of the chairside table with the clean syringes with saline and Heparin, obtained blood specimens with a vacutainer, and placed the vacutainer with the needle with blood on top of the chairside table mixed with the clean syringes with saline and Heparin. Personnel #2 worked on the dialysis machine’s keyboard with the same gloves she used accessing Patient #3’s CVC. On 12/11/24 at 2:10 PM, the surveyor showed a Patient Care Technician (PCT) (Personnel #3) the syringes and vacutainer with blood on top of the chairside table mixed with the clean syringes with saline and Heparin and Personnel #3 confirmed above 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: 34689 Based on observation, record review, and interview, the facility failed to implement and maintain a program to ensure that all equipment and/or cleansers used in the facility was used and maintained according to the manufacturer’s instructions for use (IFU) citing one of one cleanser (Steri Fab). This practice placed all patients and staff at risk for harmful inhalation or contact with a chemical. Findings included: A review of the Bed Bug Control Policy dated 11/07/2023, included, “...When a patient is identified with having bed bugs, the clinic must take immediate action to mitigate...Procedure...When the dialysis treatment is complete, use the handheld steamer to steam the chair that the patient sat in...Documentation...clinic staff should document all interventions taken and response to interventions in the medical records...” A review of Steri-Fab Bactericide-Fungicide-Mildewcide-Insecticide-Deodorant-Germicide-Viricide, included, “User Restrictions: Do not apply this product in a way that will contact workers or other person, either directly or through drift. Only protected handlers may be in the application area during application ...Do not enter or allow others to enter treated area until sprays have dried ...Do not enter or allow others to enter until vapors, mists, and aerosols have dispensed, and the treated area has been thoroughly ventilated ...” On 12/13/24 at 8:30 AM, the surveyor observed a patient with blue paper gown on, dialyzed in station #6. When the Registered Nurse (RN) (Personnel #2) was asked who and why the patient wore blue paper gown, she stated that is Patient #8 and that he is on the bedbug protocol. At 9:00 AM, when Personnel #2 was asked to explain the process facility staff do to clean the dialysis station of a patient identified to have bedbug, she stated that they use Steri Fab and spray the dialysis recliner in the treatment area with Steri Fab after the patient with bedbug leave. When asked if other patients were still on their dialysis treatments and in the treatment area when they use the Steri Fab, she stated yes. When asked if she and the other staff were trained to use the Steri Fab and informed of instruction for use (IFU), she stated, no they just told us to spray and to use the Steri Fab. On 12/13/24 at 9:15 AM, the clinic manager (Personnel #1) confirmed the above 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: 34689 Based on record review and interview, the facilty failed to ensure that the comprehensive assessment addressed the patient’s current health status and medical conditions, including co-morbid conditions by the patient’s physician, citing two of two patients (patient #3 and #8) did not include assessments or reassessments of patients’ current health status. Findings included: A review of the facility’s Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+) Policy dated 11/06/2023, included, “...Policy: In addition to dialysis precautions, all patients with hepatitis B infection (hepatitis B surface antigen positive HBsAg+) treated in the facility require additional infection control precautions...Background: Caring for HBsAg positive requires adherence to strict guidelines...” A review of the Bed Bug Control Policy dated 11/07/2023, included, “...When a patient is identified with having bed bugs, the clinic must take immediate action to mitigate...Documentation...clinic staff should document all interventions taken and response to interventions in the medical records...” 1. Patient #3: A review of the clinical records showed Patient #3 was admitted to this facility for his dialysis treatment on 12/09/24 with HepBsAg positive result and was placed in the isolation room for his treatments. There was no documented evidence of physician’s order to place Patient #3 in isolation. A review of treatment sheets dated 12/09/24 - 12/11/24 showed no documented evidence facility staff used and maintained isolation precautions during the provision of care to Patient #3. 12/13/24 at 12:45 PM the clinic manager (Personnel #1) confirmed the above findings. 2. Patient #8: On 12/13/24 at 8:30 AM, the surveyor observed a patient with blue paper gown on, dialyzed in station #6. When the Registered Nurse (RN) (Personnel #2) was asked who and why the patient wore blue paper gown, she stated that is Patient #8 and that he is on the bedbug protocol. A review of Patient #8’s clinical records showed Patient #8 showed Patient #8 was hospitalized from 11/02/24 - 12/02/24. Patient #8’s last treatment at the facility was 11/01/24 and came back for his treatment at the facility on 12/04/24. A review of Patient #8’s treatment sheets dated 10/21/24, 10/23/24, 10/25/24, 11/01/24, 12/04/24 - 12/11/24 showed no documented evidence of assessment or reassessment of the presence or absence of bedbugs and of bedbug protocol maintained by facility staff during the dialysis treatment. On 12/13/24 at 9:30 AM, the clinic manager (Personnel #1) confirmed with the above 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: 34689 Based on observation, record review, and interview, the facility failed to evaluate the appropriateness of the dialysis prescription, citing three of three dialysis patients (Patients #3, #8, and #9) who did not have physician’s orders for the provision of care. Findings included: A review of the facility’s Physician Order Documentation Policy date 07/03/2023, included, “...It is the nurses ’ responsibility to ensure that all treatments, medications, labs or any care provided to the patient have an accurately documented physician order. General PolicyNurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders...” 1. Patient #3 On 2/11//24 at 2:00 PM, the surveyor observed the Registered Nurse (RN) (Personnel #2) inside the isolation room with Patient #3 on the recliner. A review of the clinical records showed Patient #3 was admitted to this facility for his dialysis treatment on 12/09/24 with HepBsAg positive result and was placed in the isolation room for his treatments. A review of Orders Summary Report showed Hemodialysis orders start date 12/06/2024 stop date 12/05/2024 and orders start date 12/13/2024, stop date 12/12/2025 showed no documented evidence of physician’s order to place Patient #3 in isolation. A review of treatment sheets dated 12/09/24 - 12/11/24 showed no documented evidence facility staff used and maintained isolation precautions during the provision of care to Patient #3. 12/13/24 at 12:45 PM the clinic manager (Personnel #1) confirmed the above findings. 2. Patient #8 : A review of Patient #8’s clinical records showed Patient #8 was hospitalized from 11/02/24 - 12/02/24. Patient #8’s last treatment at the facility was 11/01/24 and came back for his dialysis treatment at the facility on 12/04/24. The Orders Summary Report showed Hemodialysis orders start date 10/28/2024 and stop date 10/27/2025. There was no documented evidence of Hemodialysis orders post hospitalization from Patient #8’s physician. A review of Patient #8’s treatment sheets dated 12/04/24 - 12/11/24 showed no documented evidence facility staff called and communicated with Patient #8’s physician for an update of Patient #8’s condition status post hospitalization to inquire for an updated hemodialysis treatment order changes or to continue the same hemodialysis treatment orders when he returned to the facility. On 12/13/24 at 9:30 AM, the clinic manager (Personnel #1) confirmed with the above findings. 3. Patient #9: A review of Patient #9’s treatment sheets included Patient #9 came in with pre weight 115 kilograms (kg) = 7.0 kilogram (kg) over dry weight on 12/03/24 and pre weight of 116.30 kg = 8.30 kg over his ordered dry weight on 12/12/24. Facility staff started Patient #9’s dialysis treatment. There was no documented evidence facility staff called Patient #9’s physician (Personnel #12) to notify of 7.0 kg and 8.3 kg over his dry weight prior to starting his dialysis treatment. A review of the Orders Summary Report for Patient #9 showed Hemodialysis treatment orders, “...start date 11/212024 with stop date 11/20/2025...Estimated Dry Weight (EDW) 108 kg...” There was no documented evidence of orders to start hemodialysis treatment with 7.0 kg or 8.3 kg over ordered dry weight. On 12/13/2024 at 10:32 AM, the clinic manager (Personnel #1) confirmed the above findings.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 34689 Based on interview and record review, the facility failed to ensure patients’ dialysis access were evaluated and maintained to promote and preserve their function, citing two of two patients (Patients #5 and #9), in that patients’ peritoneal dialysis catheter was flushed without a physician’s order and an arteriovenous fistula (AVF) was cannulated without a tourniquet. Findings included: A review of the facility’s Access Assessment and Cannulation Policy dated 05/06/2024 included, “...A tourniquet must be used with an Arteriovenous (AV) Fistula...” A review of the facility’s Physician Order Documentation Policy date 07/03/2023, included, “...It is the nurses’ responsibility to ensure that all treatments, medications, labs or any care provided to the patient have an accurately documented physician order. General Policy practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders...” 1. On 12/12/24 at 9:00 AM, the surveyor conducted an interview with Patient #5 and when asked when her peritoneal dialysis (PD) catheter was placed, she stated last month. When asked who flushed her PD catheter after placement, she stated, the nurse here flushed my PD catheter. A review of Patient #5’s clinical records showed Home Therapy nurses flushed Patient #5’s peritoneal dialysis catheter on 11/12/24, 11/19/24, 11/26/24, and 12/03/24. There were no documented evidence of physician order to flush Patient #5’s PD catheter after placement on 11/01/24. A review of the Referral and Physician Orders for Patients Receiving Peritoneal Access Care Services dated 11/12/24 showed the section for Physician’s Orders was blank and no documented evidence of an order to do the first flush of Patient #5’s PD catheter. On 12/13/24 at 2:15 PM, the Director of Operations (Personnel #10) confirmed the above findings 2. On 12/12/24 at 11:15 AM, the surveyor observed the patient care technician (PCT) (Personnel #16) cleansed Patient #9’s left upper arm’s arteriovenous fistula (AVF) site and cannulated AVF needles X2 without the use of a tourniquet. On 12/12/24 at 11:16 AM, Personnel #16 confirmed the above findings. When Personnel #16 was asked what the policy was with cannulating AVF sites without a tourniquet, she stated that it is allowed to use the fingers for pressure on the sites.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to review medical records on all home patients at a minimum, treatment records, flow sheets, citing one of one home therapy patient (Patient #10) in that clinical record did not include daily home treatment flowsheets to review patient’s vital signs, weights, and prescription management information when home treatments were done. Findings included: A review of the facility’s Review and Documentation of Home Therapies Patient Health Data Policy dated 03/01/2023, included, “Policy ...The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home.” Patient #10: On 12/11/24 at 11:00 AM, the surveyor observed Patient #10 during her backup/respite dialysis treatment in the HHD room. A review of Patient #10’s Home Hemodialysis (HHD) clinical record showed Patient #10 came in for her clinic visit on 9/30/24 and HHD treatment sheets given by Patient #10 and reviewed by facility staff were dated 8/20/24, 8/21/24, 8/24/24 treatments. There were no documented evidence Patient #10 provided treatment sheets for the months of 9/2024, 10/2024, and 11/2024. A review of the Home Record Documentation Education dated 8/23/24, 9/27/24, 10/10/24, and 11/11/24, included, “Reviewed the importance of documentation to proper care and evaluation of current plan ...Patient (Pt) reports she has completed treatments and taken vitals but did not record on flowsheets or use Nx2me ...reports she completes treatments every other day.” A review of Orders Summary Report, showed, “ ...start date 04/02/2024, stop date 04/01/2025 ...Home HD using NxStage with Pure Flow 5X Week ...physician (Personnel #12) ...” On 12/13/24 at 1:30 PM, the home therapy RN (Personnel #6) when asked what records she reviewed when Patient #10 comes for her clinic visits, she stated that Patient #10 told her she does treatment every other day and that she trust her. Personnel #6 confirmed the above findings.”