Zz_closed_fmcna - Idabel Dx

“BICARB JUGS RINSED DAILY/STORED DRY CFR(s): 494.40(a) 6.5 Concentrate distribution: bicarb jugs rinsed daily/stored dry Bicarbonate concentrate jugs should be rinsed with treated water and stored inverted at the end of each treatment day. Pick-up tubes should also be rinsed with treated water and allowed to air dry at the end of each treatment day. This Standard is not met as evidenced by: 34696 Based on observation and interview, the facility failed to ensure equipment in one of one area (Shower room) was properly stored. Findings included: On 04/10/2024, during a tour of the facility, the following was observed: ~At 111:50 AM, the Shower room had approximately 20 bicarbonate and acid jugs that were dirty and covered with dust. The jugs had not been rinsed with treated water and inverted to dry. On 04/10/2024 at the time of the findings, the Facility Administrator (Personnel #1) stated the jugs were not clean and properly stored.”

“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: 34696 Based on observation, interview, and record review the facility failed maintain the building to ensure the safety of the patients, the staff, and the public in two of six areas (waiting area and Men’s restroom). Findings included: A review of the facility’s “General Cleanliness and Infection Control Guidelines” policy dated 02/07/2022 included, “Facility staff are accountable for cleaning rooms/areas not assigned to contracted staff. Such cleaning should be done regularly using a schedule developed by the facility...A written schedule of cleaning procedures shall be established, reviewed, documented annually in Governing Body and implemented which sets forth the cleaning and method of decontamination considering the types of surfaces, soils, and and tasks and procedures being performed per policy.” On 04/10/2024, during a tour of the facility, the following was observed: ~ At 11:30 AM, it was observed that two water fountains in the lobby were covered with plastic that was secured with tape. The outside of the plastic was covered in dust. The Facility Administrator (Personnel #1) said the fountains were dusty, and that the housekeeping service was responsible for maintaining the fountains. ~ At 11:35 AM, it was observed in the Men’s restroom located in the waiting area, that the cord used to call staff in an emergency was wrapped around the railing next to the toilet. The alarm could not be engaged when Personnel #1 pulled the cord. He said the cord should not be wrapped around the rail.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure DPC (direct patient care) staff obtained physician’s orders with guidance to cannulate one of one patent’s (Patient #10) new AV (arteriovenous) fistula. Findings included: A review of the “New Access Cannulation Standing Order” dated 08/22/20218 included, “Registered Nurse (RN), Licensed Practical Nurse (LPN), or Vascular Access Manager/Coordinator will....consult Nephrologist/Nurse Practitioner (NP)/ Physician Assistant (PA) confirm the dialysis prescription including order to cannulate access...AV fistula successful cannulation is evidence by three consecutive treatments...two 16 gauge needles at minimum of 300 milliliter (mL)/minute blood flow rate (BFR) for the entire treatment...Step 1...AV fistula cannulation process for patient with a CVC (central venous catheter)...Clinical staff will cannulate arterial portion AV fistula with one 17 gauge needle and return blood through the CVC...Run BFR less than or equal to 300 mL/minute...at the next two dialysis treatments...cannulate AV fistula with two 17 gauge needles...Run BFR less than or equal to 300 mL/minute...Step 2...AV fistula cannulation process for patient with or without a CVC...Clinical staff will cannulate AV fistula with two 16 gauge needles...Run BFR less than or equal to 350 mL/minute...If no infiltration or complication with first cannulation using 16 gauge needles, perform access flow testing at subsequent treatments...Nurse or Vascular Access Manager/Coordinator will ensure appointment for catheter removal is scheduled...Nurse will confirm final dialysis prescription regarding time, needle gauge, and BFR...Discontinue this Standing Order.” ~ Patient #10: A surgeon’s note in the medical record included, “Patient #10 underwent a ...right AV...fistula placement...from our standpoint, it is ok to start using this for dialysis access on...03/25/2024.” There was no documented evidence of a Nephrologist’s Standing Order to begin cannulating Patient #10’s AV fistula with guidance for progression of the needle gauge and BFR. The hemodialysis treatment records dated 03/25/2024, 03/27/2024, 04/01/2024, 04/03/2024, and 04/08/2024 indicated Patient #10’s right upper arm AV fistula was cannulated with 16 and 17 gauge needles and BFRs that ranged from 200 to 350 mL/minute. On 04/12/2024 at 9:45 AM, the Direcotr of Operations and the Charge Nurse II (Personnel # 13 and #12 respectively) said there was no Nephrologist’s order to cannulate Patient #10’s new AV fistula.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 34696 Based on record review and interview, the facility failed to provide the necessary monitoring and social work interventions for two of six patients (Patients #1 and #10). Findings included: A review of the “Measuring Patient Physical and Mental Function” policy dated 04/04/2012 indicated, “The dialysis facility must provide the necessary monitoring and interventions for the patient to adjust to dialysis and to achieve optimal psychosocial and physical status. Interventions can include...counseling services...referrals for other social services...consideration by the IDT (Interdisciplinary Team) for interventions and referrals from other outside medical services, as needed...Achieving and sustaining appropriate psychosocial and physical status will be measured by a standardized mental and physical assessment tool...the KDQOL (kidney disease quality of life)...Patients with low or below average case mix adjusted scores or any score that is 10 or more points lower than a previous score require reassessment to determine areas where improvement is needed. The plan of care is adjusted, and progress notes reflect the interventions and progress toward achieving the desired outcome...Documentation...KDQOL-3...results are printed and placed in the patient’s medical record and discussed with members of the IDT...KDQOL-36...results and patient responses are discussed with the patient...and recorded in a progress note in the medical record...The plan of care is updated to reflect goals and interventions to maintain or improve function.” ~ Patient #1: The medical record indicated Patient #1 was admitted to the facility 04/09/2022. Patient #1’s initial KDQOL-36 survey dated 06/13/2022 did not include documented evidence that the survey scores were reviewed and discussed with Patient #1. The annual KDQOL-36 dated 06/20/2023 indicated Patient #1 had a 10 or more point drop from the previous score in the Mental Component Summary, Burden of Kidney Disease, Symptoms and Problems, and Effects of Kidney Disease on Daily Life. There was no documented evidence the scores were reviewed, discussed, and referrals offered to Patient #1. ~ Patient #10: The medical record indicated Patient #10 was admitted to the facility 09/12/2023. Patient #10’s initial KDQOL-36 survey dated 12/14/2023 did not include documented evidence that the survey scores were reviewed and discussed with Patient #10. On 04/11/2024 at 3:30 PM, the Director of Operations (Personnel #12) said Patients #1 and #10’s medical records did not have documented evidence the survey scores had been reviewed, discussed, and referrals offered to the patients.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 34696 Based on record review and interview, the facility failed to track, measure, and analyze quality indicators that influence and reflect the processes of care and facility operations, in that the facility failed to ensure adverse events were documented for nine (in-center hemodialysis Patients #2, #3, #4, #5, #6, #7, #11, #12, and #13) whose labs were missed, canceled, or clotted in three of four months (January 2024, February 2024, and March 2024). Findings included: A review of the “Patient Safety Event Reporting and Documentation” policy dated 02/06/2023 indicated, “Safety Event...results in mild to moderate patient clinical harm, not due to an underlying disease or condition. Requires additional monitoring, intervention, and/or medical care...Reporting...Clinical staff to notify...Physician...Clinical Manager or facility designee...Clinical Manager or facility designee to notify...Director of Operations ...Regulatory... Documentation...Clinical staff will complete documentation in the...Patient medical record...Patient Safety Data Entry Site...Clinical Manager or facility designee will...submit Notice of Potential Professional/General Liability Claim Form if applicable...Review during Quality Assessment and Performance Improvement...Documentation...Documentation of all patient events shall be...factual, complete, timely, and concise...include patient assessment...interventions and result of interventions...any conversations with the patient that are relevant to the patient event should be documented...Documentation should include that the physician was notified...Category...Clinical Lab Management...Modality...HD (hemodialysis)/HHD (home hemodialysis)/PD (peritoneal dialysis) Event Description...Clinical LabManagement-Missed Lab...Definitions...a lab was missed and/or not drawn as ordered or at the required timing/frequency.” A review of the facility’s “Lab Results/Medication Administration Summary” Report dated 04/10/2024 was conducted. The report with a date range of 01/11/2024 to 04/10/2024 indicated HD Patients #2, #3, #4, #5, #6, #7, #11, #12, and #13 had missing albumins, calciums, hemoglobins, and/or Kt/V (A number used to quantify HD and PD adequacy.) results in January 2024, February 2024, and March 2024. There was no documented evidence that Adverse Event/Patient Safety Data reports for the missing, cancelled, or clotted labs. On 04/11/2024 at 11:40 AM, the Charge Nurse II (Personnel #13) said there was no documented evidence of Adverse Event/Patient Safety Data reports for the labs. She said it was the responsibility of the Charge Nurse to enter the report.”