Qualicenters - Eugene-Springfield Ltd

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined that the facility failed to ensure the emergency preparedness program communication plan included a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Findings: Review of the facility’s “Annual Notification Requirement - Local Emergency Operations Center,” dated 09/15/2022 and addressed to the “Emergency Manager, City of Springfield” revealed the the facility failed to provide a timely update to the local Emergency Manager of the city of Springfield. During interview with the FA on 01/09/2024 at approximately 1330, they confirmed the above findings.”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on observation, interview, review of personnel files and review of documentation, it was determined the facility failed to ensure: 1. Quarterly fire drills for staff had been completed in the last 12 months. 2. The facility’s emergency evacuation kit contained updated staff and patient contact information. 3. The emergency cart was secured and contained the required emergency medications. 4. 3 of 25 staff (Staff #s 7, 11 and 24) received annual emergency preparedness training. Findings: 1. The facility lacked fire drill documentation for Q2, Q3 and Q4 of 2023. * The facility presented documentation for a fire drill for 3 shifts on Wednesday, 01/18/2023. They failed to provide documentation for a fire drill for the TTS shifts of patients. * The facility failed to provide documentation for a fire drill during Q2. * The facility failed to provide documentation they participated in a facility-wide fire drill during Q3. The only documentation presented was the individual patient fire drill forms dated 07/07/2023 and 07/08/2023. * Similar findings for fire drill documentation for 10/18/2023 and 10/19/2023. The facility failed to provide documentation they participated in a facility-wide fire drill. * During interview with the FA, DO and ATL on 01/10/2023 at 1000, the above findings were confirmed. 2. Observation of the facility treatment area on 01/08/2024 at 1130 revealed the emergency evacuation kit lacked up-to-date staff and patient contact information. The patient contact and medication information in both the evacuation cart and the emergency binder was dated 04/23/2023. * During interview with the FA, DO and ATL on 01/10/2023 at 1000, the above findings were confirmed. 3. Observation of the facility treatment area on 01/08/2024 at 1130 revealed the emergency code cart was unsecured and lacked emergency medications. * Medications could not be secured in the emergency code cart since there was no way to attach a breakable lock. The following emergency medications were stored in a bin in the CN’s office: 2 vials 10% Calcium Chloride 100 mg/mL (used for cardiac arrest), 1 vial Solu-Medrol 125 mg per vial (used for allergic reactions), 4 vials Adrenalin 1 mg/mL (used for allergic reactions) and 2 vials Diphenhydramine 50 mg/mL (used for allergic reactions). During interview with the CN on 01/09/2024 at approximately 1420, they stated that the Medical Director had planned to discontinue any emergency medications to be kept in the emergency cart due to staff not comfortable with the training and use of anaphylaxis medications. During interview with staff working on the treatment floor on 01/09/2024 at 1255, they stated that the Medical Director was to eliminate any emergency medications for the emergency cart. They stated the staff felt unprepared to administer the emergency medications. 4. The following staff members failed to have up-to-date annual emergency disaster training: * Staff #7, identified as an RN with a DOH of 08/24/2020, last completed “Emergency Preparedness Annual” training on 09/02/2022. * Staff #11, identified as a PCT with a DOH of 11/04/2019, last completed “Emergency Preparedness Annual” training on 01/02/2023. * Staff #24, identified as a RD with a DOH of 10/05/1992, lacked a completion date for Emergency Preparedness Annual” training. * During interview with the FA on 01/10/2024 at 1000, they confirmed some staff had not completed the annual emergency preparedness during the last 12 months. Review of the facility policy “Emergency Medications, Equipment and Supplies,” dated as 05/01/2023 stipulated the following: - In the Emergency Cart section: “The emergency cart must be: Locked when not in use.” - In the Emergency Evacuation Boxes section: “An emergency evacuation box must ... Be available to grab in case of fire or the immediate need to evacuate the clinic ... Contain all patient and staff emergency contact information ...” - In the Organizing Emergency Medications section: “Medications should be organized to meet the needs for specific emergency situations. For example ... Cardiac arrest medications should be grouped together in code cart ... Mediations to treat allergic reactions and hypoglycemia should also be maintained at the medication prep area ...” - In the Emergency Medications section: “The Pharmacy and Therapeutics Committee and the Medical Advisory Board identified a reasonable selection of medications to manage emergency situations such as allergic reactions, hypoglycemia, and cardiac arrest pending arrival of EMS when the physician is present or under the direct order of the physician. These medications and recommended quantities must be maintained at the dialysis facility. Any requests by the Governing Body to modify the minimum required medications must be approved by the FKC Corporate Medical Office ...” The policy included a table of the required medications, the situational use of the medications and the quantity of the medications to have on hand. The facility lacked some of the medications, lacked the required quantities of the some of the medications and/or the medications were not immediately available: - Cardiac Arrest * “Calcium Chloride 10% 10 mL prefilled syringe or vial.” The medication was stored in the CN’s office and not readily available. * “Sodium Bicarbonate 8.4% 50 mL prefilled syringe OR Sodium Bicarbonate 50 mL vial plus syringe.” The policy required 2, none were available; - Allergic Reaction * “Diphenhydramine 50 mg pre-filled syringe OR Diphenhydramine 50 mg vial plus syringe.” The medication was stored in the CN’s office and not readily available. * “Epinephrine (Adrenalin) 1:1000.” The medication was stored in the CN’s office and not readily available. * “Solu-Medrol 125 mg vial OR SoluCortef 100 mg vial.” One vial was available in the medication area and one was stored in the CN’s office and not readily available. * The only hypoglycemia medication available was Glucose gel. - Overdose * “Naloxone 0.4 mg vial.” The policy required 1. None were available.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined the facility failed to participate in an exercise of choice (a table-top exercise or workshop) drill to test the emergency plan at least annually per facility policy. Findings: Review of the facility’s EP binder revealed it lacked documentation that the facility participated in a table-top exercise or workshop during the last 12 months. During interview with the FA on 01/09/2024 at 1045, they confirmed the facility failed to participate in a table-top exercise or workshop during the past 12 months.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 47148 Based on observation and interview, it was determined the facility failed to maintain a safe treatment environment by failing to ensure that expired medications and supplies were not available for use and that medications were labeled as required. Findings: Observation of the facility treatment area on 01/08/2024 beginning at 1130 revealed: - 100 2.7 mL lab tubes with an expiration date of “2023-12-31.” - 2 6 mL lab tubes with an expiration date of “2023-11-08.” - 1 3.5 mL lab tube with an expiration date of “2023-11-30.” - 5 4.5 mL lab tubes with an expiration date of “2023-12-31.” - 1 5 mL lab tube with an expiration date of “2023-12-31.” - One bottle of “Blood Leak Test Strips” with an expiration date of “2023-12-31.” - 4 30 mL MDVs of “Heparin Sodium Injection” lacked a date, time and the initials of the person who opened them. - An opened vial of “Xylocaine 1%” (a local anesthetic) with a hand-written BUD of “9/10/2023” was available for use. - 1 bottle of “Minncare HD Residual Test Strips” with an expiration date of “2023-10-18” was in use in the water room. “3/8/23” was hand-written on the bottle. One other bottle of the test strips with the same expiration date was as available for use. - 7 bottles of “Residual Chlorine Reagent Strips” lacked a date, time and the initials of the person who opened them. During an interview with the FA and ATL on 01/08/2024 at 1530, the above findings were confirmed.”

“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: 37237 Based on observation, interview and review of facility policies and procedures, it was determined the facility failed to ensure the building was maintained to ensure the safety of patients, staff and the public. Findings: Observations of the treatment area on 01/08/2024 beginning at 1130 and 01/10/2024 beginning at 0900 revealed: - Multiple areas of the wood and laminate nurses’ stations were scratched, gouged, chipped, peeling and had old pieces of scotch tape stuck on. The areas could not be effectively cleaned for infection control purposes. - There were areas of the floor in the treatment area where the seams failed to come together, leaving large gaps between the flooring pieces and areas where the laminate was gouged out. While on-site, the biomed taped over the worst of the gapped areas. - Multiple sinks throughout the treatment floor were stained with a white film. Many of the sinks also had an accumulation of white precipitate built up in the sink and around the faucets. The laminate around the sinks also was stained with a white film that could not be cleaned. - The privacy screens, used to provide patient privacy during treatments, contained rips and tears in the plastic panels and the aluminum supports were covered in multiple areas with layers of tape. With the ripped and torn sheeting, patient privacy could not be guaranteed and the plastic panels could not be effectively cleaned for infection control purposes. * During interview with staff on 01/10/2024 at approximately 0900, they stated that there was tape on the privacy screen frames to hold two or more together. They also stated there was a patient that consistently requested the use of the privacy screens in order to urinate during treatment without being disconnected. Staff also mentioned that when a patient coded recently, the privacy screens failed to effectively shield the patient from onlookers. - Areas in the wood and laminate in the lobby had scratches and nicks, exposing the substrate underneath. These areas could not be cleaned effectively for infection control purposes. - The door between the treatment area and the hall leading to offices remained propped open during the first survey day and the beginning of day two of the survey. Review of the facility policy, “Physical Security and Facility Access,” dated 09/05/2023 stipulated “All secondary external entrances (employee entrance doors, deliver doors) to the facility are to kept closed and locked when not in use while still allowing emergency egress.” During interview with the FA, ATL and CN on 01/10/2024 at 1030, the above findings were confirmed. Failure to maintain surface integrity could result in ineffective cleaning and the potential for cross-contamination from microbial growth on porous surfaces.”

“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: 47148 Based on review of documentation and review of patients’ medical records, it was determined the facility failed to ensure that patients received hemodialysis treatments as prescribed for 6 of 9 patients (Patient #s 1, 3, 4, 6, 8 and 9). Findings: 1. Review of Patient #1’s treatment flowsheets dated 12/09/2023 through 01/06/2024 (13 hemodialysis treatments) revealed: - The 12/05/2023 treatment flowsheet reflected the PCT documented the patient’s systolic BP dropped from 110 mmHg at 1426 to 80 mmHg at 1432 with no documentation to show the RN was notified or there was an RN follow-up to assess patient condition. - The 12/11/2023 treatment flowsheet reflected the PCT documented the patient’s BP increased from 137/56 mmHg at 1259 to 229/204 mmHg at 1322 then decreased to 129/60 mmHg at 1347 with no documentation to show the RN was notified or there was an RN follow-up to assess patient condition. 2. Review of Patient #3’s treatment flowsheets dated 12/13/2023 through 01/06/2024 (13 hemodialysis treatments) revealed: - The 12/13/2023 treatment sheet reflected orders for Heparin that included “Heparin Pump Off Time: 60 minutes.” At 1135, a PCT documented “Treatment discontinued without problem” and the Heparin “Stop Date/Time” at “12/13/2023 11:36.” Documentation failed to reflect a reason the treatment was not given as prescribed. *Similar findings on treatment sheets dated 12/21/2023 and 12/27/2023. - The 12/13/2023 treatment flowsheet reflected the hemodialysis order included “BFR: 450.” At 0735, the PCT documented a BFR of “350” where it remained for the remainder of the treatment with no documentation to show the RN was notified or the RN followed-up to evaluate whether this change was appropriate. - The 12/16/2023 treatment flowsheet reflected the PCT documented the patient’s systolic BP dropped from 138 mmHg at 0701 to 108 mmHg at 0742 with no documentation to show the RN was notified or there was an RN follow-up to assess patient condition. 3. Review of Patient #4’s treatment flowsheets dated 12/9/2023 through 01/06/2024 (13 hemodialysis treatments) revealed: - The 12/21/2023 treatment flowsheet reflected the hemodialysis order included “BFR: 400.” At 1059, the PCT documented a BFR of “350.” At 1305, an LPN documented a BFR of “325” where it remained for the remainder of the treatment with no documentation to show the RN was notified or the RN followed-up to evaluate whether this change was appropriate. * Similar findings on treatment flowsheets dated 12/21/2023, 12/26/2023, 12/30/2023, 01/04/2024 and 01/06/2024. 4. Review of Patient #6’s treatment flowsheets dated 12/06/2023 through 01/05/2024 revealed: - The 12/13/2023 treatment flowsheet reflected the hemodialysis order included “BFR: 450.” At 0735, the PCT documented a BFR of “350” where it remained for the remainder of the treatment with no documentation to show the RN was notified or the RN followed-up to evaluate whether this change was appropriate. 5. Review of Patient #8’s treatment flowsheets dated 12/09/2023 through 01/06/2024 (13 hemodialysis treatments) revealed: - The 12/14/2023 treatment flowsheet reflected orders for Heparin that included “Heparin Pump Off Time: 60 minutes.” At 1000, a PCT documented “Treatment discontinued without problem” and the Heparin “Stop Date/Time” at “12/28/2023 1009.” Documentation failed to reflect a reason the treatment was not given as prescribed. *Similar findings on treatment sheet dated 12/28/2023. -The 01/06/2024 treatment flowsheet revealed the patients BP was 200/179 at 0517 with no documentation to show the RN was notified or there was an RN follow-up to assess patient condition. 6. Review of Patient #9’s treatment sheets dated 09/28/2023 through 01/05/2024 (13 hemodialysis treatments) revealed: -The 09/28/2023 treatment flowsheet reflected orders for Heparin that included “Heparin Pump Off Time: 60 minutes.” At 1647, a PCT documented “Treatment discontinued without problem” and the Heparin “Stop Date/Time” at “09/28/2023 1650.” Documentation failed to reflect a reason the treatment was not given as prescribed. *Similar findings on treatment flowsheets dated 10/10/2023, 10/17/2023, 11/04/2023, 11/28/2023, 12/09/2023 and 12/23/2023. - The 11/28/2023 treatment flowsheet reflected the PCT documented the patient’s BP decreased from 153/65 mmHg at 1504 to 85/21 mmHg at 1547 with no documentation to show the RN was notified or there was an RN follow-up to assess patient condition. Review of facility policy titled “Patient Assessment and Monitoring,” version 4 dated 05/01/2023, stipulated “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg ... Diastolic blood pressure greater than 100 mm/Hg ... Blood Pressure less than or equal to 100 mm/hg systolic ...” Further review of the policy revealed, “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow ... Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ... If heparin pump is used, ensure heparin is infusing at prescribed rate.” During an interview with the FA and ATL on 01/09/2024 at 1600, the above findings were confirmed.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 47148 Based on interview, review of medical records and review of documentation, it was determined that the facility failed to ensure the QAPI program was effective in identifying medical injuries and medical errors. Findings: Review of Patient #1’s medical records revealed nurse documentation dated 12/18/2023 at 1649, “pt sent to ER for bleeding post tx from arterial site transferred after 1:30. MD notified by teams.” Further review of the corresponding treatment sheet reflected the “Nursing Evaluation” dated “12/18/2023” at 1631, “pt d/c to ER for post arterial bleeding.” Review of the facility’s “Adverse Events Report” dated “01/08/2024” revealed documented events between 01/14/2023 through 01/08/2024 which failed to include the above mentioned adverse event for patient #1. Review of the facility’s policy “Patient Safety Event Reporting and Documentation” version 2 dated “02/06/2023” stipulated, “When a Near Miss, Safety Event or Serious Safety Event occurs, staff are required to report, document and review the event ...” The policy further defines “Safety Event” as “... results in mild to moderate patient clinical harm ... Requires additional monitoring, intervention, and/or medical care ...” It states, “Clinical staff will complete documentation in the: Patient Safety Data Entry Site” and defines “Blood Loss - Vascular Access ... Blood loss that occurs at any time from the patient’s dialysis access ... bleeding of cannulation sites ... or prolonged bleeding post treatment.” Review of Patient #5’s medical records revealed nurse documentation dated 12/07/2023 at 0741, “Tx r/s due to difficulty with cannulation, swelling mild infiltration.” Documentation by a nurse on 12/09/2023 at 1250 reflected, “Pt came in for a rescheduled tx today d/t infiltration yesterday. Upon assessment ... unable to cannulate d/t pain and swelling, redness and hematoma noted. warm and firm to touch ...” Review of the facility’s “Adverse Events Report” dated “01/08/2024” revealed documented events between 01/14/2023 through 01/08/2024 which failed to include the above mentioned adverse event for patient #5. During an interview with the FA and ATL on 01/10/2024 at 1000, the above findings were confirmed.”

“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: 37237 Based on interview and review of documentation, it was determined the facility failed to ensure that 9 of 25 staff (Staff #s 1, 5, 7, 11, 14, 16, 18, 20 and 24) had the qualifications and demonstrated competencies to meet the comprehensive care needs of the patients. Findings: The review of documentation included the “ESRD Survey Worksheet: Personnel Review” completed by the Facility Administrator on 01/11/2024 revealed: * Staff #1- Identified as an LPN with a DOH of 09/09/2019, last completed “Competencies and Skills” training on 07/12/2022 and “H20 Dialysate Training” on 08/05/2022. Both trainings are annual trainings. * Staff #5 - Identified as a PCT with a DOH of 06/28/2010, last completed “H2O Dialysate Training” on 03/26/2022. * Staff #7 - Identified as an RN with a DOH of 08/24/2020, last completed “Competencies and Skills” training on 11/18/2022, “Infection Control” training on 10/18/2022 and “Emergency Preparedness Annual” training on 09/02/2022. All trainings are annual trainings. * Staff #11 - Identified as a PCT with a DOH of 11/04/2019, last completed “Competencies and Skills” training on 06/06/2022 and “Emergency Preparedness Annual” training on 01/02/2023. Both trainings are annual trainings. * Staff #14 - Identifed as an LPN with a DOH of 03/27/2017, last completed “Competencies and Skills” training on 10/04/2022. * Staff #16 - Identifed as a PCT with a DOH of 11/01/2021, last completed “Competencies and Skills” training on 02/02/2022. * Staff #18 - Identifedas a PCT with a DOH of 11/07/2016, last completed “Competencies and Skills” training on 07/06/2022. * Staff #20 - Identifed as a PCT with a DOH of 11/16/2018, last completed “Competencies and Skills” training on 09/01/2022. * Staff #24 - Identifed as a RD with a DOH of 10/05/1992, lacked completion dates for “Infection Control Training” and Emergency Preparedness Annual” training. The FA confirmed the above findings on 01/10/2024 at 1030.”