Usrc Portland Dialysis

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 37237 Based on interview, review of medical records and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and VS monitoring was completed according to facility policy for 9 of 9 patients (Patient #s 1-9). The cumulative effect of the failure of staff to ensure patients were checked and visualized as required resulted in this condition-level deficiency that substantially limits the capacity of the facility to provide safe and adequate care. Findings: Refer to findings cited at Tag V503 under CfC §494.80(a)(2) - Standard: Appropriateness of Dialysis Prescription that stipulates the patient’s comprehensive assessment must include evaluation of the appropriateness of the dialysis prescription. * The facility failed to ensure staff followed facility policy to visualize patients and check vital signs every 30 minutes. * The facility failed to ensure patients’ dialysis prescriptions were followed as ordered by the MD.”

“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: 37237 Based on observation and interviews, it was determined that the facility failed to ensure a sanitary environment to minimize the transmission of infectious agents within the facility and other public areas. Findings: Observation of the facility on 08/20/2024 beginning at 0925 revealed: - A red biohazard bin and a biohazard sharps bin were placed under an accordion hook where PPE gowns and stethoscopes were hung. One gown was hanging so it covered the top of the biohazard sharps bin and was in contact with the second biohazard bin. - The treatment chair in station #8 had rips in the upholstery. - Areas that could not be cleaned for infection control purposes: * The RN station had multiple chips in the laminate and a section of edging laminate was peeling off the side of one of the cabinets. * Multiple areas throughout the treatment area had unfilled holes in the walls and chipped paint that exposed the drywall underneath. * One area on the treatment floor where the laminate chase countertop, wall and white wall protector came together had: A long hole at the wall corner next to the wall protector; A large round indentation that exposed the drywall all around the indentation; An area where the countertop failed to make contact with the wall and the exposed area was not sealed or caulked; The area above the counter backsplash was cracking; and The top of the corner guard was not sealed to the wall. * Two ceiling tiles failed to fit properly, creating two holes in the ceiling. One ceiling tile had an old water stain. The above observations were confirmed by the RN CC, FA of a sister facility and the ABM on 08/20/2024 at 1015 and 08/22/2024 at 1500.”

“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: 31224 Based on observation, interview and review of documentation, it was determined the facility failed to maintain a safe and functional treatment environment. Findings: Observations of the facility on 08/20/2024 starting at 0925 included: - 1 large, opened box of 15 g button hole AVF needle sets expired on 01/07/2024. - 1 opened box of BD brand butterfly needle sets expired on 01/31/2023. - 2 Starswab II Specimen Collection and Transport System kits expired on 08/19/2024. - 1 opened bottle of RPC brand E-Z Chek pH test strips expired on 05/31/2023. - An MDV of Tubersol (used for TB testing) lacked a BUD label. - Two opened vials of glucometer testing solutions expired on 08/17/2024 and also lacked BUD labels. - One of the eyewash station nozzles lacked a cover, the cap was hanging off to the side. - The drain in the lab dirty sink was surrounded by a rust-colored discoloration. The inside the cabinet under the sink was stained and contained a gallon jug of bleach. - On oxygen cylinder located in a storage room failed to be secured. Review of facility policy “Handling of Supply Inventory,” dated as last revised in “01/2020,” stipulated: * “Dispensing of supplies into the clinic area for utilization shall occur on a “first-in, first-out” basis.” * “All stock shall be rotated forward with incoming stock placed to the back of storage areas.” * The policy did not address reviewing inventory for expired items or disposing of expired items, if found. During interview on 08/20/2024 at 0940, an RN confirmed the expiration dates found above. During interview on 08/22/2024 at 1500, the RN CC confirmed the 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: 37237 Based on interview and review of documentation, it was determined that the facility failed to ensure equipment was maintained and operated in accordance with facility policies and manufacturer’s recommendations. Findings: Review of 11 of 11 “Oxygen Concentrator Filter Cleaning Log” sheets completed from 01/01/2024 through 08/20/2024 revealed weekly filter cleaning was missed for the weeks of 03/25/2024, 06/24/2024, 07/22/2024 and 08/05/2024. Further review of the “Oxygen Concentrator Filter Cleaning Log” sheet dated as last revised in 01/2020 revealed “Oxygen Concentrator Filter Maintenance (air intake gross particle filter will be cleaned weekly).” Review of the “Glucose Meter Control Test Record” log sheet dated as last revised in 02/2023 revealed staff failed to complete the section “Initials ... Print Name.” It could not be determined which staff completed the glucometer testing. The above findings were confirmed on 08/21/2024 at 1530 by the ABM, RN CC and FA of a sister facility.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 37237 Based on observation and interview, it was determined the facility failed to prominently display notices that included the current State Agency mailing address and telephone complaint number and a complete copy of patients’ rights and responsibilities that could be easily seen and read by patients. Findings: Observation of the facility lobby on 08/22/2024 at 1340 revealed the “Contact Information for Reporting a Grievance” notice, posted in a locked glass bulletin board, contained inaccurate information for complaints and grievances reported to the state agency. The contact information posted listed the wrong SA, that included an incorrect address and phone number. The patients’ rights documents displayed in the lobby were also located in the locked glass bulletin board. Only page 1 of 4 of the policies, “Patients Rights and Responsibilities,” was displayed for both the English and Spanish versions. A patient or patient representative would not be able to review the complete document. The above findings were confirmed by the RN CC and FA of a sister facility on 08/22/2024 at 1345.”

“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: 31224 37237 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring, dialysis treatment as ordered, or complete dialysis treatments for 9 of 9 patients (Patients #s 1 through 9). Findings: Patient #1 Review of Patient #1 dialysis orders and treatment flowsheets dated 07/02/2024 through 08/17/2024 (13 hemodialysis treatments) revealed: - Physician orders included a BFR of 400 mL/min and a dialysis duration of 240 min. - The BFR was changed without documentation to indicate why the physician orders were not followed in 5 of 13 treatments. - The dialysis treatment was not completed and the time was shortened by the patient in 4 of 13 treatments. - Staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes. The treatment flowsheet dated 07/09/2024 revealed the following: - The BFR was set to 350 mL/min by the PCT and verified by the RN without documentation of the rationale. - The treatment time was shortened by the patient to 200 min. The PCT documented the patient signed out AMA, but no signed AMA form was provided. - The patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented a VS and visualization of the patient at 1720. The next check was documented at 1837, 77 minutes later. The treatment flowsheet dated 07/16/2024 revealed: - The BFR was set to 200 mL/min by the PCT and verified by the RN. The BFR was changed during the treatment by the PCT and ranged from 200 to 350 mL/min. There was no documentation of the rationale or that the RN was notified of the changes. - A set of VS was taken at 1746. The next set of VS was taken at 1853, 67 minutes later. - Staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented a VS and visualization of the patient at 1718. The next check was documented at 1958, 160 minutes later. The treatment flowsheet dated 07/23/2024 revealed: - The BP at the start of treatment was 187/107. Elevated BPs were recorded five additional times and ranged from 182/103-190/109. There was no documentation to indicate the RN was notified of the elevated BPs. - Staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented a VS and visualization of the patient at 1810. The next check was documented at 1908, 58 minutes later. A PCT documented a VS and visualization of the patient at 2005. A RN documented the next check at 2101, 56 minutes later. - Similar findings were noted on 07/02/2024, 07/06/2024, 07/20/2024, 08/03/2024, 08/06/2024, 08/10/2024, 08/13/2024, and 08/17/2024. Patient #3 Review of Patient #3 dialysis orders and treatment flowsheets dated 07/20/2024 through 08/17/2024 (13 hemodialysis treatments) revealed: - Staff failed to ensure the patient met the prescribed target end weight for 13 of 13 treatments. *Review of the 13 treatment flowsheets revealed the patient’s target weight was prescribed as 80 kg. The patient was above the prescribed end weight during the 13 dialysis treatments reviewed. * Further review of the patient’s medical record revealed the only “Post Weight Variance” document between 08/17/2024 and 07/20/2024 was signed by an LVN on 07/20/2024. - For 13 of 13 treatments, staff failed to follow the prescribed “Special Instructions” that stipulated “ ... [Please] monitor BP every 15 mins.” - Staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes for 13 of 13 treatments. * On 08/17/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, documentation of BP checks failed to be completed every 15 minutes and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 1725. The next documentation was 62 minutes later at 1827 when a PCT documented “... Access visualized and no problems noted.” Staff documented next at 1953, 86 minutes later. * On 08/10/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, documentation of BP checks failed to be completed every 15 minutes and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 1722. The next documentation was 121 minutes later at 1923 when a PCT documented “... Access visualized and no problems noted.” * Similar findings were identified for treatment dates: 08/15/2024, 08/13/2024, 08/08/2024, 08/03/2024, 07/30/2024, 07/27/2024, 07/25/2024, 07/23/2024 and 07/20/2024. - The dialysis treatment was not completed and the time was shortened by the patient in 3 of 13 treatments. The prescribed treatment time was 210 minutes. * On 08/06/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, documentation of BP checks failed to be completed every 15 minutes and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 1745. The next documentation was 156 minutes later at 2021. The treatment was terminated at 2047. During the patient’s 185-minute treatment, staff checked and documented on the patient one time. In the “Post-Dialysis Comments” the RN wrote “Pt is not feeling well, requested cut tx early ...” There was no signed AMA form for early termination of treatment. * Similar findings were identified for 08/01/2024 and 07/30/2024. Patient #7 Review of Patient #7’s dialysis orders and treatment flowsheets dated 06/28/2024 through 08/09/2024 (12 hemodialysis treatments) revealed staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes for 12 of 12 treatments. - On 07/25/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 0648. The next documentation was 33 minutes later at 0721. when a PCT documented “... Access visualized and lines secure.” The next time staff documented was 223 minutes later at 1104 when a PCT documented “Treatment completed.” At 1117, 13 minutes after treatment was terminated, the PCT documented “Access visualized and lines secured.” The patient went 3 hours and 43 minutes without a staff person assessing the patient. - For 4 of 12 treatments, staff failed to follow the prescribed “Special Instructions” that stipulated “Do not add prime and rinse back ...” * On 08/09/2024 treatment was initiated at 0639. At 0648, the “IV Fluids/Meds” column indicated “Prime 250” and the LVN documented “Pre Dialysis.” * Similar findings were identified for treatment dates: 07/05/2024, 07/03/2024 and 07/01/2021. Patient #9 Review of Patient #9 dialysis orders and treatment flowsheets dated 07/24/2024 through 08/19/2024 (13 hemodialysis treatments) revealed staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes for 13 of 13 treatments. - On 08/19/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 0519. The next documentation was 76 minutes later at 0635 when a PCT documented “... Access visualized and lines secure.” - On 08/09/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 0514. The next documentation was 90 minutes later at 0644 when a PCT documented “... Access visualized and lines secure.” Staff documentation again 56 minutes later at 0740. - On 07/29/2024 the patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented treatment start time as 0520. The next documentation was 126 minutes later at 0726 when a PCT documented “... Access visualized and lines secure.” - Similar findings were identified for treatment dates: 08/16/2024, 08/14/2024, 08/12/2024, 08/07/2024, 08/15/2024, 08/02/2024, 07/31/2024, 07/26/2024, 07/25/2024 and 07/24/2024. Similar findings were noted for Patient #s 2, 4, 5, 6 and 8. Review of facility policy, “Intradialytic Monitoring of Patient,” dated as last revised 09/2020 revealed in the section “Patient” that: * “Vital signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters...” * “Ensure Patient’s Access, Blood Lines and Face are Visible At All Times... During every 30 minute monitoring, the access and visualization of the face must be observed.” Review of the facility policy, “Reportable Parameter to CN,” dated as last revised in 01/2020 stipulated that: * “PCT/CCHT/LPN: Report to Charge Nurse Pre-Dialysis ... B/P Systolic >200 or <90 Diastolic>110.” * “PCT/CCHT/LPN: Report to Charge Nurse Intra-Dialysis ... B/P Systolic >200 or <100 Diastolic>110.” * “PCT/CCHT/LPN: Report to Charge Nurse Post-Dialysis ... Weight >1 kg above or below EDW ... B/P Systolic >180 or <90 Diastolic >100.” Review of facility policy, “Against Medical Advice,” dated as last revised 01/2020 revealed the AMA form would be used for patients who “Refuse to complete prescribed treatment.” A specific amount of time the treatment was shortened by to require an AMA form was not included. During interview with FA of a sister facility and the RN CC on 08/21/2024 at 1530, the above findings were confirmed. The RN CC also reported an AMA form was required when the treatment time was shortened by greater than 15 minutes.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 31224 Based on interview, review of facility policy and review of clinical vaccine records, it was determined the facility failed to implement facility policy that ensured pneumococcal vaccines were offered per CDC recommendations to qualifying patients for 7 of 90 patients reviewed (Patient #s 9-15) or reassess a patient’s refusal of receiving a vaccine as a part of the comprehensive assessment for 11 of 90 patients reviewed (Patient #s 16-26). Findings: 1. Review of the facility’s immunization tracking spreadsheet printed on 08/20/2024 revealed the pneumococcal vaccination status for 90 patients on the facility census. The report revealed the following: * The order of pneumococcal vaccine administration did not follow facility policy or CDC recommendations. - Patient #9 received the PPSV23 vaccine on 03/11/2022. A dose of PCV13 was administered over one year later on 08/11/2023. - Patient #10 received the PPSV23 vaccine on 09/22/2020. A dose of PCV13 was administered on 12/17/2022. - Similar findings were noted for Patient #s 11-13. * Patients who were identified to receive a pneumococcal vaccine did not receive it in a timely manner. - Patient #14 received the previous dose of PPSV23 on 01/30/2019 and was eligible to receive the next dose as of 01/30/2024, but had not yet received it. - Patient #15 received the previous dose of PPSV23 on 04/16/2019 and was eligible to receive the next dose as of 04/16/2024, but had not yet received it. 2. Further review of the facility’s immunization tracking spreadsheet printed on 08/20/2024 revealed Patient #s 16-26 each had a documented history of refusing one or more vaccines, but their willingness to receive the vaccine was not reassessed and they were not offered the vaccine again. For example: * Patient #16 had refused to receive the pneumococcal vaccine on 01/31/2022. There was no documentation to show their willingness to receive the vaccine was reassessed and they were not offered the vaccine again. * Patient #20 had refused to receive the hepatitis and pneumococcal vaccines on 05/11/2023. Their willingness to receive the vaccine was not reassessed and they were not offered the vaccine again. * Similar findings were noted for Patient #s 17-19 and 21-26. 3. Review of facility policy titled, “Pneumococcal Vaccination”, dated as last revised in 11/2022, stipulated: * “Prevnar 20 (PCV20) is the preferred pneumococcal vaccine.” * “Pneumovax23 (PPSV23) vaccine may still be appropriate in certain circumstances.” * For adults greater than 19 years old with a history of receiving 1 or 2 doses of PPSV23, “Administer one dose of PCV20 at least 1 year after the last dose of PPSV23 and then vaccinations are complete.” * The policy did not address reassessment of a patient’s willingness to receive a pneumococcal vaccine. 4. Review of facility policy titled, “Patient Hepatitis B Testing/Vaccination/Seroconversion”, dated as last revised in 11/2022, did not address reassessment of a patient’s willingness to receive the hepatitis B vaccines. 5. Review of facility policy titled, “Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)”, dated as last revised in 04/2024, stipulated: * On Page 1: “The CIPA/POC will address, but not limited to, each of the 10 criteria listed below:” followed by a list of criteria that did not include medication or vaccination history. * Page 5 included a “CORRELATION GRID FOR CIPA AND POC” that identified “V506 Medication/immunization history” as a component of the CIPA/POC. 6. The CDC recommended pneumococcal vaccination for adults with chronic renal failure. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf The recommended pneumococcal vaccine timing for adults over 19 years old with chronic renal failure who have a history of receiving only the PPSV23 vaccine at any age was to administer either the PCV20 or PCV15 at least one year after the last dose of PPSV23. The PCV13 vaccine was not recommended as a follow up vaccine in any situation. During interview on 08/21/2024 at 1530, the RN CC stated there was no written policy to address reevaluation of a patient’s willingness to receive a vaccine and confirmed the above findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37237 Based on interview, review patient medical records and review of documentation, it was determined that the facility failed to ensure that 2 of 9 patients’ plan of care (Patient #s 7 and 9) was signed by the patient or patient’s designee. Findings: Review of Patient #9’s medical record reveal a Plan of Care dated 07/23/2024. The POC was approved by the MD, RN, MSW and RD on 07/23/2024. Review of the document, “Invitation: Plan of Care Meeting” revealed that on 07/03/2024, staff “Reviewed chairside” the POC meeting date and time with the patient. The box for “I will not be able to attend the Interdisciplinary Team meeting, but will review the plan of care when completed” was checked. The facility failed to present documentation that the POC was reviewed with the patient or patient representative. - Similar findings were identified for Patient #7. On 08/22/2024 at 1345, during interview with FA of a sister facility and the RN CC, they stated that the “Patient Acknowledgement Form-Plan of Care” is the signature sheet for the patient’s chosen level of participation in the care plan meeting. They confirmed there was no “Patient Acknowledgement Form-Plan of Care” attached to Patient #7’s and Patient #9’s plan of care and could not verify that the care plan was reviewed with patient.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 31224 Based on interviews and the review of patient medical records, it was determined that the facility failed to maintain a complete, accurate and accessible medical record for all patients. Findings: Patient 1 Review of the medical record for Patient #1 revealed the patient shortened the duration of the dialysis treatment for 4 of 13 treatments. - Treatment flowsheet dated 07/06/2024 revealed the physician order was for a treatment duration of 240 minutes. A RN documented “Patient Requested Sign-Off” after completing 212 minutes of treatment. An AMA form signed by the patient was not located. - Similar findings were noted on 07/09/2024, 08/06/2024, and 08/10/2024. Patient 5 Review of the medical record for Patient #5 revealed there was no H&P. Review of the medical record for Patient #9 revealed the last annual H&P was dated 06/13/2023. Review of facility policy “Against Medical Advice,” dated as last revised in 01/2020, stipulated, “The AMA form will be maintained in the patient’s medical record.” Review of facility policy “Medical Records,” dated as last revised in 02/2024, stipulated the contents of an active record would include, “History and Physical (H&P): a. Initial H&P... b. Current H&P ... Oregon require[s] a H&P on admission and at least annually.” During interview on 08/21/2024 at 1530 and 08/22/2024 at 1500, the RN CC confirmed the above findings.”