Pnrs Tualatin

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. 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 all susceptible patients were offered vaccination against Hepatitis B. Findings: Review of the facility’s “Hepatitis B Summary Report,” created “11/12/2024,” that included documentation of Hepatitis B vaccination status of 60 patients revealed 12 of 18 patients who were determined as susceptible lacked documentation of receiving the vaccine series. Review of the facility policy titled, “Patient Vaccination for Hepatitis B,” dated “02/07/2022 ... Version: 5” stipulated “The Hepatitis B vaccine shall be offered to all susceptible patients including peritoneal and home dialysis patients.” The policy provided guidelines for offering vaccination series or booster doses. During review of the vaccine documentation with the Clinical Care RN on 11/12/2024 at 1335, they confirmed the above findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47148 Based on observation, interviews, and review of documentation it was determined that the facility failed to ensure that medications were prepared and stored correctly. Findings: Observation of the treatment floor and medication preparation areas on 11/12/2024 at 0920 revealed: - Two prefilled syringes labeled with a preprinted patient label indicating “Heparin” and one prefilled syringe labeled with a preprinted patient label indicating “Lidocaine” on the chairside of patient station #5. Each label on the syringes lacked the time and the preparer’s initials. - Two prefilled syringes labeled with a preprinted patient label indicating “Heparin” on the chairside of patient station #16. Each label on the syringes lacked the time and the preparer’s initials. - Two prefilled syringes labeled with a preprinted patient label indicating “Heparin” and two prefilled syringes labeled with a preprinted patient label indicating “Lidocaine” on the medication preparation area identified as “Pod 4.” Each label on the syringes lacked the time and the preparer’s initials. - A MDV of Lidocaine 1% was in the drawer of the isolation room. The vial lacked documentation of the date and time the vial was opened. During further observation of the treatment floor revealed two separate medication prep areas in unused patient care area with various vials of medication labeled as “Heparin” and “Lidocaine 1%” in unsecured drawers. Review of the facility policy titled, “Medication Preparation and Administration” dated “02/06/2023” stipulated, “All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of the patient, date, time and initials of the person who prepared the medication” ... “When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT must place the date and time the vial was opened on the medication label along with their initials” ... “All medications will be kept in a locked cabinet except when in use.” During an interview on with the DO and FA on 11/12/2024 at 1500, the above findings were confirmed.”

“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: 37237 Based on observation, and review of documentation, it was determined that the facility failed to ensure that the building was constructed and maintained to ensure the safety of the patients, staff and the public. Findings: Observation of the treatment floor on 11/12/2024 beginning at 0925 and 11/14/2024 beginning at 1225 revealed: - A box or Retacrit (an erythropoiesis-stimulating agent) vials expired on 10/31/2024. - When the sides of treatment chairs at stations 22 and 23 were opened, there was an accumulation of white stains on the inside of the chairs. - An oxygen concentration machine next to an unused patient chair with a used nasal cannula with 2L of oxygen flowing. Review of the facility policy, “Medication Preparation and Administration,” dated as 02/06/2023 stipulated in the “Monitoring Expired Medications” section that “Expiration dates for all stored medication are to be monitored on a monthly basis ... Expired medications are to be discarded via Fresenius Kidney Care off-site return program or in accordance with local and/or state law.””

“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 and interview, it was determined the facility failed to maintain the building in which dialysis services were provided was constructed and maintained to ensure the safety of the patients, the staff and the public. Findings: Observation of the treatment floor on 11/12/2024 beginning at 0925 and 11/14/2024 beginning at 1225 revealed areas that could not be effectively cleaned for infection control purposes: - Numerous areas of the linoleum-tiled floor was worn, stained, chipped, bubbled and cracked. - The vinyl baseboard in numerous areas of the treatment floor area was damaged and not secured between the floor and wall. In the pod area with treatment chairs 17 - 20, the baseboard was detaching from the wall and the wallboard underneath was crumbling. - An area of the side of the countertop on that same pod had exposed raw wood. - Areas of the walls throughout the facility were stained, with gouges, chipped paint and exposed drywall. - A metal wall plate between treatment chairs 22 and 23 had rust on and around the plate. - The laminate around many of the sinks was worn down and stained. - The connection of the metal fixture of an eyewash station had an accumulation of green precipitate. Observation of the facility on 11/12/2024 beginning at 0925 revealed cabinets in the medication room, at the nurses’ station and one of the sinks were broken, and potentially could fall off when opened. Multiple cabinet surfaces had scotch tape remnants stuck to the surface that could not be effectively cleaned for infection control purposes. The above findings were confirmed by the FA and DO on 11/14/2024 at approximately 1300.”

“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: 47148 Based on observation, document review and interview, it was determined that the facility failed to post a written notice of patients rights that included the correct contact information for the State Agency to whom patients can report complaints. Findings: Observation of the waiting room on 11/12/2024 at 0900 revealed a posted notice of patient rights. Review of the posted notice failed to reflect the correct name and address for the State Agency to which patients can report complaints. During an interview with the DO and FA, on 11/12/2024 at 1300, the above findings were confirmed.”

“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: 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 or that the dialysis prescription was followed for 5 of 6 patients (Patient #s 1, 3, 4, 5 and 6). Findings: Patient #1 Review of Patient #3’s dialysis orders and treatment sheets dated 10/12/2024 through 11/09/2024 (13 hemodialysis treatments) revealed: - The physician order for DFR was 600 mL/min. The treatment flowsheets reflected the DFR was set or changed by a PCT to a rate different than what was ordered. PCT documentation and RN evaluation did not note why the physician orders were not followed. For example: * On 10/29/2024 treatment was initiated at 0516. At 0516, the DFR was set to, and remained at, 800 mL/min by the PCT with no documentation to note why the physician order was not followed. * On 11/07/2024 treatment was initiated at 0606. At 0609, the DFR was set to, and remained at, 800 mL/min by the PCT with no documentation to note why the physician order was not followed. Patient #3 Review of Patient #3’s dialysis orders and treatment sheets dated 10/15/2024 through 11/09/2024 (12 hemodialysis treatments) revealed: - Vital signs and access checks were missed on two dates. * On 10/30/2024 VS were documented at 1130 and 62 minutes later at 1232. On 11/07/2024 VS were documented at 1303 and 67 minutes later at 1410. - The patient’s treatment time was prescribed as 4 hours. * On 10/19/2024 treatment was initiated at 1040 and terminated 2 hours and thirty-seven minutes later at 1317. The medical record lacked a signed AMA. * Similar findings were identified for 10/26/2024 and 11/05/2024. Patient #5 Review of Patient #5’s dialysis orders and treatment sheets dated 10/16/2024 through 11/11/2024 (12 hemodialysis treatments) revealed: - The physician order for BFR was 450 mL/min and the DFR was Autoflow 1.5. The treatment flowsheets reflected the BFR was set or changed by a PCT to a rate different than what was ordered. PCT documentation and RN evaluation did not note why the physician orders were not followed. For example: * On 10/17/2024 the BFR was set to 400 mL/min and the DFR was 0 when treatment was initiated at 1055 and remained at 400 mL/min and 0 for the rest of the treatment with no documentation to note why the physician order was not followed. * On 10/18/2024 treatment was initiated at 0635. At 0640, the BFR was set to, and remained at, 400 mL/min by the PCT with no documentation to note why the physician order was not followed. Similar findings were identified for treatment dates 10/16/2024, 10/21/2024, 10/3/2024, 10/28/2024, 10/30/2024, 11/04/2024, 11/06/2024 and 11/08/2024. - The patient’s treatment time was prescribed as 4 hours and 15 minutes. * On 10/17/2024 treatment was initiated at 0635 and terminated 3 hours and eight minutes later at 0959. The medical record lacked a signed AMA. * Similar findings were identified for 10/18/2024. - On 10/18/2024 the patient’s BP was recorded as 96 mmHg/47 mmHg at 0731. The next BP reading was recorded at 0803. There was no documentation that an RN was notified, or the BP was rechecked. Patient #6 Review of Patient #6’s dialysis orders and treatment sheets dated 10/15/2024 through 11/09/2024 (13 hemodialysis treatments) revealed: - The physician order for BFR was 400 mL/min. The treatment flowsheets reflected the DFR was set or changed by a PCT to a rate different than what was ordered. PCT documentation and RN evaluation did not note why the physician orders were not followed. For example: * On 10/19/2024 treatment was initiated at 0616. At 0620, the BFR was set to, and remained at, 350 mL/min by the PCT with no documentation to note why the physician order was not followed. * On 10/29/2024 treatment was initiated at 0618. At 0625, the BFR was set to, and remained at, 350 mL/min by the PCT with no documentation to note why the physician order was not followed. Review of facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” * “Document machine parameters and safety checks every 30 [min] or more often as needed but not to exceed 45 minutes or per state regulations.” * “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.” * “Record blood pressure ... Recheck blood pressures after a drop that requires interventions such as administering normal saline. Reposition electronic cuff or use a manual cuff for aberrant blood pressure reading. Report to the nurse ... Blood Pressure less than or equal to 100 mm/hg systolic During an interview on 11/14/2024 at 1130, the FA confirmed the above findings.”

“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: 37237 Based on interview and review of documentation, it was determined that the facility failed to offer the pneumococcal vaccine to patients based on assessment of status as required by facility policy for 22 of 60 patients (Patient #s 1, 3, 4, 6 and 7 - 24). Findings: Review of the “Pneumonia Vaccination Report,” printed on 11/11/2024 revealed 22 of 60 patients had “11/12/2024” entered in the “Next Due Date” column. The “Suggested Action(s)” column for all 22 patients advised administration of the appropriate pneumococcal vaccine product specific to each patient based upon age and current vaccination status per facility policy. Documentation failed to reflect that the vaccine had been offered to those patients. Examples included but are not limited to: * Patient #7 had documentation of receiving the PCV13 on 02/02/2017 and the PPSV23 on 03/09/2019. The “Suggested Action(s)” documentation for this patient advised “Admin PCV 20 as ordered on or after last dose 03/09/2024.” * Patient #8 had documentation of receiving PPSV23 on 06/05/2017 and PCV13 on 04/10/2017. The “Suggested Action(s)” documentation for this patient advised “Admin PCV 20 as ordered on or after 06/05/2022. Similar findings were identified for Patient #s 1, 3, 4, 6 and 9 - 24. Review of the facility policy titled, “Pneumococcal Vaccine for Adults,” dated “02/05/2024 Version: 6” stipulated, “Patients should receive vaccines based on the administration frequencies outlined below.” The policy provided guidelines for offering pneumococcal vaccines to patients based on age and vaccination history as recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices in September 2023. During review of the vaccine documentation with the Clinical Care RN on 11/12/2024 at 1335 they 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 of 6 of 6 patients’ plan of care (Patient #s 1 - 6) and review of documentation, it was determined that the facility failed to ensure that plans of care were signed by the patient and/or the patient’s designee or that a reason for refusal was documented. Findings: Review of medical records of Patient #3 included a 30-day Plan of Care dated 07/18/2024 and a 90-day Plan of Care dated 09/26/2024, both lacked the signature of the patient or patient’s designee. The plan of care also revealed that there was no documentation if the patient chose not to sign the plan of care or why the signature was not provided. The facility also failed to provide documentation that Patient #s 1 - 6 had been notified of the dates of their care plan conference. Similar findings were identified on the plans of care for Patient #s 1, 2, 4, 5 and 6. Review of the facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated as 07/03/2023 stipulated, “The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” During an interview with DO and FA on 11/14/2024 at 1130, the above findings were confirmed. Failure by the facility to ensure that patient or patient designee participated in the care plan meetings could result in a failure to design, implement, monitor and evaluate a treatment plan that could effectively meet the individualized care needs of the patient.”

“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 #3’s medical records revealed: - The document titled, “Clinical Notes Report” for the patient revealed nurse documentation dated 10/02/2024 at 0843 reflected “Pt unable to dialyze today d/t clotting needles x4 ...” - On the treatment sheet dated 10/18/2024 at 0922, a PCT documented, “tx cut by 38 mins due to system starting to clot no blood loss rn aware.” - On the treatment sheet dated 10/28/2024 at 0946, a PCT documented, “clotting in arterial chamber” and at 0958 a PCT documented, “Treatment interrupted ... tx cut by 15 mins due to system clotting no blood loss.” At 1221, an RN documented “Venous did alarm and a clot seen in venous chamber. Off early ...” Review of document titled “Adverse Event Report Report Start Date 10/28/2023 Report End Date: 10/28/2024” revealed that the report failed to reflect the incidents mentioned above. Review of the facility policy titled, “Patient Safety Event Reporting and Documentation” 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 as noted in this policy.” During an interview with the FA and DO on 11/16/2024 at 1300, they confirmed that events documented in the adverse report were the only incidents that were tracked, monitored and analyzed in QAI.”

“PQ-CHARGE NURSE-12 MO NURSING+3 MO DIALYSIS CFR(s): 494.140(b)(3)(i)-(ii) The charge nurse responsible for each shift must- (i) Be a registered nurse, a licensed practical nurse, or vocational nurse who meets the practice requirements in the State in which he or she is employed; (ii) Have at least 12 months experience in providing nursing care, including 3 months of experience in providing nursing care to patients on maintenance dialysis; This Standard is not met as evidenced by: 37237 Based on interviews, it was determined the facility failed to ensure a charge nurse was in place and responsible for nursing care during each shift. Findings: During interview with RN 1 on 11/13/2024 at 1330, they stated the facility did not have a regular charge nurse. During interview with RN 2 on 11/14/2024 at 1212, they stated the facility does not have a charge nurse. If they have a question for a charge nurse, they said they would call other RNs or the CN at a sister facility. During interview on 11/14/2024 at 1045 with the FA, they stated the facility had not had a CN on-site since June 2023. Review of the Charge Nurse Job Description, version 02/11/2019, stipulated: * “Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Provides day to day direction and supervision to assigned direct patient care staff. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Provides safe, effective delivery of patient care in compliance with standards outlined in the facility procedure manual, as well as regulations set forth by the company, state and federal agencies...” Duties outlined in the job description that require direct interactions with staff and patients: * “Coordinate Charge Nurse duties with Staff RNs acting in the relief charge capacity.” * “Assess daily patient care needs and develop and distribute patient care assignments appropriately.” * “Assume primary responsibility in an emergency situation.” * “Assess patient needs, respond to dialysis treatments, and communicate concerns to rounding physician.” * “Monitor and supervise all patient care activity during dialysis and assist as necessary.” * “Continuously monitor patient’s condition with regards to problems and potential complications associated with dialysis.””