Fkc Easton

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 36372 Based on review of facility policy/procedure, observations, and an interview with the facility Clinical Nurse Manager, the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for one (1) of two (2) ‘Discontinuation of Dialysis and Post Dialysis Care for AV Fistula or Graft’ observations (Observation#2) Findings include: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. Policy ‘Clinical Services’ Termination of Treatment Using Arteriovenous Fistula or Graft and Optiflux Single Use Ebeam Dialyzer’ (Setting: IC. IPS) Termination: Disconnecting the Patient’ step (3) states “Disconnect the bloodlines from the needle lines and remove the needles according to the Post Treatment Needle Removal Procedure’. Policy ‘Clinical Services’ ‘Post Treatment Fistula Needle Removal’ (Setting: IC. HT, IPS) ‘Procedure’ section (2) states “Person removing needles perform hand hygiene and don clean gloves.” Observations conducted in the patient treatment area on July 16, 2024 between approximately 8:20 a.m. and 12:15 p.m. and on July 17, 2024 between approximately 11:00 a.m. and 11:30 a.m, revealed the following: Observation #2: During observation #2 of 2 of ‘Discontinuation of Dialysis and Post Dialysis Care for AV Fistula or Graft’ on 07/16/24 at approximately 9:20 a.m., of patient #7, Employee #12 at station #4 did not perform hand hygiene/don clean gloves after reinfusing the extracorporeal circuit/disconnecting the bloodlines and before removing the needles. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. confirmed the above findings.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Clinical Nurse Manager, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for one (1) of two (2) ‘Central Venous Catheter (CVC) Exit Site Care’ and ‘Initiation of Dialysis with Central Venous Catheter’ observations (Observation #2). Findings: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. Policy ‘Central Venous Catheter (CVC) Dressing Change’ (Setting: IPS) ‘Purpose’ states “The purpose of this procedure is to ....... and maintaining a protective barrier to prevent infection.” ‘Removal of Dressing and Inspection of Site’ ‘Follow the steps below to remove a catheter dressing and inspect the exit site before initiation of treatment: ...Step (5) “Inspect and remove the old dressing. ...” ...... ‘Applying the dressing’ Step (1) ....Apply the catheter dressing over the dry exit site, .... Policy ‘Initiation of Treatment using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer’ (Setting: IC, IPS) ‘Preparing the Catheter: Dressing Change’ “..... dressing replacement must be completed prior to accessing the bloodstream. ....” ‘Prior to Initiation: Assessment and Machine Parameters’ Step (1) “Perform hand hygiene and donn full PPE.” ....Step (9) “....perform hand hygiene then donn new gloves.” ‘Preparing the Catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heparin Administration’ step (1) states “Check to make sure catheter clamps are closed. Step (2) states “Remove cap from clamped arterial limb.” Step (3) states “Using a sterile alcohol pad .....” Observations conducted in the patient treatment area on July 16, 2024 between approximately 8:20 a.m. and 12:15 p.m. and on July 17, 2024 between approximately 11:00 a.m. and 11:30 a.m, revealed the following: Observation #2: On 07/16/24 at approximately 9:00 a.m. while observing ‘Central Venous Catheter Exit Site Care’ observation #2, for patient #2, station #1; employee #7 left the CVC site exposed and began ‘Initiation of Dialysis with Central Venous Catheter’. After completing the initiation steps and connecting sterile syringes to each port, employee #7 then applied a sterile dressing to the CVC exit site. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. 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: 36372 Based on a review of facility policy/procedure, manufacturers directions for use, and an interview with the facility Clinical Nurse Manager, facility failed to ensure home therapy dialysis machines were maintained per the manufacturers directions for use for six (6) of six (6) dialysis machine (DM) maintenance documentation records reviewed (DM#1- DM#6). Findings: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. ‘NxStage Machine: Operational Preparation’ (Setting: IC, HT) Policy’ states “ The NxStage machine will be operated according to the appropriate NxStage Users Guide and if indicated, the Pure Flow Users Guide and Express Warmer Users Guide.” A review was conducted of the dialysis machine manufacturers ‘NxStage Pureflow SL User Guide’ on July 18, 2024 at approximately 10:30 a.m. ‘Item’ ’’Air Filter’ Maintenance Schedule’ states “Clean or replace every three months. It might require more frequent cleaning depending on environmental conditions.” Maintenance documentation was requested from the facility home therapy nurse (employee #13) on 07/18/24 at approximately 9:30 a.m. Employee #13 could not produce documentation to show the dialysis machine air filters were maintained according to the manufacturers directions for use. The following machines are currently in use by home therapy patients: DM#1: This NxStage dialysis machine (serial #51326) is currently utilized by patient #8 (started home therapy 07/05/23). No documentation provided of the machine air filter being cleaned or replaced every three months. DM#2: This NxStage dialysis machine (serial #37593) is currently utilized by patient #9 (started home therapy 09/11/23). No documentation provided of the machine air filter being cleaned or replaced every three months. DM#3: This NxStage dialysis machine (serial #41088) is currently utilized by patient #10 (started home therapy 07/17/23). No documentation provided of the machine air filter being cleaned or replaced every three months. DM#4: This NxStage dialysis machine (serial #45997) is currently utilized by patient #11 (started home therapy 07/05/23). No documentation provided of the machine air filter being cleaned or replaced every three months. DM#5: This NxStage dialysis machine (serial #55271) is currently utilized by patient #4 (started home therapy 05/22/23). No documentation provided of the machine air filter being cleaned or replaced every three months. DM#6: This NxStage dialysis machine (serial #6250) is currently utilized by patient #12 (started home therapy 08/01/23). No documentation provided of the machine air filter being cleaned or replaced every three months. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. and email correspondence with the facility Administrator on July 19, 2024 at approximately 10:35 a.m. confirmed the above findings.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Clinical Nurse Manager, the facility failed to ensure that the staff performed proper aseptic technique while initiating treatment for one (1) of two (2) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ observations (Observation #2). Findings include: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. Policy ‘Clinical Services’ ‘Access Assessment and Cannulation’ ‘Assessment of Vascular Assess’ (Setting: IC, HT) ‘Assessment of Vascular Access’ Step (1) states “Prior to treatment, ask patient to wash area with soap per hand hygiene procedure. Wash access (per above) if patients unable to clean their access.” Observations conducted in the patient treatment area on July 16, 2024 between approximately 8:20 a.m. and 12:15 p.m. and on July 17, 2024 between approximately 11:00 a.m. and 11:30 a.m, revealed the following: Observation #2: On 07/17/23 at approximately 11:00 a.m., patient #6 at station #9, employee #8 began to initiate dialysis treatment. Employee #8 did not wash skin over access with soap and water or antibacterial scrub, prior to evaluating access site, nor verbally confirm that the patient had cleansed the access site. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, employee files, medical records, and an interview with facility Clinical Nurse Manager, it was determined the facility failed to ensure TB (tuberculosis) screening was conducted according to facility policy for one (1) of three (3) employee files (EF) reviewed (EF#4) and failed to ensure TB (tuberculosis) screening was conducted according to facility policy for three (3) of five (5) medical records (MR) reviewed (MR#1, MR#3, MR#5). Findings include: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. Policy ‘Employee Tuberculosis Testing’ (Setting:IC, HT, IPS) ‘New Hire Screening Policy’ states “ TB testing using the two step tuberculin skin test (TST) method is required upon hire. .........” A review of employee files was completed on July 17, 2024 at approximately 11:40 a.m. Employees date of hire is listed below. EF#4 Date of hire 07/25/22: Documentation provided of first TST administered late on 04/03/24. No documentation of second step TST being administered. Policy ‘Patient Tuberculosis Testing’ (Setting: IC, HT) ‘New Admission Screening’ states “ .... On admission, review the medical records of each patient to determine if they have received TB testing within the last year. ...... Patients who have no documented TB test within the last year will be tested using the TST. ...” A review of medical records was completed on July 18, 2024 at approximately 1:15 p.m. Patients date of admit is listed below. MR#1, date of admit 04/19/24: No documentation provided of a TB test (TST) being conducted upon admit. MR#3, date of admit 02/02/22: Documentation provided of a TB test (TST) being conducted late on 03/02/24. MR#5, date of admit 03/25/24: Documentation provided of a TB test (TST) being conducted late on 04/30/24. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. confirmed the above findings.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, medical records, and an interview with facility Clinical Nurse Manager, it was determined the facility failed to ensure documentation of conductivity of dialysate solution prior to patient treatment for two (2) of three (3) incenter hemodialysis patient medical records (MR) reviewed (MR#2, MR#3). Findings include: A review was conducted of facility policy/procedure on July 18, 2024 at approximately 1:15 p.m. Policy ‘Checking Conductivity and pH of Final Dialysate’ ‘Purpose’ “The purpose of this policy is to provide guidelines to verify final dialysate conductivity and pH prior to initiating hemodialysis treatments and during treatments if required.” ‘Test Verification Prior to Treatment’ .”..... Note: If BlueStar software is enabled for independent conductivity and pH readings, an external meter is not a requirement to measure pre-treatment conductivity and pH. This is only allowed on Bluestar machines with a bibag system.” ..... Documentation’ “Record conductivity and pH readings in the FKC treatment record.” A review of medical records was completed on July 18, 2024 at approximately 1:15 p.m. Patients date of admit is listed below. MR#2, date of admit 02/17/18: This patient is treated on a ‘2008T BlueStar Hemodialysis Machine’ which utilizes bibags (bicarbonate bags). Patient treatment flowsheet dated 07/06/24 was reviewed. No documentation (flow sheet or elsewhere) of the theoretical conductivity value (TCD) and actual conductivity being within normal limits, prior to the start of treatment. MR#3, date of admit 05/16/22: This patient is treated on a ‘2008T BlueStar Hemodialysis Machine’ which utilizes bibags (bicarbonate bags). Patient treatment flowsheet dated 07/12/24 was reviewed. No documentation (flow sheet or elsewhere) of the theoretical conductivity value (TCD) and actual conductivity being within normal limits, prior to the start of treatment. An interview with the facility Clinical Nurse Manager on July 18, 2024 at approximately 1:30 p.m. confirmed the above findings.”