Fkc Mon Valley

“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: 46886 Based on observations and reviews of policy, the facility staff failed to follow infection control policy and require patients to perform hand hygiene during two (2) of three (3) observations of Post Dialysis AV fistula care (PAVF1&3) and require a patient to wear a mask during one (1) of two (2) observations of post dialysis Central Venous Catheter Care (PCVC1). Findings include: A 7/3/25 review of Hand Hygiene policy revealed: “ All staff, patients, patient care givers ...must follow the same requirements for hand hygiene. ...Hands will be decontaminated using alcohol -based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves ...Hand Hygiene: Patients should perform hand hygiene if able, prior to and after each dialysis treatment. “ During a 6/30/25 observation of post dialysis Arteriovenous Fistula (AVF) care (PAVF1) at approximately 12:20 pm Patient2 was witnessed at station 7 applying pressure to their fistula site with a gloved hand post treatment. Patient2 removed the glove before leaving the dialysis station but failed to perform hand hygiene prior to exiting the treatment area. During a 7/1/25 observation of post dialysis AVF care (PAVF3) at approximately 1:45 pm Patient 3 was witnessed at station 3 applying pressure to their fistula site with an ungloved hand. Patient 3 failed to perform hand hygiene, left the dialysis station handling an electronic device. Patient3 then plugged the electronic device into the wall adjacent to the med prep area and clean sink without appropriate device disinfection. During a 6/30/25 observation of post dialysis Central Venous Catheter Care (PCVC1) at approximately 10:00 am at station 13, RN3 was observed disconnecting Patient4 ’ s CVC from the hemodialysis circuit. RN3 failed to require Patient 4 to cover their nose and mouth with a mask during the CVC disconnection procedure. Observations PAVF1, PAVF2, and PCVC1 were reviewed with EMP1 Clinical Manager and EMP2 Director of Operations during an exit conference on 7/3/25 at approximately 11:00 am.”

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 46886 Based on observations, policy reviews, and interviews with staff, the facility failed to clearly label acid distribution outlets for positive concentrate identification in the patient care area during one (1) of three (3) observation periods. (OBS2) Findings include: A 7/2/25 review of Concentrate Labeling Requirements policy revealed: “ Labeling strategies must allow for the positive identification of the contents ...Policy: Permanent Labeling: Valve Panels (Incenter, Inpatient) valve panels ...or wall boxes must be labeled to identify the fluid that is delivered ...Valve panels must use appropriate HMIS [hazard materials identification system] labeling. “ During 7/1/25 prescription verification observations (OBS2) conducted between approximately 10:30 am to 11:00 am the following was noted: A prescription review conducted at approximately 10:30 at station #6 with EMP1 (clinic manager) revealed that Patient1 was to receive 3.0 K 2.5 Ca Granuflo. Observations of the hemodialysis machine ’ s Hansen connection appeared to reveal that the patient was receiving 3.0 K 3.0 Ca via the acid valve panel. A chairside observation/interview with EMP1 at station 6 revealed that the valve was incorrectly labeled and that the facility no longer provided 3.0 K 3.0 Ca acid via the distribution system. EMP1 stated, [The correct label] “ must have fallen off. “ Further observations of hemodialysis stations revealed that Station #9 and #2 ’ s acid distribution valve labelling was illegible, rendering the acid formulation to be distributed from the valve panel unidentifiable. An interview with EMP1 revealed that the labels had become worn during the facility ’ s routine disinfection processes conducted by staff after each patient ’ s dialysis treatment. The findings were reviewed with EMP1 (clinic manager) and EMP2 (Director of Operations) during an exit interview on 7/3/25 at approximately 11:00 am.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46886 Based on medical record (MR) and policy reviews, the facility staff failed to monitor and ensure provision of a patient ’ s ordered dialysis prescription for four (4) of five (5) MRs reviewed. (MRs 1-4) A review of Patient Assessment and Monitoring procedure on 7/3/25 revealed: “ Data Collection ...If the PCT/LPN note any changes or abnormal findings in the patient ’ s condition or vascular access are observed or reported by the patient ...The registered nurse must assess the patient... The RN will notify the patient ’ s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement. During Treatment 3. Machine Parameters and Extracorporeal Circuit Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. “ A treatment sheet review conducted on 7/2/25 between 10:30 - 1:00 revealed: MR4: 3/18/23. MR4 ’ s Treatment Sheet dated 6/13/25, 6/23/25, and 6/25/25 noted dialysis prescriptions with a Blood Flow Rate (BFR) of 350 mL/min, Dialysate Flow Rate (DFR) of 800 mL/min and a treatment time of 4 hours. Treatment Data on 6/13/25 recorded a BFR adjustment to 400 mL/min but staff failed to follow policy and document the reason the prescribed BFR was adjusted. Treatment Data for 6/23/25 and 6/25/25 noted shortened dialysis treatment times to approximately 3.5 hours with DFR adjustments to 600 mL/min. RN1 and RN2 failed to follow policy and document notification of the physician or physician extender to the abnormal hemodialysis treatment outcomes. A treatment sheet review conducted on 7/3/25 between 9:30 - 9:45 revealed: MR1: Admit date: 4/12/25. MR1 ’ s Treatment Sheets dated 6/14/25, 6/17/25, 6/19/25, and 6/21/25 noted dialysis prescriptions with a Blood Flow Rate (BFR) of 500 mL/min. Treatment Data on 6/14, 6/17, and 6/21/25 recorded BFR adjustments to 400 mL/min and 450 mL/min but staff failed to follow policy and document the reason the prescribed BFR was unable to be met. Treatment Data on 6/19/25 recorded a BFR adjustment to 450 mL/min by PCT1 but failed to document RN notification of the patient ’ s change in vascular access function. MR2: Admit date: 9/17/18. MR2 ’ s Treatment Sheets dated 6/17/25 and 6/24/25 noted dialysis prescriptions with a BFR of 500 mL/min. Treatment Data on 6/14 and 6/24 recorded BFR adjustments to 450 mL/min but staff failed to follow policy and document the reason the prescribed BFR was unable to be met. The BFR adjustment on 6/19 by PCT1 failed to document RN notification of the patient ’ s change in vascular access function. MR3: Admit Date: 12/20/23. MR3 ’ s Treatment Sheets dated 6/14/25, 6/17/25, and 6/28/25 noted dialysis prescriptions with a BFR of 400 mL/min. Treatment Data on 6/14, 6/17, and 6/28 recorded BFR adjustments between 375 mL/min to 300mL/min but staff failed to follow policy and document the reason the prescribed BFR was unable to be met. The BFR adjustments on 6/14 and 6/28 by PCT2 and 6/17 by PCT1 failed to document RN notification of the patient ’ s change in vascular access function. Facility staff failed to follow policy and document events necessitating intradialytic BFR adjustments and RN/physician notification of abnormal findings and events for MRs 1-4. The findings were reviewed on 7/3/25 at approximately 11:00 pm during an exit conference with EMP1, Clinical Manager, and EMP2 Director of Operations.”

“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: 46886 Based on observations and policy reviews, the facility medical director failed to ensure that all staff adhered to policies and procedures related to patient assessment and monitoring for one (1) of two (2) post dialysis Arteriovenous fistula care (PAVF) observations. (PAVF2) Findings include: A 7/1/25 review of Venipuncture Site Clamps policy revealed: “ While the clamp remains on the access, check for thrill every 10 minutes. It is recommended not to exceed clamps in place longer than 20 minutes. Patient care staff must monitor clamp placement carefully while in use as clamp may slip and result in blood loss. Venipuncture Clamp Procedure ...11. Leave clamp on until the bleeding has stopped. Do not leave the clamp in place longer than 20 minutes without removing it to check that bleeding has stopped. 12. Check access for thrill every 10 minutes ... “ During observation PAVF2 on 7/1/25 at approximately 9:40 am RN4 was witnessed at hemodialysis station #4 applying a venipuncture clamp to patient 5 ’ s arteriovenous fistula site to prevent bleeding after needle removal. The clamp remained on patient 5 ’ s arm until approximately 10:05 am, 25 minutes. During clamp application, facility staff failed to follow policy and palpate patient 5 ’ s AVF site every ten minutes to assess for fistula function or “ thrill. “ The finding was reviewed with EMP1, clinical manager, and EMP2, Director of Operations, during an exit interview on 7/3/25 at approximately 11:00 am.”