Fkc Clairton

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 46886 Based on observations (OBS) of the facility and employee interviews (EMP) the facility failed to comply with accepted public health procedures regarding the disposition of out-dated devices for one (1) of three (3) OBS. (OBS3) Findings included: During OBS3 on 3/26/24 at approximately 1:00 pm in the office of the water treatment technician, 200 BD Vacutainer no additive specimen collection tubes, Lot #2013625 and 51 tubes with Lot #2010916 were found with the expiration date of 6/3/2023. The disposition of the expired items was reviewed in an interview with EMP2, water technician, and EMP1, clinical manager. It was unable to be determined if the expired collection tubes were removed from active stock and being held for appropriate disposal. This finding was reviewed with EMP1, clinical manager, and EMP3, Administrator, during an onsite exit interview on 3/28/24 at approximately 1:00 pm.”

“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: 46886 Based on a review of medical records (MR), policies, facility documentation, and interviews (EMP), the facility staff failed to follow facility policies, evaluate the appropriateness of blood flow rates (BFR), and communicate changes in the dialysis prescription with physicians for three (3) of four (4) MRs reviewed. (MR 1,3, and 4) Findings included: A review of facility policy Patient Assessment and Monitoring on 3/28/24 revealed: “ Data Collection ... If the PCT [patient care technician] note any changes or abnormal findings in the patient ’ s condition or vascular access ...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 for additional instruction ...Access ...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 ...Check arterial pressure is less than negative 250 mmHg .... “ A review of facility policy Patient Monitoring and Safety Checks During Hemodialysis Treatment on 3/28/24 revealed: “ ...Verify dialysate lines are attached and in correct position and DFR (dialysate filtration rate) BFR (blood filtration rate) and UFR (ultrafiltration rate) is set and functioning per treating physician order ... “ A review of facility policy New Access Cannulation Standing Order on 4/2/24 revealed, “ AV Graft Cannulation Steps ...AV Graft Cannulation Process ...Clinical staff ...will ...run BFR less than or equal to 450 mL/min per physician/NP/PA order ...if infiltration or complications occurs with any cannulation with 15-gauge needles: ...nurse to consult Nephrologist/NP/PA before restarting cannulation ... “ A medical record review conducted on 3/27/24 between approximately 1:45 pm to 3:00 pm revealed: MR1: Start of Care (SOC): 7/28/23. Access type Maturing/Healing AV Graft status, needle size 15 gauge. A review of MR1 patient treatment flow sheets between 3/12/24 to 3/23/24 noted a prescribed BFR of 450 mL/min. The BFR was delivered below the prescribed rate on 3/14, 3/16, 3/19, and 3/23. Treatment notes dated 3/14/24 and 3/23/24 did not document a reason for BFR changes as per facility policy. Treatment note dated 3/14/24 documented use of a 15-gauge needle with three cannulation [needle insertion into skin] episodes. One cannulation restart on 3/14/24 was due to pain and the treatment note did not document Nephrologist/NP/PA consult before restarting cannulation as per facility policy. A review of facility policy New Access Cannulation Standing Order on 4/2/24 revealed, “ AV Graft Cannulation Steps ...AV Graft Cannulation Process ...If access flow is less than 600 mL/min ...nurse will inform Nephrologist/NP/PA and determine next step: ...Nurse will confirm final dialysis prescription regarding: time, needle gauge and BFR. A medical record review conducted on 3/28/24 between approximately 11:30 am to 1:00 pm revealed: MR3: SOC: 6/1/23. Access type Maturing/Healing, AV Fistula with Graft. A review of MR3 treatment flow sheets between 1/25/24 and 2/22/24 noted a prescribed BFR of 450 mL/min. A prescribed BFR of 450 mL/min was confirmed by PCT [patient care technician] on 2/6/24 and delivered via 17-gauge cannulation needles at 300 mL/min. A prescribed BFR of 450 mL/min was confirmed by a PCT on 2/17/24 then delivered at 400 mL/min using 16-gauge cannulation needles. Treatments delivered on 2/6 and 2/27 did not follow the New Access Cannulation Standing Order procedure which stated, “ Nurse will confirm final dialysis prescription regarding: time, needle gauge and BFR. “ MR4: SOC: 11/8/23. Access type AV fistula. A review of MR4 treatment flow sheets between 3/11/24 to 3/22/24 noted a prescribed BFR of 450 mL/min. The BFR was delivered at less than the prescribed rate of 450 mL/min on 3/11, 3/13, 3/20, 3/18, and 3/22. The dialysis prescription on 3/13/24, 3/18/24, 3/20/24, and 3/22/24 was confirmed by PCTs which did not follow the New Access Cannulation Standing Order procedure which stated, “ Nurse will confirm final dialysis prescription regarding: time, needle gauge and BFR. “ The findings were reviewed during an onsite exit interview with EMP1, clinical manager, and EMP3, Administrator, on 3/28/24 at approximately 1:00 pm. The New Access Cannulation Standing Order procedure was provided by EMP1, clinical manager, on 4/1/24.”