Dci Chippewa

“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: 31759 Based on observation, review of facility policy, and staff (EMP) interview, the facility failed to ensure staff changed gloves and performed hand hygiene when going from a dirty area to a clean task for one (1) of two (2) observations (OBS5) of discontinuation of dialysis with an arteriovenous fistula (AVF). Findings included: Review of facility policy on December 9, 2025, at 11 a.m. showed, “Use of Gloves Including Hand Hygiene. ... 3. Chairside computers keyboards/screens can easily become contaminated because of their proximity to the patient station. Hand hygiene is imperative after contact with the chairside computer and before contact with the patient, regardless of whether contact with the computer occurred through gloved or ungloved hands. 4. Gloves will be changed for the following: ... When going from a ‘dirty’ area or task to a ‘clean’ area or task ... 5. A new pair of clean gloves must be used each time for the following: access site care.” Observation (OBS5) of discontinuation of dialysis with an AVF on December 8, 2025, at 10:15 a.m. at station 7 revealed EMP5 don gloves and prepare clean supplies at chairside. EMP5 then connected patient’s bloodlines back to the machine before touching the screen on the hemodialysis machine (dirty area). Then with same gloved hands, EMP5 removed needles from patient’s arm and applied dressings (a clean task). Interview with EMP5 on December 8, 2025, at 10:20 a.m. confirmed findings.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 31759 Based on observation, review of facility policy, and staff (EMP) interview, the facility failed to ensure the patient wore a mask appropriately for one (1) of two (2) observations of discontinuation of dialysis with a central venous catheter (OBS1). Findings included: Review of facility policy on December 9, 2025, at 10 a.m. showed: “Central Venous Catheter (CVC) Scrub the Hub Protocol for Connections and Disconnection ... 1. Perform hand hygiene and don PPE, including new clean gloves. Ensure face mask is worn by both staff and patient. ... Wearing a face mask decreases the risk of transmitting microorganisms from the respiratory tract of the staff member or patient, onto the catheter site itself as well as potentially into the vascular system of the patient when the catheter ports are open to air.” “Termination of Dialysis Utilizing Fresenius 2008 K, K2 & T Dialysis Delivery Systems with CombiSet Bloodlines ... 1. Don PPE and perform hand hygiene. If patient has a catheter, ensure patient and staff member wear a mask covering both the nose and mouth.” Observation (OBS1) of discontinuation of dialysis on December 8, 2025, at 10:50 a.m. at station 4 revealed EMP4 disconnect patient’s blood lines from patient’s catheter, disinfect catheter hubs, and cap lines but the patient’s mask did not cover his/her nose. Interview with EMP4 on December 8, 2025, at 11 a.m. confirmed findings.”

“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: 31759 Based on review of facility policy, clinical records (CR), and staff (EMP) interview, the interdisciplinary team (IDT) failed to develop and implement a plan of care to provide the necessary care and services to manage the patient’s volume status for one (1) of one (1) incenter hemodialysis patient (CR1) with unmanaged hypertension (blood pressure) for 15 weeks. Findings included: Review of facility policy on December 9, 2025, at 11 a.m. showed, “Care Plans ... The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards [EMPHASIS]. ... The interdisciplinary team must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. ... 1. The interdisciplinary team must develop a plan of care that integrates all disciplines. ... Requirements of Content 1. Each area should be addressed and problems identified and addressed on [the] care plan if out of range. a. Dose of dialysis including volume status ... 2. If expected outcomes are not achieved , the IDT must adjust the patient’s plan of care to achieve the specified goals ... a. adjust the plan of care to reflect the patient’s current condition ... c. implement plan of care changes to address the issues identified.” According to the Centers for Medicare and Medicaid’s (CMS) Measure Assessment Tool (MAT), which lists current professionally-accepted clinical standards and current CMS CPM (clinical performance measures), “Euvolemic [normal or balanced volume of body fluid] & pre-BP <140/90; post-BP <130/80 (adult).” Refer to the Measures Assessment Tool (MAT) which lists the current professionally-accepted clinical standards and current CMS CPMs. Review of facility policy on December 10, 2025, at 2:11 p.m. showed, “Intradialytic Patient Assessment and Monitoring PURPOSE: To provide guidelines for intradialytic monitoring of a patient on hemodialysis. SUPPORTIVE DATA: Patients’ blood pressures [BP] must be monitored pre, during, and post treatment and abnormally high or low values must be addressed (V543).” “Post-Treatment Assessment PURPOSE: To provide guidance on the posttreatment assessment of a hemodialysis patient. SUPPORTIVE DATA: Patients’ blood pressures must be monitored pre, during, and post treatment and abnormally high or low values must be addressed (V543).” Review of CR1 on December 8, 2025, at 10 a.m. showed the patient was admitted from the home therapy program to incenter hemodialysis on August 4, 2025. Review of CR1’s plan of care showed it was completed on September 17, 2025. Review of CR1’s treatment sheets or “HEMODIALYSIS FLOWSHEET” before the above plan of care was completed showed patient was experiencing pre, intra, and post-dialysis hypertension. For instance, on 8/22/2025, the patient recorded a pre-treatment BP of 160/87, and a post-treatment BP of 196/104. On 9/1/2025, the patient’s pre-dialysis BP was 168/73. Towards the end of treatment, the patient’s BP rose to 185/106 and their post-treatment BP was 184/92. According to the notes from the 9/1/2025 treatment, “MED CLONIDINE HCL [anti-hypertensive drug] Reason not given: Parameter Not Met.” On 9/8/2025, the patient’s pre-dialysis BP was 198/93 and their post-treatment BP was 185/98, and once again no Clonidine HCL was given per the treatment sheet because the parameter had not been met. On 9/10/2025, the patient’s pre-treatment BP was 195/102 and their post-treatment BP was 183/93, and once again no Clonidine HCL given because the parameter had not been met. A review of CR1’s orders showed that a BP greater than 180/100 was the parameter that needed to be met for the patient to receive Clonidine HCL. Further review of CR1’s plan of care did not show it contained measurable and expected outcomes and estimated timetables to address the patient’s volume status and hypertension-- there was no mention of the patient’s volume status on the plan. Review of facility policy on December 9, 2025, at 11 a.m. showed, “Care Plans ... The interdisciplinary team must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. ... 1. The interdisciplinary team must develop a plan of care that integrates all disciplines. ... Requirements of Content 1. Each area should be addressed and problems identified and addressed on [the] care plan if out of range. a. Dose of dialysis including volume status ... 2. If expected outcomes are not achieved , the IDT must adjust the patient’s plan of care to achieve the specified goals ... a. adjust the plan of care to reflect the patient’s current condition ... c. implement plan of care changes to address the issues identified.” There were no changes to CR1’s plan of care related to volume status until 10/3/2025 when their target weight was changed to 65.5kg (kilograms). Another order occurred on 10/13/2025, when the patient’s target weight was reduced to 64.5kg. There were no further changes to the patient’s plan of care, however the patient continued to experience hypertension as outlined in the below treatment sheets. On 11/12/2025, the patient’s pre-treatment BP was 164/119. The patient’s intra-dialytic BP was as high as 199/100. The patient’s post-treatment BP was 185/109 with no Clonidine HCL given. On 11/17/2025, the patient’s pre-treatment BP was 179/90. The patient’s intra-dialytic BP was as high as 180/97. The patient’s post-treatment BP was 180/94 with no Clonidine HCL given. On 11/28/2025, the patient’s pre-treatment BP was 191/92. The patient’s intra-dialytic BP was as high as 207/112. The patient’s post-treatment BP was 190/105. Per the day’s treatment notes, “MED CLONIDINE HCL [was not effective] [patient] to take BP medicine at home as well.” On 12/3/2025, the patient arrived to the facility with a BP of 194/113. The patient’s intra-dialytic BP was as high as 203/124. The patient’s post-treatment BP was 199/121 with no Clonidine HCL given. Per the day’s treatment notes, “NP [nurse practitioner] aware of BP during rounds at end of [treatment]. Patient to take BP meds at home.” On 12/8/2025, the patient’s pre-treatment BP was 201/106, and completed treatment with a BP of 170/93. Interview with EMP1 (nurse manager) and EMP9 (facility administrator) on December 9, 2025, at 2 p.m. confirmed there were no changes to the plan of care after 10/13/2025, and that the patient’s volume status was not a problem that was addressed on the initial plan of care and that a plan was not implemented to address the patient’s current condition.”