Fkc Liberty Dialysis Banksville

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 38039 Based on review of facility policy, observations, and staff interview (EMP), the facility failed to ensure that the staff followed infection control protocols, included but not limited to use of Personal Protective Equipment (PPE) for two (2) of two (2) observations. (Observation # 1 & #2). Findings include: Review of agency policy on 7/19/24 at approximately 11:00 a.m. revealed Clinical Services Policy: “Personal Protective Equipment (PPE)...All personal protective equipment shall be removed prior to leaving the treatment area.” Observation #1 on 7/19/24 at 10:37 a.m., EMP #8 was observed exiting the treatment room floor to outside lobby without removing personal protective equipment (PPE) and returned to the treatment floor without changing PPE. Observation #2 on 7/19/24 at 10:45 a.m., EMP #8 was observed exiting the treatment room floor to outside lobby without removing personal protective equipment (PPE) and returned to the treatment floor without changing PPE. Interview on 7/19/24 at approximately 12:30 p.m. with the Director of Operations (EMP1) and Clinical Nurse managers (EMP2 and EMP3) confirmed that PPE should be removed prior to leaving the clinical floor.”

“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: 38039 Based on review of facility policy, review of medical records (MR) that included patients who received in-center hemodialysis(ICHD), home peritoneal dialysis (PD) and home hemo-dialysis (HHD) and staff (EMP) interview the facility failed to assess and/or monitor patient status for three (3) of eight (8) MR reviewed. (MR2-ICHD, MR3-ICHD, MR6-ICHD). Findings include: Review of facility policy on 7/18/24 at approximately 9:45 a.m. revealed: Patient Assessment and Monitoring... During Treatment-“Obtain blood pressure and pulse rate every 30 minutes or more as needed but do not exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” Review of MRs on 7/17/24 at approximately 9:30 a.m. to 12:30 p.m. for ICHD and on 7/18/24 at approximatley 8:30 a.m. to 9:30 a.m. for PD and HHD revealed the following: MR2, admission date of 5/8/22. Review of treatment records dated 7/2/24 through 7/13/24. Treatment sheet dated 7/9/24 revealed patient was assessed at 11:01 a.m. and patient was not assessed again until 12:06 p.m. (65 minutes between assessments). MR3, admission date of 6/6/22. Review of treatment records dated 7/2/24 through 7/13/24. Treatment sheet dated 7/5/24 revealed patient was assessed at 12:05 p.m. and patient was not assessed again until 1:04 p.m. (59 minutes between assessments). MR6, admission date of 4/29/24. Review of treatment records dated 7/3/24 through 7/15/24. Treatment sheet dated 7/8/24 revealed patient was assessed at 1:33 p.m. and patient was not assessed again until 2:31 p.m. (58 minutes between assessments). Interview on 7/19/24 at approximately 12:30 p.m. with the Director of Operations (EMP1) and Clinical Nurse managers (EMP2 and EMP3) confirmed the above findings.”