Fkc Greater Northeast

“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: 40929 Based on observation of the clinical area, facility policy and an interview with the facility administrator and director of operations, the facility did not ensure infection control procedure regarding handwashing for one observation (OBS# 1) Findings include: Facility policies were reviewed on 8/6/25 at approximately 10:00 AM and revealed the following: Policy titled, “Hand Hygiene” stated “Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water before and after direct contact with patients, entering and leaving the treatment area...after contact with inanimate objects near the patient....after contact with other objects within the patient station or treatment space...” Observations conducted in the patient treatment area on 8/4/25 between approximately 9:45 AM and 12:00 PM revealed the following: OBS #1. Station # 11, PCT # 1. PCT #1 was at station 11 entering data into the computer screen to set up the dialysis machine. PCT then left station 11 and proceeded to bring clean lab supplies to another patient’s station (station #20) without first performing hand hygiene. An interview with the director of operations conducted on 8/6/25, at approximately 2:30 PM 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: 40929 Based on review of facility policy/procedure, observations, and an interview with the facility Administrator and director of operations, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters, for two (2) of three (3) ‘Central Venous Catheter Exit Site Care’ observations (Observation #1, Observation #3). Findings: Facility policies were reviewed on 8/6/25 at approximately 10:00 AM and revealed the following: Policy titled, “Central Venous Catheter (CVC) Dressing Change” stated, “Removal of Dressing and Inspection of Site Note: the patient and Inpatient Services Staff must wear a mask for all procedures that require assessing the catheter to help prevent contamination by airborne nasal bacteria....Place an underpad under the catheter limbs to protect the work area and clothing, apply a mask to the patient and the Inpatient Services Staff, perform hand hygiene...Cleaning the Catheter Site...Using gentle back and forth friction, clean the exit site beginning in the center ans continuing outward the area of the size of the dressing to be applied in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds....” Observations conducted in the patient treatment area on 8/4/25 between approximately 9:45 AM and 12:00 PM revealed the following: Observation #1 : On 8/4/25 at approximately 10:15 AM while observing ’’Central Venous Catheter Exit Site Care’ observation #1 of 3, station #12 RN #1 failed to ensure face mask on patient was above nose throughout the procedure. Observation #3: On 8/4/25 at approximately 10:52 AM while observing ’’Central Venous Catheter Exit Site Care’ observation #3 of 3, station 4, PCT #3 removed old CVC dressing and cleansed CVC exit site for approximately 3-5 seconds prior to applying clean/new dressing. An interview with the director of operations on 8/6/25 at approximately 2:30 p.m. confirmed the above findings.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 40929 Based on review of facility policy, observations (OBS), and interview with facility administrator and director of operations, the facility failed to ensure the staff conducted manual pH testing of the dialysate prior to initiation of dialysis for one (1) of three (3) OBS. (OBS #3) Findings include: Facility policies were reviewed on 8/6/25 at approximately 10:00 AM and revealed the following: Policy titled, “Checking Conductivity and pH of Final Dialysate” stated, “Bluestar Independent Conductivity/pH Test Option...The Machine will perform the independent pH calculation only if its equipped with BiBag and BiBag is actively in use. If any other source of bicarbonate is being used, staff must test the dialysate pH using an independent method such as a handheld meter or pH test strip.” Observations conducted in the patient treatment area on 8/4/25 between approximately 9:45 AM and 12:00 PM revealed the following: OBS #3, On 8/4/25 at approximately 11:22 AM, station 16, PCT #2 intiated dialysis without manually testing the dialysate pH. It can be noted that the facility is utilizing 2008T Bluestar hemodialysis machines without use of BiBags therefore per policy a manual pH testing method is required prior to dialysis initiation. An interview with the Director of Operations, on 8/6/25 at approximately 2:30 PM confirmed the above 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: 40929 Based on review of facility policies, medical records (MR), hemodialysis (HD) treatment records, and an interview with the facility administrator and director of operations, the facility failed to conduct RN assessment of patient per facility policy prior to the initiation of treatment for two (2) of six (6) incenter hemodialysis (ICHD) patients (MR# 1 & 6). Findings include: Facility policies were reviewed on 8/6/25 at approximately 10:00 AM and revealed the following: Policy titled, “Nursing Supervision and Delegation” stated, “The registered nurse must evaluate each patient preferably within an hour or according to state requirements...confirm identity, review patient’s condition, review accurracy and completeness of treatment and patient data, review patient treatment prescription and equipment parameters...confirm that the correct vascular access is being used and that the access is visible, observe patient’s response to treatment, verify machine safety checks have been completed, talk to the patient to elicit information such as changes in condition, response to treatment, new injures, information/education needs or complaints, satisfaction with care” A review of medical records was conducted on 8/5/25 from 9:00 AM to 2:30 PM, and again on 8/6/25 from 9:00 AM to 11:00 AM and revealed the following: MR#1. Admit Date: 5/30/25. ICHD treatment records reviewed from 7/21/25 through 8/1/25 and found the following: On 8/1/25 HD treatment was initiated by the Patient Care Technician (PCT) at 2:21 PM. RN completed the initial assessment at 4:20 PM (approximately two hours after treatment was intiated). MR #6. Admit Date: 11/25/24. ICHD treatment records reviewed from 7/21/25 through 7/30/25 and found the following: On 7/30/25 HD treatment was initiated by the PCT at 3:39 PM. RN completed the initial assessment at 7:52 PM (it was documented as a “late note”). An interview conducted with the director of operations on 8/6/25 starting at 2:30 PM confirmed the above findings.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 40929 Based on a review of medical records, facility policy, peritoneal dialysis (PD) documentation, and an interview with the administrator, clinical services manager, and home peritoneal/home hemodialysis nurse, the facility failed to provide evidence of adequate home peritoneal dialysis (PD) monitoring for two (2) of two (2) PD patients: MR#9 & 10 and failed to provide evidence of adequate home hemodialysis (HHD) monitoring for one (1) of two (2) HHD patients: MR #7. Findings include: Facility policies were reviewed on 8/6/25 at approximately 10:00 AM and revealed the following: Policy titled, “Clinic Visits for Home Dialysis Patients” stated, “The routine patient visits shall include (but is not limited to) the following content...Review...Home treatment records, self-monitoring data and other information recorded by the patient or designated care partner for completeness and trends, treatment records for accuracy and appropriateness...missed or shortened treatments...Provide: patient/care partner education as needed...” Policy titled, “Patient Monitoring During Hemodialysis Treatment” stated, “All Home Hemodialysis patients will be monitored at a minimum of every 30 minutes for at least the first 3 months from initiation of treatment....” Policy titled, “Review and Documentation of Home Therapies Patient Health Data” stated, “The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home...” Policy titled, “Patient Assessment and Monitoring. Setting IC (Incenter), HT (Home therapies)” stated, “During treatment...obtain blood pressure and pulse rate every 30 minutes or more as needed not to exceed 45 minutes or per state regulations...” A review of medical records was conducted on 8/5/25 from 9:00 AM to 2:30 PM, and again on 8/6/25 from 9:00 AM to 11:00 AM and revealed the following: MR#7. Admit Date: 4/3/15. The HHD prescription dated 5/13/25 contained order for treatment to be completed four (4) days per week for a total of 4 hours (240 minutes) each treatment. A flowsheet calendar report for 6/29-8/4/25 was reviewed. During the following weeks only three (3) treatments were completed: 6/29/25-7/5/25, 7/6/25-7/12/25, 7/13/25-7/19/25, 7/27/25-8/2/25. Treatment flowsheets reviewed from 7/23/25 through 8/2/25. Treatment dated 7/23/25 was a total of 211 minutes (29 minutes shorter than prescibed). ). Also blood pressure (BP) was taken during treatment at 2:08 PM, 3:27 PM (One hour 19 min between readings). Treatment dated 7/25/25 was a total of 226 minutes (14 minutes shorter than prescribed). Also BP was taken during treatment at 3:22 PM but treatment continued until 6:24 PM with a post-treatment blood pressure taken (approximately 3 hours between BP readings) Treatment dated 7/26/25 was a total of 219 minutes (21 minutes shorter than prescribed). Also blood pressure was taken during treatment at 3:52 PM and 5:10 PM ( approximately 1 hour 15 min between BP readings). In addition, BP was not taken until end of treatment at 6:08 PM (approximately one hour between BP readings). Treatment dated 7/28/25 was a total of 210 minutes (30 minutes shorter than prescribed). Also blood pressure was taken during treatment at 4:55 PM and again at end of treatment 6:33 PM (approximatley 1.5 hours between BP readings). Treatment dated 7/30/25 was a total of 180 minutes (60 minutes shorter than prescribed). Also blood pressure was taken during treatment at 5:09 PM and 6:09 PM (one hour between BP readings). Treatment dated 8/2/25 was a total of 181 minutes (59 minutes shorter than prescribed). ). Also blood pressure was taken during treatment at 10:10 AM, 11:10 AM, 12:10 PM (one hour between each reading). Monthly visit note from HHD nurse on 7/14/25 stated, “Patient encouraged to do at least 4 treatments per week. Reminded to take BP q 30 (every 30 minutes).” Note did not address the possible risks of not completing treatments or BPs as required during treatments. In addition, note was not specific about how many missed treatments patient had. MR#9. Admit Date: 2/23/24. The PD prescription dated 9/9/24 contained orders for treatment to be completed seven (7) days per week with a total time of ten (10) hours per treatment. Treatment flowsheets were reviewed from June and July 2025 and patient did not record any vital signs (pre/post treatment weights, blood pressures, pulse, blood sugar and temperatures) during this time period. In addition there were missed treatments on 6/1/25-6/7/25, 6/25/25, 7/4/25 and 7/10/25. Monthly visit note from 7/14/25 written by the PD nurse did not address the missing vital signs or missing treatments. MR#10. Admit Date: 10/3/24. The PD prescription dates 2/12/25 contained orders for treatment to be completed seven (7) days per week with a total of 7.5 hours per treatment. Treatment flowsheets were reviewed form June and July 2025 and patient did not record any vital signs (pre/post treatment weights, blood pressures, pulse, blood sugar and temperatures) during this time period. In addition there were missed/reduced treatments on 6/3/25, 6/9/25, 6/10/25 and 6/25/25. Monthly visit note from 7/14/25 written by the PD nurse did not address the missing vital signs or missing treatments. An interview with the director of operations conducted on 8/6/25 starting at 2:30 PM confirmed the above findings.”