Fkc Towanda

“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: 21832 Based on review of facility policy, observations, and an interview with the Clinical Nurse Manager, 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) observation. (Observation # 1 & # 2). Findings include: Review of agency policy on 5/30/24 at 12:00 PM titled, Personal Protective Equipment (PPE) and potential areas of use, States, “all personal protective equipment shall be removed prior to leaving the treatment area.” Observation # 1 on 5/29/24 at 10:00 AM: EMP #6 was observed exiting the treatment room floor to outside lobby without removing her personal protective equipment (PPE) and returned with a wheelchair without changing her PPE. Observation #2: 5/29/24 at 10:05 AM: EMP #2 was observed exiting the treatment room floor to outside lobby without removing her PPE , then returned to the treatment floor and immediately excited the treatment floor again without removing her PPE. An interview with the Clinical Nurse manager on 5/29/24 at approximately 3:00 PM confirmed the above findings.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 21832 Based on review of facility policy, manufacturer’s directions for use, clinical records (CR), and staff (EMP) interview, the facility failed to ensure the patient (treatment) flow sheets contained machine parameters to show conductivity safety checks were completed and in range for five (5) of five (5) in-center hemodialysis clinical records reviewed (CR1 - CR5). Findings included: Review of facility policy on 5/30/24 at 9:00 AM states, “TSB - Regulatory Guidance for Using the 2008 Independent Conductivity and pH...Advances in the Fresenius 2008 Technology in Relation to Independent Conductivity and pH Verification. The latest 2008T Bluestar functional software version 2.72 or later now incorporates a method for the machine to independently verify conductivity and pH when used in accordance with the machine instruction for use and using the bibag disposable, which states: “ Note: If the Service Mode ’ Independent Cond Test ’ option is enabled (functional software version 2.72 or later), the Independent Conductivity selftest will be listed among the selftests. Running this test will independently verify the conductivity of the dialysate. If the bibag disposable is the bicarbonate source for the treatment, the Independent Conductivity/pH selftest will be listed and the machine will independently verify both the conductivity and pH of the dialysate. “ “ This option is used to choose whether or not to independently verify the dialysate conductivity as part of the Dialysis/SLED “ Test & Options “ screen self-tests. If this option is set to ’ Yes ’ , the Independent Conductivity reading will be displayed on the “ Dialysate “ screen under the heading “ Pre Tx Conductivity “ . The ’ Independent Conductivity ’ test will also be listed among the self-tests. When the bibag disposable is used as the bicarbonate source for the treatment, the Independent Conductivity self-test will be displayed as ’ Independent Conductivity/pH ’ and the machine will then independently verify the conductivity and pH during the self-test. “ Policy: “Checking Conductivity of pH and final dialysate, states, “Checking Conductivity and pH of Final Dialysate ... Conductivity and pH of dialysate are measurements used to verify proper proportioning of acid concentrate, bicarbonate concentrate and treated water. ... Policy ... The final dialysate conductivity and pH must be tested prior to each patient’s treatment. ... Treatments may not be initiated, or current treatment must be stopped. ... The conductivity falls outside of the +/- 0.5 mS/cm [the unit of conductivity] of TCD [theoretical conductivity] ... BlueStar machine software allows independent conductivity and pH readings to be enabled in Service Mode. Per manufacturer’s Instructions For Use, the machine will verify conductivity and calculate the theoretical pH of dialysate while running self-tests. ... Staff/care partners must maintain limits at +/- 0.5 mS/cm of the TCD. Staff/care partners May Not Adjust them to any other position than +/- mS/cm of the TCD. ... Record conductivity ... readings in the FKC treatment record.” Review of clinical records on 5/30/24 at approximately 9:30 AM revealed CR1 Review of incenter hemodialysis treatment sheets from 5/15/24 to 5/27/24 did not show that the hemodialysis machine’s TCD and conductivity were within normal safe limits to start treatment. There is no documentation that TCD was verified and that the conductivity is within 0.5mS/cm of the theoretical conductivity value. CR2 Review of incenter hemodialysis treatment sheets from 3/27/24 to 4/26/24 did not show that the hemodialysis machine’s TCD and conductivity were within normal safe limits to start treatment. There is no documentation that TCD was verified and that the conductivity is within 0.5mS/cm of the theoretical conductivity value. CR3 Review of incenter hemodialysis treatment sheets from 5/10/24-5/27/24 did not show that the hemodialysis machine’s TCD and conductivity were within normal safe limits to start treatment. There is no documentation that TCD was verified and that the conductivity is within 0.5mS/cm of the theoretical conductivity value. CR4 Review of incenter hemodialysis treatment sheets from 5/15/24-5/29/24 did not show that the hemodialysis machine’s TCD and conductivity were within normal safe limits to start treatment. There is no documentation that TCD was verified and that the conductivity is within 0.5mS/cm of the theoretical conductivity value. CR5 Review of incenter hemodialysis treatment sheets from 5/15/24-5/29/24 did not show that the hemodialysis machine’s TCD and conductivity were within normal safe limits to start treatment. There is no documentation that TCD was verified and that the conductivity is within 0.5mS/cm of the theoretical conductivity value. Interview the regional biomedical technician on 5/10/24 at approximately 11:00 AM confirmed the policies as noted above.”