Fkc Back Mountain

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 19122 Based on review of facility policies/procedures and clinical records, and based on interview with the clinical manager (Employee #1), the facility failed to ensure the initial plan of care (POC) was developed as per facility policy and procedure for one (1) of two (2) patients for whom chronic hemodialysis treatments began after December 1, 2023. (Patient #3) Findings include: On March 7, 2024 at approximately 4:06 PM, review of facility policy 45283, titled “Comprehensive Interdisciplinary Assessment and Plan of Care” revealed the following: on page 2: An initial...plan of care (POC) must be conducted on all patients new to dialysis within...13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. Patient #3: On March 7, 2024 at approximately 10:24 AM, review of the medical record revealed the chronic hemodialysis start of care date was 01/24/2024. Review of hemodialysis treatment documentation revealed the thirteenth hemodialysis treatment (session) was completed on 02/28/2024. There was no documentation in the clinical record which provided evidence the initial POC was completed by 02/28/2024. During interview conducted on March 7, 2024 at approximately 12:04 PM, the CM reported the initial POC is scheduled to be conducted on 03/20/2024 so that family members can attend. There was no documentation in the medical record which provided evidence that the patient and/or family requested a delay in the initial POC meeting. During interview conducted on March 7, 2024 at approximately 4:20 PM, the CM confirmed that the delay in the development of the initial POC was related to availability issues for the patient’s nephrologist. During interview conducted on March 7, 2024 at approximately 4:20 PM, the CM confirmed the initial POC for patient #3 was not developed by the thirteenth hemodialysis treatment.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 19122 Based on review of facility policies/procedures, clinical records and documentation, observation, staff interview (Employee #3) and interview with the clinical manager (Employee #1), the facility failed to ensure planned actions were completed for two (2) of two (2) action plans (performance improvement projects). (Action Plans #1 and #2) Findings include: On March 7, 2024 at approximately 11:42 AM, review of facility policy 26799, titled “Quality Assessment and Performance Improvement Program” revealed the following on page 5: Following root cause analysis, action plans will be determined...The facility must take immediate and appropriate actions to address any serious threats and ensure patient safety. During observation of hemodialysis staff between March 4, 2024 at approximately 9:45 AM and March 6, 2024 at approximately 11:01 AM revealed the following: Employee #2: After inserting the access needles into the fistula and completing the treatment initiation process for the patient seated at station #12 during the second shift on 03/05/2024, the registered nurse (RN) carried the laboratory specimen to the lab room. After departure from the laboratory specimen room, the RN removed gloves but failed to perform hand disinfection/washing before obtaining a clean pair of gloves from the supply box. After removing the access needles from the fistula from the patient seated at station #4 during the second shift on 03/05/2024, the RN removed gloves but failed to perform hand disinfection/washing before obtaining additional clean supplies to complete the hemodialysis treatment termination process. After removing one (1) blood line from the central venous catheter (CVC) for the patient seated at station #6 during the first shift on 03/06/2024, the RN removed gloves but failed to perform hand disinfection/washing before obtaining a new pair of gloves from the supply box. The RN then removed the second blood line but failed to perform hand disinfection/washing after completion of the treatment termination process. Employee #3: After inserting the access needles into the fistula for the patient seated at station #1 during the second shift on 03/05/2024, the RN entered the medication preparation room without removing personal protective equipment (gown and gloves), The RN then proceeded to remove gloves but failed to perform hand disinfection/washing before preparing an intravenous (IV) medication. During interview conducted on 03/05/2024, the RN reported that the IV medication which the RN prepared was heparin. Employee #4: After removing the bloodlines from the access needles for the patient seated at station #5 on the first shift on 03/06/2024, the certified clinical hemodialysis technician (CCHT) removed gloves but failed to perform hand disinfection/washing before obtaining a clean pair of gloves from the supply box. Patient #1: On March 6, 2024 at approximately 1:22 PM review of the medical record revealed the blood/bloodline culture obtained on 12/30/2023 was positive for growth of viridans streptococcal group (bacteria). Patient #3: On March 7, 2024 at approximately 10:24 AM review of the medical record revealed the blood/CVC culture obtained on 02/09/2024 was positive for growth of staphylococcus huminis (bacteria). Patient #4: On March 7, 2024 at approximately 12:19 PM, review of laboratory results included in the medical record revealed the patient is hepatitis C reactive (positive). Patient #5: On March 7, 2024 at approximately 1:37 PM, review of the medical record revealed Vancomycin (antibiotic) was administered on 01/26/2024 after assessment findings documented by the RN (Employee #1) revealed the CVC site exhibited greater than expected redness and tenderness at insertion site. Action Plan #1: On March 6, 2026 at approximately 11:56 AM, review of an “Action Plan” implemented on 01/12/2024 revealed the following: Analysis of Findings (Root Causes)/Goals: Goal for 100% adherence to infection control policies and procedures by the end of the increased auditing period. Actions Planned/Time Frame/Person Responsible: -Infection control audits increased to twice weekly; -Staff Acknowledgment to be signed regarding infection control policies and where to find applicable polices; -Time Frame: Increased auditing period over 6 weeks; -Person responsible: Clinical manager (CM). Review of infection control audit findings documentation revealed week six (6) of the twice weekly infection control audits was completed on 03/01/2024. There was no documentation the CM (Employee #1) completed the planned action for hemodialysis staff to sign an acknowledgment regarding infection control policies and where to find applicable polices. Patient #4: On March 7, 2024 at approximately 12:19 PM, review of the medical record revealed the following was documented on the hemodialysis treatment sheet dated 02/26/2024: -8:03 AM: 200 milliliters (ml) of normal saline solution (NSS) was administered for blood pressure of 85/38 which was obtained at 8:01 AM, The next blood pressure assessment (91/47) was documented as having been completed at 8:29 AM which was 26 minutes after the administration of NSS. -9:31 AM: 100 ml of NSS was administered for a blood pressure of 82/40, The next blood pressure assessment (89/44) was documented as having been completed at 10:00 AM which was 29 minutes after the administration of NSS. Action Plan #2: On March 6, 2026 at approximately 11:58 AM, review of an “Action Plan” implemented on 01/14/2024 revealed the following: Analysis of Findings (Root Causes)/Goals: Goal to achieve medical record documentation which is free from omission or errors. Actions Planned/Time Frame/Person Responsible: -CM to pull 4 treatment records from the treatment week to review errors with staff the following week. -Time Frame: Increased treatment sheet auditing period over 6 weeks starting 01/22/2024. -Person responsible: Clinical manager will audit treatment sheet records, provide feedback to staff and documents updates in the action plan. Review of treatment sheet audit documentation revealed during week 1 (01/22/2024 through 01/25/2024), one (1) instance of low blood pressure with fluid administration did not include a recheck of the patient until 14 minutes later when “ideally”, the need to recheck the patient is within 5 to 7 minutes. There was no documentation the CM (Employee #1) completed the planned action to review treatment sheet omissions/errors with staff the following week and to provide feedback to staff as required in the above referenced action plan. During interview conducted on March 7, 2024 at approximately 4:20 PM, the CM confirmed the above referenced planned actions were not completed as per the requirements included in action plans #1 and #2.”