Atlantis Carolina

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 15884 Based on observational tour of the patient treatment area on 07/09/2024 thought 07/10/2024 from 8:30 AM through 1:20 PM, interview with nursing supervisor (employee #1) and clinical manager (employee #11), it was determined that the facility failed to document pertinent information related with Covid positive cases and to monitor the physical environment in order to promote a sanitary environment to minimize the transmission of infectious agents at the facility. Findings include: 1.On 07/09/2024 at 9:15 AM nursing supervisor (employee #1) inform that two patients Covid positive receive treatment on 07/04/2024 and 07/06/2024 (sample selection case #12 and #13). She informed that both patients receive treatment on the Tuesday and Thursday second shift, and they put then in cohort (physical separation at the end of one of the hallways end-of-row station, away from the main flow of traffic) to prevent the spread of the virus to the rest of the patients. She also informs that facility assigns staff to work only with them and promotes the required infection control precautions. Information related with both patients’ assessment when received treatment on 07/04/2024 and 07/06/2024 was requested to the facility nursing supervisor (employee #1) on 07/09/2024 at 9:39 AM. Accordingly with information provided by facility nursing supervisor on 07/09/2024 at 10:00 AM both patient’s assessment was performed by nurse in charge of the patients and was documented as part of the hemodialysis flowsheet. No information was found documented on the hemodialysis flowsheet in relation with nursing assessment of common signs and symptoms of a respiratory infection (such as chills, nasal congestion, muscle pain, headache, sore throat, loss of taste or smell, and gastrointestinal symptoms) if any presented by patient case review #12 and #13. No information was found documented by personnel in charge of both cases in relation to onset of Covid symptoms, Covid test results if any provided by patients and physician order or communication by physician to proceed with the hemodialysis treatment. Facility clinical manager (employee #11) was asked on 07/10/2024 at 1:45 PM in relation to pertinent documentation related with case #12 and #13 onset of Covid symptoms, Covid test results and physician order or communication by physician to proceed with the hemodialysis treatment. Facility clinical manager (employee #11) stated on interview on 07/10/2024 at 1:50 PM that this information was not documented by facility personnel in charge of cases 2. The dialysis facility failed to monitor the physical environment due to the potential for contamination with blood and pathogenic microorganisms, accordingly with the following findings identified on 07/10/2024 at 8:55 AM: a. Biohazard waste container located behind nursing station #3 was observed with open lid exposing the content to the environment on 07/10/2024 from 8:55 AM through 9:30 AM. b. Biohazard waste container located at the main entrance at the left side of the weighing scale area was observed with open lid exposing the content to the environment on 07/10/2024 from 9:05 AM through 9:30 AM. 17959 3. The following observations was performed on 07/09/2024, during the first shift and second shift of hemodialysis treatment from 8:30 AM thru 1:10 PM: a. Ceiling tiles stained with yellow spots, were observed in the nurse bathroom. b. At 9:46 AM ambulance employees entered the hemodialysis unit without gown, did not wash their hands, put their hands in the glove box, gloves hands and take the patient of station #33 to be weighed and then go out to the unit. c. At 10:04 AM in hemodialysis stations #27 were observed the patient covers touching the floor. d. At 10:18 AM when the nurse (employee #9) ended the disconnection on hemodialysis station #24 placed the undisinfected screen on the of nursing station #6 and she left to take the patient to the exit. e. At 11:12 AM from 12:05 PM brown and yellow spots and dust particles were observed at the base of all the hemodialysis machines where gallons of bicarbonate are placed. f. At 11:12 AM from 12:05 PM were observed that the patients hemodialysis treatment seats on stations #6, #9, #10, #17, #21, #22, #23, #25, #26, #28 and #32 were observed with broken and exposed areas. 47384 4. The following observations was performed on 07/09/2024, during the first shift and second shift from 8:30 AM thru 12:30 PM: a. Approximately at 8:45 AM a pressure monitoring cuff was observed on top of biohazard trashcan and touching biohazard sharp container on treatment station #12. b. Approximately at 8:45 AM the bio medical waste room door was observed opened and with broken locking mechanism c. Sharp containers were observed touching dialysis chairs when completely extended and close to dialysis machines.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 47384 Based on observational tour of the water treatment area and personnel interview on 07/09/2024 approximately at 11:20 AM, with Regional Biomedical Technician (employee #7), it was determined that the facility failed to perform a correct monitoring of free chlorine, chloramine process. Findings include: 1.During the observation process carried out to validate the chlorine testing by the nursing staff, it was observed that the strip drying process was not carried out. 2. During the observation of the test, it was also observed that the staff makes contact of the strip with the color table, this can affect the integrity of the card and affect the reading.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 15884 The facility failed to ensure accurate patient weight is measured by personnel in charge of patients accordingly with the following findings identified during survey procedures on 07/09/2024 and 07/10/2024 from 8:30 AM through 1:20 PM. Findings include: 1. It was informed on 07/09/2024 by the nursing supervisor (employee #1) that patient digital scale was not working correctly since morning at 6:00 AM when the first shift begins. 2. When personnel weigh a patient, the scale starts calculating the weight but does not stop showing the final weight measured. Instead of this, the scale continues showing different weights lower and higher making it difficult for the nursing personnel to registry the patient’s weight. 3. On 07/10/2024 at 9:20 AM nursing personnel (employee #2) was observed weighting a patient that was located on station #13 who finish treatment. While weighing the patient it was observed that scale does not stop showing the final weight measured. Instead of this the scale continues showing different weights lower and higher making difficult for employee #2 to registry the patient weight. When employee #2 finished weighing the patient was asked how she decided that was the final weight measured by the scale and she stated that she chooses the weight which is repeated twice. 4. On 07/10/2024 at 9:36 AM nursing personnel (employee #4) was observed weighting a patient that was located on station #33 who finish treatment. While weighing the patient it was observed that scale does not stop showing the final weight measured. Instead of this the scale continued showing different weights lower and higher making it difficult for employee #4 to registry the patient weight. When employee #4 finished weighting the patient was asked how he decide that was the final weight measured by the scale and he stated that he chooses the weight which stays longer on the scale digital screen. 5.On 07/10/2024 at 10:10 AM nursing personnel (employee #5) was observed weighting a patient that was located on station #38 who finish treatment. While weighing the patient it was observed that scale does not stop showing the final weight measured. Instead of this the scale continues showing different weights lower and higher making it difficult for employee #5 to registry the patient weight. 6. On 07/10/2024 at 10:18 AM nursing personnel (employee #5) was observed weighing a patient that was located on station #39 who finish treatment. While weighing the patient it was observed that scale does not stop showing the final weight measured. Instead of this the scale continue showing different weights lower and higher making difficult for employee #5 to registry the patient weight. When employee #5 finish weighting patient located on station #38 and #39, she was asked how she decide that was the final weight measured by the scale on both cases and she stated that she chooses the weight which appears first on the digital when she locate patients on the scale. 7.On 07/10/2024 at 10:06 AM nursing leader (employee #3) was asked that since the scale does not stop showing every patient’s final weight measured how the decide that was the final weight measured by the scale, and she stated that they choose the weight that prevails on the scale digital screen. 8. Facility failed to maintain equipment in good condition to promote dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment accordingly with the following findings identified during survey procedures on 07/09/2024 from 8:30 AM through 1:20 PM: a. On 07/09/2024 at 10:00 AM nursing personnel (employee #8) was observed while performing a disconnection procedure of patient located on station #38. This female patient had a chest catheter located on right side. For the procedure employee #8 use a privacy screen. The privacy screen used by employee #8 was observed that lacked balance and incline heading towards the patient. Despite the fact that the privacy screen lack balance and incline heading towards the patient, employee #8 did not replace it for other.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47384 Based on observational tour of the treatment area and personnel interview on 07/09/2024, with Regional Biomedical Technician (employe #7), it was determined that the facility failed to maintain a program to ensure that all equipment is maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Approximately at 9:40 AM dialysis machines #11 and #40 were observed with water leaks from bottom back part of machine creating a puddle of water. 2. Approximately at 9:40 AM dialysis machine #20 was found with the Diasafe filter lid laying on the floor. 3. Approximately at 10:10 AM the data cable on station #27 was observed broken and with exposed cables. 4. Data cables, electrical cords and drain tubes behind were observed dragging on the floor and not securely tighten to prevent contamination when cleaning the area. 5. During the arrest cart review, it was identified that one of the straight laryngoscopes had a fused bulb. 6. Approximately at 11:40 AM during review of the arrest cart it was observed that the suction pump meter was stained and does not permit a clear reading. 7. 29 out of 46 dialysis machines were observed with stained or peeled components 8. After reviewing five (5) dialysis machine preventive maintenance (PM) it was noticed that the PM on machine did not follow operation hours sequence when worked on.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 15884 Based on observational tour, review of policies and procedures, and interview with facility nursing supervisor (employee #1), it was determined that the facility failed to ensure that patients receive treatment in a manner that allows staff to have full view of patient’s access sites for the first shift and second shift during on 07/09/2024 & 07/10/2024 from 8:30 AM thru 1:20 PM at patient’s stations #3, #26 #31, #33, #34,#36 #38 and #40. This deficient practice affects 8 out of 27 patients observed receiving treatment. Findings include: Upon review of the facility’s policy # 3.03 Patient assessment Before, During and After Dialysis last update on 06/2014, Patient assessment and Monitoring on 07/10/2024 at 1:00 PM. Policy clearly stated that during dialysis personnel in charge must monitor the function and condition of the patient’s vascular access. This policy stated that the cannulation site/catheter insertion site and the line connections must remain visible. 1. During observations of the hemodialysis treatment area on 07/09/2024 & 07/10/2024 from 8:30 AM thru 1:20 PM the following was observed: a. Patient located on station #3 was observed with line connections located on left arm covered with blankets while receiving treatment. b. Patient located on station #26 was observed with face and body covered with a blanket. He maintains his right-side chest catheter area covered while receiving treatment. c. Patient located on station #13 was observed with her left arm vascular access (graft) and line connections covered with a blanket while receiving treatment. d. Patient located on station #33 was observed with line connections located on right chest catheter covered with blankets while receiving treatment. e. Patient located on station #34 was observed with line connections located on left femoral catheter covered with blankets while receiving treatment. f. Patient located on station #36 observed with face and body covered with a blanket. She maintains his right-side chest catheter area covered while receiving treatment. g. Patient located on station #38 was observed with line connections located on right chest catheter covered with blankets while receiving treatment. h. Patient located on station #40 was observed with face and body covered with a blanket. She maintains his left side arm vascular access (graft) and line connections covered with a blanket while receiving treatment. 2. No personnel were observed informing patients of the importance of keep their vascular access area visible to prevent needle dislodgement and/or vascular access-bloodline separation. 3. Facility nursing supervisor (employee #1), stated on interview on 07/09/2024 at 1:07 PM as per policy established that if nursing identifies that vascular access and line connections are not visible, they must request to their patient to uncover the vascular access. She stated that policy established indicates that nursing personnel must educate and explain to the patient in a manner that the patient understands about the risks associated if not maintain the vascular access visible at all times during the treatment. 4. The facility failed to promote policies and procedures that establish that access sites are to be left uncovered to allow complete visibility by the nursing staff, during hemodialysis treatment.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on observation and interviews made during the survey on 07/09/24 Regional Biomedical Technician (Employee #7), it was determined that the facility failed comply with provisions of the Life Safety Code (NFPA 101) Findings include: 1. Unprotected wall penetrations were observed between the hemodialysis unit and administrative and waiting area. 2. During the evaluation of the evacuation plan and the evaluation of the use of the mechanical evacuation chair, it was identified that the landing of the lateral staircase does not allow free handling of the equipment. Reference made to NFPA 101 7.2.8; this could limit the response time in a real evacuation.”

“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: 17959 Based on seventeen records reviewed (RR) and Review of Policy and Procedure (P&P), it was determinate that the facility failed to monitor and document the assessment perform to patients when a hemodialysis machine emits a blood pressure alerts according to the facility policy for 5 of 17 sample selected. (RR #5, RR#6, RR#8, RR#9 and RR#10). Findings include: 1. RR #5 is a 69-year-old male patient admitted to the facility on 05/25/2023 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 07/09/2024 at 3:00 PM, it was found that patient has hemodialysis treatment three a week for four hours, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 800, Dialyzer with NR160 and patient Dry Weight (EDW) 60.0 kilogram (kg). a. On 07/09/2024 at 3:00 PM review of the medical record revealed that on 07/02/2024 the patient developed seven alerts of hypertension during received the hemodialysis treatment, on 07/04/2024 developed five alerts of hypertension during received the hemodialysis treatment, on 07/06/2024 six alerts of hypertension the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician. 2. RR #6 is a 71-year-old male patient admitted to the facility on 02/01/2023 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 07/09/2024 at 3:15 PM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Graft Looped Left Forearm, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 700, Dialyzer with NR 180 ELEC BEAM and patient Dry Weight (EDW) 90.0 kilogram (kg). a. On 07/09/2024 at 3:30 PM review of the medical record revealed that on 06/26/2024 the patient developed four alert of hypertension during received the hemodialysis treatment, on 06/28/2024 the patient refused the heparin however received the hemodialysis treatment but no evidence that the nurse notify the physician related to this and on 07/08/2024 three alerts of hypertension, the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician. 3. RR #8 is a 64-year-old male patient admitted to the facility on 01/27/2023 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 07/10/2024 at 10:25 AM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Catheter Double Lumen Ciffed Right Internal Jugular Vein, Blood Flow Rate (BFR) of 300, Dialysis Flow Rate (DFR) of 800, Dialyzer with NR 180 ELEC BEAM Filter and patient Dry Weight (EDW) 78.0 kilogram (kg). a. On 07/10/2024 at 10:25 AM review of the medical record revealed that on 06/25/2024 the patient developed five alert of hypertension during received the hemodialysis treatment, on 06/27/2024 the patient developed two alert of hypotension during received the hemodialysis treatment and received treatment of Saline Solution 200 ml., on 07/02/2024 two alerts of hypotension and on 07/04/2024 two alerts of hypotension, the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician. 4. RR #9 is a 38-year-old female patient admitted to the facility on 05/06/2021 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 07/10/2024 at 8:55 AM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Catheter Double Lumen Cuffed Right Internal Jugular Vein, Blood Flow Rate (BFR) of 300, Dialysis Flow Rate (DFR) of 800, Dialyzer with NR 160 ELEC- BEAM Filter and patient Dry Weight (EDW) 94.0 kilogram (kg). a. On 07/10/2024 at 10:25 AM review of the medical record revealed that on 07/01/2024 the patient developed episodes of hypotension and the hemodialysis machine emit four alert of hypotension during received the hemodialysis treatment, on 07/05/2024 the patient developed five alert of hypotension during received the hemodialysis treatment and the nurse repeat the blood pressure per four times and the hemodialysis machine emit four alerts and on 07/08/2024 eight alerts of hypotension. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician. 5. RR #10 is a 59-year-old female patient admitted to the facility on 09/15/2022 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 07/10/2024 at 11:30 AM, it was found that patient has hemodialysis treatment three a week for 4.0 hours, Graft Curved Left Upper Arm, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 800, Dialyzer with NR 180 ELEC BEAM Filter and patient Dry Weight (EDW) 119.50 kilogram (kg). a. On 07/10/2024 at 10:25 AM review of the medical record revealed that on 06/25/2024 the patient developed four alerts of hypotension during received the hemodialysis treatment, on 06/27/2024 the patient developed two alerts of hypotension, on 06/29/2024 three alerts of hypotension, on 07/02/2024 two alerts one of hypotension and one hypertension, on 07/04/2024 three alerts of hypotension and one alert of hypertension, on 07/06/2024 three alerts hemodialysis machine emits blood pressure alerts. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician.”