Dci East Cooper

“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: 41879 Based on observations, staff interview, and review of facility policies and procedures, the End Stage Renal Dialysis (ESRD) staff failed to use standard infection control practices for hand hygiene after glove removal for one of three Patient Care Technicians (PCT) observed. (PCT 1) The findings are: On 03/13/2023 at 10:22 AM, observations in the dialysis treatment area revealed PCT 1 setting up a dialysis machine at dialysis station #3. PCT 1 touched multiple surfaces in the dialysis station and had contact with the patient wearing gloves. PCT 1 removed her gown, doffed her gloves at the doorway, and exited the dialysis treatment area. No hand hygiene was observed after PCT 1 doffed the soiled gloves and exited the dialysis treatment area. The findings were verified with PCT 1 on 03/13/2024 at 10:30 AM. Facility policy, titled, “Infection Control For Dialysis Facilities,” reads, “Hand Hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, and before touching clean areas such as supplies.””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 41879 Based on observations, staff interview, and facility policy and procedures review, the End Stage Renal Dialysis (ESRD) staff failed to disinfect non disposable items to prevent cross contamination between patients for one of three Patient Care Technicians (PCT) observed. (PCT 1) The findings are: On 03/13/2024 at 10:10 AM, observations in the dialysis treatment area revealed PCT 1 setting up a new patient at dialysis station #3. PCT 1 touched multiple surfaces in dialysis station #3 including the patient and the patient’s belongings. PCT 1 exited the dialysis station and obtained a thermometer from the counter at the nurse station on a clean drape. PCT 1 did not doff gloves and perform hand hygiene before touching the thermometer. PCT 1 scanned the patient’s forehead, and then left the dialysis station, and returned the thermometer to the clean drape without disinfecting the thermometer. The findings were verified with PCT 1 on 03/13/2024 at 10:30 AM. Facility policy, titled, “Infection Control In Hemodialysis,” reads, “Items taken to a patient’s dialysis station, including those placed on top of the machine, should either be disposed of, dedicated for use on that patient, or cleaned and disinfected before being returned to a common clean area or used for other patients, including blood pressure cuffs and conductivity meters.””

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 41879 Based on observations, staff interview, and facility policy and procedure review, the End Stage Renal Dialysis facility failed to follow standard infection control practices for use of multi-dose vials and expired medications in the dialysis treatment area. The findings are: On 03/11/2024 at 1:35 PM, a tour of the facility revealed one opened vial of Heparin in the medication preparation area located in the dialysis treatment area. The vial of Heparin had no cap and the septum had puncture sites. No time, date, or staff initials were on the vial of medication. The findings were verified with Registered Nurse (RN) 1 on 03/11/24 at 1:40 PM. Facility policy, “Medication Policy,” reads, “Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer as in the case of vaccines or state pharmacy regulations. Each vial is labeled with the initials of the person opening the vial and the expiration date.” The policy also states, “Medications are ordered and replaced prior to expiration.””

“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: 41879 Based on observations, staff interview, and facility policy and procedure review, the End Stage Renal Dialysis (ESRD) facility failed to check and removed expired supplies from patient care areas. The findings are: On 03/11/2024 at 1:13 PM, a tour of the facility yielded one box with approximately 100 recanulation connectors expired on 11/30/2023. The findings were verified with the Nurse Manager on 03/11/2024 at 1:30 PM. Facility policy, titled, “Infection control for Dialysis Facilities,” reads, “Supplies must be rotated First in -First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 41879 Based on record review, staff interview, and facility policy and procedure review, the End Stage Renal Dialysis (ESRD) Center failed to follow physician orders for the Blood Flow Rate (BFR) and Dialysis Flow Rate (DFR) for two of five In Center Hemodialysis (ICHD) patient records reviewed. (Patient 1 and 5) The findings are: Patient 1 Review of Patient 1’s chart on 03/12/24 at 2:49 PM revealed one of ten dialysis treatment sheets documented incorrect Blood Flow Rate (BFR) and two of ten dialysis treatment sheets documented incorrect DFR. “Hemo Treatment Orders” dated 02/09/2024, read, “Blood Flow Rate: 400 and Dialysis Flow Rate: 600.” BFR On 02/26/2024, Patient 1’s dialysis treatment started at 12:07 PM with a BFR of 350. The BFR was raised to 380 at 12:28 PM. The BFR ran at 380 the rest of the dialysis treatment which ended at 13:42 PM. DFR On 03/04/2024, Patient 1’s dialysis treatment started at 12:33 PM with a DFR of 800. The DFR ran at 800 the entire dialysis treatment which ended at 4:07 PM. On 03/06/2024, Patient 1’s dialysis treatment started at 11:46 PM with a DFR of 800. The DFR ran at 800 the entire dialysis treatment which ended at 3:53 PM. Patient 5 Review of Patient 5’s chart on 03/13/2024 at 2:30 PM revealed one of ten dialysis treatment sheets documented incorrect DFR. “Hemo Treatment Orders” dated 07/17/2023, read, “Blood Flow rate 400 and Dialysis Flow Rate 600.” DFR On 03/07/2024, Patient 5’s dialysis treatment started at 15:6:39 AM. The DFR was documented as 800. The DFR was documented 800 the entire dialysis treatment which ended at 100:00 AM. Facility Policy, titled, “CWOW-PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT,” reads, “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain blood flow rate) the reason will be documented and the licensed nurse informed.””

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 41879 Based on record review, staff interview, and facility policy and procedure review, the End Stage Renal Dialysis (ESRD) Center staff failed to follow physician orders for Dialysate for one of five Incenter Hemodialysis patients (Patient 6), and ESRD staff failed to perform conductivity on dialysis machines as per manufacturers guidelines for one of three Patient Care Technicians (PCT) observed. (PCT #1) The findings are: Dialysate On 03/12/2024 at 10:00 AM, observations in the dialysis treatment area revealed Registered Nurse (RN) 1 starting Patient 6’s dialysis treatment. Patient 6’s prescription was verified with RN 1 once the patient treatment was started. Patient 6 was running on a 3K (Potassium) 2.5 CA (Calcium) bath, but the prescribed dialysate was 2K 2.5 CA. The findings were verified with RN 1 on 03/12/2024 at 10:20 AM who immediately switched the dialysate to the correct bath. Conductively On 03/12/2024 at 10:40, observations in the dialysis treatment area revealed PCT 1 setting up the dialysis machine in dialysis station 3 for a new patient. PCT 1 changed the acid bath for the new patient, but no conductivity test was observed performed on the new acid bath. PCT 1, on 03/12/2024 at 11:50 AM, stated, “I did the conductivity earlier. Surveyor observed the dialysis machine just finished test and start up mode. PCT 1 stated, “Yes I am suppose to do the conductivity after the test mode is finished.” Facility policy, “ Set-Up & Priming a Single Use Dialyzer Utilizing Fresnius 2009 K, K2 and T Dialysis Delivery System with Streamline Bloodlines, “ reads, “Verify dialysis prescription: Ensure bicarbonate and prescribed dialysis are connected to dialysis machine.” Finish testing dialysis machine per facility policy. Perform alarm and pressure tests. When all the tests pass the message ‘test complete’ will display. Check temperature, conductivity and pH of dialysate using independent meter.””