Dci West Spartanburg

“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: 41743 Based on observations, interviews, and review of the facility’s policy, entitled, “Termination of Dialysis with a Fistula or Graft”, the dialysis staff failed to monitor and implement accepted principles of infection control for hand hygiene for 6 random patients observed exiting the dialysis treatment floor without performing hand hygiene after holding pressure to the dialysis exit sites at termination of the patient’s dialysis treatment. (Random Patient A, B, C, D, E, and F). The findings include: Observations on 11/27/2023 between 9:00 AM and 11:30 AM revealed random Patient A exiting the dialysis treatment room at 9:20 AM, random Patient B exiting the dialysis treatment room at 9:35 AM, random Patient C exiting the dialysis treatment room at 9:37 AM, and random Patient D exiting the dialysis treatment room at 9:42 AM without performing hand hygiene after holding a gloved hand to the dialysis access sites. Observations on 11/29/2023 revealed random Patient E exiting the dialysis treatment room at 12:00 PM without performing hand hygiene after holding gloved hand to access sites. Observations on 11/30/2023 at 9:30 AM revealed random Patient F exiting the dialysis treatment room at 9:29 AM without performing hand hygiene after holding gloved hand to access sites. On 11/30/2023 at 10:58 AM, Clinical Manager reported “We have had this problem”. Facility Policy, titled, “Termination of Dialysis with a Fistula or Graft”, revealed, “Patient should be given a glove to use when holding pressure and instruct patient to wash or sanitize hands after removing gloves from holding pressure”.”

“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: 41743 Based on observations, interviews, and review of the facility’s policy, entitled, “Handling, Use, and Storage of Sterile Injectable’s and Medications”, the dialysis staff failed to follow facility policy and current best practice by having medications, pre-filled and unfilled syringes, left unattended on the medication counter. The findings include: Observations on 11/27/2023 between 9:00 AM and 11:30 AM in Front Bay revealed 3 empty, labeled syringes and 1 multidose vial labeled Heparin lying unattended on the counter. In Back Bay, 5 empty labeled syringes and 1 multidose vial labeled Heparin lying unattended on the counter. Observations on 11/28/2023 between 11:10 AM and 12:38 PM revealed in Back Bay, a medication tray at the nursing station with a large amount of orange fluid spilled and not cleaned in a timely manner. Observations on 11/30/2023 between 9:00 AM and 9:35 AM revealed 4 empty and 2 prefilled labeled syringes, opened multidose vial labeled Heparin, and unopened multidose vial labeled Heparin left unattended on the counter. In Back Bay, 2 labeled empty syringes and 1 open multidose vial labeled Heparin left unattended on the counter. On 11/30?2023 at 9:18 AM, Skilled Nurse (SN) #4 reported when questioned about medication tray, “I cleaned the tray up and put new cups on it ...we can’t bring the tray to the patients ...we keep each cup labeled for that patient and we know each station”. Facility policy, entitled, “Handling, Use, and Storage of Sterile Injectable’s and Medications”, revealed, “All medications and biologicals are to be stored in a secure and orderly manner without crowding”.”

“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: 41743 Based on observations and interview, the dialysis staff failed to provide a safe environment for patients by failing to remove expired supplies from staff access, failed to follow best practice by leaving used supplies on chair side table, and littered on the floor and failed to clean wet floors in a timely manner. The findings include: Observations on 11/27/2023 between 9:00 AM and 11:30 AM in the supply room 3 revealed Yankeur suctions expired 11/22/2023. In the medication room was 63 1 ml(milliliter TB (Tuberculin) syringes expired 07/31/2023. The findings were verified by Clinical Manager at 9:35 AM. Opened alcohol packets, 2 x(by) 2 gauze, tape, saline syringe, clear wrappers, bits of paper, and bits of blue gloves on the dialysis treatment room floors were noted on the floor and on chair side tables. Observations on 11/29/2023 between 11:30 AM and 12:30 PM revealed open alcohol packets, 2 x 2 gauze and tape on the dialysis treatment room floor and chair side tables. Large amounts water on the floor at dialysis stations were not cleaned in a timely manner and no safety signs used to let patients and staff know of the hazards. Observations on 11/30/2023 between 9:00 AM and 9:35 AM revealed bits of paper, blue gloves, roll of tape, and gauze on the dialysis treatment room floor. On 11/30/2023 at 10:58 AM, Clinical Manager reported “We just had a staff member twist their ankle on a tape roll”.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 41743 Based on chart review, interview, and review of the facility’s policies, entitled, “PATIENT ASSESSMENTS: DURING DIALYSIS (CHRONIC)” and “INITIAL/ANNUAL STANDING HEMODIALYSIS OUTPATIENT ORDERS”, the facility staff failed to follow the facility’s policy for Hypertension medication and monitoring for 3 of 6 patients. (Patient #2, #3, and #6) The finding includes: Chart review on 11/29/2023 at 10:09 AM for Patient #2 revealed: Dialysis Treatment dated 11/18/2023: “pt(patient) did not take any bp(blood pressure) medicine today. Clonidine given before start of tx (treatment)”. At 9:18 AM, BP 231/116, BP reading at 10:01 AM of 247/232, BP Reading reading at 10:31 AM of 177/95. Nicardipine administered at 10:04 AM. Per policy standing orders, Nicardipine is to be given 30 minutes after Clonidine if BP remains high, but the Nicardipine was given 46 minutes after the Clonidine. On 11/29/2023 at 1:35 PM, Clinical Manager verified the findings. Chart review on 11/28/2023 at 2:55 PM for Patient #3 revealed: Dialysis Treatment dated 11/17/2023: BP 133/81 at 8:31 AM and the next BP reading of 123/62 at 9:31 AM which was 60 minutes between staff observation of patient. On 11/29/2023 at 1:30 PM, the Clinical Manager verified the findings. Chart review on 11/28/2023 at 2:32 PM for Patient #6 revealed: Dialysis Treatment dated 11/13/2023: BP 174/104 at 11:00 AM and the next BP reading of 173/94 at 11:53 AM was 53 minutes between staff observation of patient. Dialysis Treatment dated 11/20/2023: BP 142/85 at 11:55 AM and the next BP of 183/100 at 12:55 PM was 60 minutes between staff observation of patient. On 11/29/2023 at 12:59 PM, Clinical Manager verified the findings. Facility policy, entitled, “PATIENT ASSESSMENTS: DURING DIALYSIS (CHRONIC)”, revealed, “Patient and machine parameters will be monitored and documented, at a minimum, every 30 minutes at this facility”. Facility policy, entitled, “INITIAL/ANNUAL STANDING HEMODYALYSIS OUTPATIENT ORDERS”, revealed, “Hypertension is defined as systolic BP 170 or higher and Diastolic BP 95 or higher for two consecutive readings ...If patient is hypertensive and has minimal fluid gains initiate hypertensive medication immediately. Administer Catapress (Clonidine) 0.1 mg SL (sublingual). If hypertension persists after 30 minutes administer Cardene (Nicardipine) 20 mgs(milligrams) PO (Oral). After 1 hour if the BP does not lower administer Catapress (Clonidine) 0.2 mg SL. After 1 hour if patient continues to be hypertensive notify MD (Medical Doctor)”.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 41743 Based on record reviews, interviews, and facility policies, entitled, “Neutral Volume Catheter Cap Replacement and Catheter Flushing” and Hemodialysis Catheter Dressing Change and Exit Site Care”, the facility staff failed to provide documentation for weekly dressing changes and catheter end cap replacements for 2 of 2 applicable patients. (Patient #2 and Patient #4) The findings include: Chart review on 11/29/2023 at 10:09 AM for Patient #2 revealed for the weeks of 11/06/2023 and 11/20/2023, there was no documentation for Central Venous Catheter (CVC) site care, dressing change, or end cap replacement. On 11/29/2023 at 1:35 PM, the Clinical Manager verified the findings. Chart review on 11/29/2023 at 10:34 AM for Patient #4 revealed for weeks of 11/06/2023 and 11/13/2023, there was no documentation for CVC site care, dressing change, or end cap replacement. On 11/29/2023 at 1:30 PM, the Clinical Manager verified the findings. Facility policy, entitled, “Neutral Volume Catheter Cap Replacement and Catheter Flushing”, reveals, “Neutral volume catheter caps will be changed every seven days”. Policy entitled “Hemodialysis Catheter Dressing Change and Exit Site Care” reveals, “Catheters dressed with a Tegaderm will be changed every seven days of whenever dressing is soiled, loose, or wet”.”