Usrc Powderhorn Dialysis

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 28883 Based on record reviews, interviews, and review of the facility’s policy, titled, “Patient Hepatitis B Testing/Vaccination/Seroconversion”, the dialysis clinic’s nursing staff failed to ensure the Engerix vaccine was scheduled and/or administered according to facility policy/dosing schedule recommended by the manufacturer for Patient #5 who is one of two patients reviewed with physician orders for the Engerix vaccine. The findings included: The dialysis clinic admitted Patient #5 on 2/3/23 with diagnoses including End Stage Renal Disease. On 11/29/23 at 12:30 PM, review of physician orders revealed the Hepatitis B vaccine, Engerix, was ordered for administration on 7/17/23, 8/16/23, and 9/18/23. The next dose of Engerix was scheduled for 1/16/24. Review of the patient’s dialysis treatment sheets revealed the patient did not receive a dose of Engerix on 7/17/23 and the dose was “rescheduled”. There was no documentation to indicate the patient received a dose of Engerix in July 2023. On 11/29/23, review of the facility’s policy, titled, “Patient Hepatitis B Testing/Vaccination/Seroconversion”, revealed, the Engerix B dosing schedule was for patients to receive 4 (total) doses at month 0, 1, 2, and 6. During an interview on 11/29/23 at 1:26 PM, the Facility Administrator reviewed the patient’s record and facility policy and verified the patient had missed a dose of the Engerix vaccine in July 2023, and the Engerix was not rescheduled and/or the dosing administered according to the timeframe listed in the facility policy/dosing schedule.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 28883 Based on observations, interview, and review of the facility policy, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation”, Patient Care Technician (PCT) #2 who was one of two PCTs observed for initiation of the patient’s dialysis treatment failed to re-clean the skin over the dialysis access site with antiseptic prior to sticking needles in after touching the sites with gloved hands. The findings included: Observations on 11/27/23 at 11:41 AM revealed Patient Care Technician (PCT) #2 in dialysis station 21 at dialysis machine 16. PCT #2 cleaned the patient’s skin with alcohol over the two dialysis access sites. Then, PCT #2 touched the skin with gloved hands palpating the access site to feel where to stick the needles. PCT #2 did not re-clean the skin with alcohol prior to sticking both needles in. On 11/28/23 at 12:15 PM, review of the facility’s policy provided by the dialysis clinic, entitled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation”, revealed, “...Repeat access preparation if cannulation area has been touched/contaminated...”.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 28883 Based on observations, interview, and review of the facility’s policy, titled, “Accessing and De-Accessing the Dialysis Catheter”, Registered Nurse (RN) #2 who was one of two registered nurses observed discontinuing a dialysis treatment for a patient with a Central Venous Catheter failed to ensure the patient’s mask covered his/her nose to prevent possible contamination of the catheter by nasal droplets/bacteria. The findings included: Observations on 11/27/23 at 1:02 PM revealed Registered Nurse (RN) #2 discontinuing a treatment for a patient at dialysis machine 21 in dialysis station 8. While accessing the catheter, the patient’s mask was down not covering the patient’s nose. During an interview on 11/27/23 at 1:15 PM, the finding was verified by RN #2. On 11/28/23 at 12:15 PM, review of the facility’s policy provided by the dialysis clinic, entitled, “Accessing and De-Accessing the Dialysis Catheter”, revealed, “...Don full PPE (Personal Protection) including mask; assist patient to don mask...”.”

“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: 28883 Based on observations, interview, and review of the RPC Test strips Instructions for Use and the clinic’s policy, entitled, “Total Chlorine Testing”, Patient Care Technician (PCT) #1, one of two PCTs observed testing the dialysis water for total Chlorine failed to wait 20 seconds for the RPC test strip to develop. PCT #3, one of two PCTs interviewed about the maximum amount of total Chlorine allowed in dialysis water was not knowledgeable of the limit of 0.1/less than 0.1 ppm (parts per million). The findings included: Observations on 11/27/23 at 2:28 PM revealed Patient Care Technician #1 performing a total Chlorine water check. After swishing the RPC test strip in the water for 1 minute, PCT #1 folded the test strip and placed the test strip against the color chart to read the result. There was no timer used by PCT #1. The surveyor asked how long PCT #1 waited after swishing the strip and before reading the result. PCT #1 stated that she/he waited 2 seconds, and verified she/he did not time the wait. The surveyor timed the wait and informed PCT #1 that she/he had waited 10 seconds before holding the test strip to the color chart and it was 15 seconds total before PCT #1 read the result. PCT #1 again stated she/he doesn’t time this but it takes about 2 seconds to fold the strip and read the result after comparing it to the color chart. Review with PCT #1 on 11/27/23 at 2:32 PM of the RPC Ultra-Low Total Chlorine Test Strips Instructions For Use, revealed, “...Wait 20 seconds for the test strip color to develop...After the 20 second wait period, immediately compare the strip color to the ...color chart to determine the Total Chlorine level in the sample...”. Observations on 11/28/23 at 11:27 AM revealed Patient Care Technician #3 performing a total Chlorine water check correctly. During an interview at 11:30 AM, PCT #3 when asked what the maximum allowable limit of total Chlorine was, stated it was 0.01. The surveyor asked PCT #3 if she/he was sure and to point to the maximum allowable limit on the color chart. PCT #3 stated 0.01 and pointed to the color corresponding to the 0.01 result. The surveyor interviewed PCT #3 re: procedures for breakthrough Chlorine to which PCT #3 again stated the action level would be 0.01. On 11/28/23 at 12:15 PM, review of the facility’s policy provided by the dialysis clinic, entitled, “Total Chlorine Testing”, revealed, “To provide safe water for dialysis by ensuring that ....patients are dialyzed only with water having Chlorine/Chloramine levels with the limits specified by the Association for the Advancement of Medical Instrumentation (AAMI)...clinics measure Total Chlorine to ensure the Chlorine/Chloramine levels are less than 0.1 ppm...”.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 28883 Based on observations, interviews, and review of the Fresenius 2008T Hemodialysis machine operator’s manual, one of two Registered Nurses, (RN) #1, and one of two Patient Care Technicians, (PCT) #1 failed to ensure a check of the independent conductivity and pH of the ordered dialysate was completed before attempting to start a patient treatment. The findings included: Observations on 11/27/23 at 10:37 AM revealed Registered Nurse (RN) #1 in dialysis station 7 at dialysis machine 14, checking the independent pH and conductivity of the dialysate. Dialysis machine 14 was in a 3K(Potassium) 2.5 Ca(Calcium) acid concentrate. At 10:50 AM, RN #1 changed the dialysis machine settings and acid concentrate to the ordered 2K 2.5 Ca acid concentrate. At 10:59 AM, RN #1 and Patient Care Technician (PCT) #1 stated they would start the patient’s dialysis treatment in 2 minutes. The surveyor asked if there was anything else that needed to be done. RN #1 reported he/she was unsure, but when the surveyor mentioned she/he had changed the acid concentrate/dialysis machine settings, RN #1 stated they would need to check the independent conductivity and pH of the ordered dialysate. On 11/29/23 at 11:15 AM, review of the 2008T Machine Operator’s Manual revealed “...Warning! Always verify the conductivity and approximate pH of the dialysate solution through independent means before initiating each dialysis treatment...”.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 28883 Based on record reviews and interview, the dialysis clinic staff failed to ensure that 5 of 5 patient care plans reviewed for Patient #1, #2, #3, #4, and #5) were authenticated by all the interdisciplinary team members to include the Registered Nurse (RN). The findings included: On 11/28/23 and 11/29/23, review of the patients’ care plans revealed the following: Patient #1 had care plans dated 8/22/23 and 10/24/23 that had not been signed by a registered nurse. Patient #2 had a care plan dated 6/20/23 that was not signed by the registered nurse. Patient #3 had care plans dated 10/24/23 and 11/14/23 that did not have a registered nurse signature. Patient #4 had a care plan meeting on 9/19/23 with no RN signature on the care plan. Patient #5’s care plan dated 6/20/23 did not have a registered nurse signature. The findings were verified by the Facility Administrator (FA) during an interview on 11/29/23 at 1:36 PM.”

“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: 28883 Based on record reviews, interview, and review of the facility’s policy, “Intradialytic Monitoring of Patient”, the clinic’s nursing staff failed to ensure patient vital signs and/or monitoring had been documented timely for Patient #3 who was one of five patients reviewed for dialysis care. The findings included: The dialysis clinic admitted Patient #3 on 5/3/23 with diagnoses including End Stage Renal Disease. On 11/28/23 at 1:53 PM, review of the patient’s dialysis treatment sheets revealed that on 11/623, staff monitoring was documented at 10:32 AM and again at 11:43 AM. On 11/10/23, vital signs were documented at 10:05 AM and again at 11:40 AM, and staff monitoring was documented at 10:09 AM and again at 12:00 Noon. The findings were verified by the Facility Administrator during an interview on 11/29/23 at 1:36 PM. On 11/29/23, review of the facility’s policy provided by the dialysis clinic, entitled, “Intradialytic Monitoring of Patient”, revealed, “vital signs are obtained and documented at least every 30 minutes, and that during the every 30 minute monitoring, the patient’s access, blood lines, well-being/face would be evaluated along with the delivery of the dialysis prescription and response to treatment.” A comment regarding the patient status/staff observation would be documented every 30 minutes.”