Dentsville Kidney Center

“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: 30011 Based on observations, interview, and review of facility policy and procedure, the facility failed to ensure 1 of 2 Certified Clinical Hemodialysis Technicians (CCHT) 1 did not follow accepted infection control practices to prevent potential cross contamination in the renal setting in the use of tape in the dialysis treatment room. The findings include: Observations on 01/24/24 at 9:30 AM in the dialysis treatment room revealed CCHT 1 tore strips of clean tape and placed the tape on the side of the dirty bedside table that had no prior disinfection in dialysis station 11. Observations revealed the patient was de-cannulated post treatment and the tape strips from the dirty bedside table were applied to the patient’s access site. During an interview on 01/24/24 at 12:42 PM, CCHT 1 stated, “I normally tear my tape as I go and put it on the side of the bedside table.””

“BACT OF H20-MAXIMUM & ACTION LEVELS CFR(s): 494.40(a) 4.1.2 Bacteriology of water: max & action levels Product water used to prepare dialysate or concentrates from powder at a dialysis facility, or to process dialyzers for reuse, shall contain a total viable microbial count lower than 200 CFU/mL and an endotoxin concentration lower than 2 EU/mL The action level for the total viable microbial count in the product water shall be 50 CFU/mL, and the action level for the endotoxin concentration shall be 1 EU/mL. If those action levels are observed in the product water, corrective measures shall promptly be taken to reduce the levels. This Standard is not met as evidenced by: 36779 Based on record reviews and interview, the facility failed to take prompt action when the product water was above action level four times from 8/7/23 to 8/28/23 witth no documentation of action taken. The findings include: On 1/23/24 at 9:30 AM, review of the facility’s Water Quality and Water Systems Log binders revealed a report, titled, “Environmental CQI Report” dated 7/1/23 to 8/30/23. The report showed the Bicarbonate Distribution System Return had colony counts above the Action Level (AL) of 50 CFU/mL (colony forming units per milliliter). On 8/7/23, the colony count was greater than 300; on 8/14/23, the colony count was 234; on 8/21/23, the colony count was 300; and on 8/28/23, the colony count was greater than 300. The documentation in the report showed the colony counts on those date were at or above the Maximum Allowable Level (MAL). During an interview with the Biomedical Technician (BMT) on 1/23/24 at 1:30 PM, he/she confirmed the findings.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 30011 Based on record reviews and interview, the dialysis facility failed to ensure the Interdisciplinary team (IDT) members developed a plan of care (POC) for 2 of 2 peritoneal dialysis (PD) patients (Patient 1 and 2) and for 3 of 5 in-center patient charts (Patients 3, 4, and 5). The findings include: Record review on 01/23/24 at 12:41 PM revealed Patient 2 was admitted to the home therapy program on 09/13/23 for Hypertensive Chronic Kidney Disease (CKD) with stage 1. Review of the patient’s chart revealed an initial stable comprehensive assessment/POC dated 09/29/23 with different signature dates by the IDT: Registered Nurse (RN) 10/05/23, Registered Dietician (RD) 09/29/23, Social Worker (SW) 09/29/23, and Medical Doctor (MD) 10/05/23. Further review revealed a 90 day stable comprehensive/POC dated 12/31/23 with different signature dates by the IDT: RN 01/22/24, RD 01/23/24, SW 01/22/24, and MD 01/23/24. During an interview on 01/24/24 at 2:19 PM, PD Nurse 1 verified the findings. Record review on 01/23/24 at 11:21 AM revealed of Patient 3’s chart was admitted to on 01/30/23 for End Stage Renal Disease (ESRD). Review of an unstable comprehensive assessment/POC dated 09/13/23 revealed different signature dates for the IDT: Registered Nurse (RN) 09/14/23, dietician (RD) 09/15/23, social worker (SW) 09/14/23 and physician (MD) 08/24/23. Further review revealed a stable comprehensive assessment/POC dated 11/29/23 with different signature dates for the IDT: RN 12/04/23, RD 01/23/24, SW 11/29/23 and MD 11/22/23. During an interview on 01/24/24 at 2:38 PM, the Clinic Manager (CM) stated, “We thought we had 30 days for everyone to close out their portion of the meeting. We each meet with the patient individually and develop our own plan of care for the patients”. Record review on 01/23/24 at 2:22 PM revealed of Patient 4’s was admitted on 07/03/23 for End Stage Renal Disease (ESRD). Review of an unstable comprehensive assessment/POC dated 09/18/23 revealed different signature dates for the IDT: Registered Nurse (RN) 09/18/23, dietician (RD) 10/16/23, social worker (SW) 09/15/23 and physician (MD) 09/29/23. Further review revealed a stable comprehensive assessment/POC dated 10/25/23 with different signature dates for the IDT: RN 11/22/23, RD 12/04/23, SW 11/14/23, and MD 11/14/23. During an interview on 01/24/24 at 3:06 PM, the Clinic Manager (CM) verified the findings. 36779 On 1/24/24 at 2:50 PM, review of Patient #1’s record revealed the patient was admitted on 8/15/22 with a diagnosis of Diabetes Mellitus Type 2. Review of the patient’s record revealed the Interdisciplinary Team (IDT) Comprehensive Assessment Plans of Care were on 11/13/23 and 12/28/23. The IDT POC dated 11/13/23 was signed by the Nurse on 12/1/23, the Dietitian, and Social Services on 11/30/23, and the Physician on 12/1/23. The IDT POC dated 12/28/23 was signed by the Nurse and Dietitian on 1/4/24, Social Services on 12/29/23, and the Physician on 1/22/24. There was no documented evidence the IDT met to review and update the plans of care on 11/13/23 and 12/28/23. These findings were confirmed in an interview with the Clinic Manager on 1/24/24 at 3:15 PM. On 1/24/224 at 2:40 PM, review of Patient #5’s record revealed the patient was admitted on 9/29/23 with a diagnosis of End Stage Renal Disease. Review of the patient’s IDT POC dated 12/11/23 revealed the IDT POC on 12/11/23 was signed by the nurse on 12/29/23, the Dietitian on 12/28/23, Social Service on 12/29/23 and the Physician on 12/12/23. There was no documented evidence the IDT met to review and update the plans of care on 12/11/23. These findings were confirmed in an interview with the Clinic Manager on 1/24/24 at 2:48 PM.”

“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: 30011 Based on record reviews, interviews, and review of the facility’s policy and procedure, the dialysis facility failed to ensure the ultrafiltration rate for 1 of 3 in-center patients (Patient 4) was not exceeded during dialysis treatment. The findings include: Record review on 01/23/24 at 2:22 PM revealed Patient 4 was admitted for End Stage Renal Disease (ESRD). Patient 4 presented with a 6.4 IFG (intradialytic fluid gain) on 01/03/24. Review of the standing orders dated 07/07/23 revealed the “ordered maximum ultra filtration rate” for the patient was “13.0 ml (milliliter)/kg (kilogram)/hr (hour)”. Patient 4’s treatment time was 3 hours and 30 minutes, dry weight was 68 kgs which meant the total volume of fluid to be removed was 3094 mls. Review of the dialysis treatment sheet noted Patient 4 dialyzed for 3 hours and 30 minutes with 3695 ml removed during the dialysis treatment which was 601 ml over the amount of fluid to be removed. During an interview on 01/24/24 at 3:06 PM, the Clinic Manager (CM) stated, “They are not to pull over the set max ultrafiltration treatment amounts on the treatment sheets”. Record review on 01/23/24 at 2:22 PM revealed Patient 4 was admitted for End Stage Renal Disease (ESRD). Patient 4 presented with a 9.1 IFG on 01/15/24. Review of the patient’s dialysis treatment sheet dated 01/15/24 revealed Patient 4 dialyzed for 3 hours and 30 minutes, dry weight was 68 kgs which meant the total volume of fluid to be removed was 3094 ml. Review of the dialysis treatment sheet showed 4007 mls was removed during the dialysis treatment which was 913 ml over the amount of fluid to be removed. During an interview on 01/24/24 at 3:06 PM, the CM verified the findings.”