Clinton Dialysis Clinic

“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: 28883 Based on observation, interview, and policy review, Patient Care Technician (PCT) #1, one of two PCT’s observed discontinuing a patient treatment, failed to encourage a patient to perform hand hygiene before leaving the treatment room. The findings include: Observation on 8/5/24 at 11:35 AM revealed a patient at machine #13, station #17, holding pressure with a gloved hand to stop the bleeding after a dialysis needle had been removed. The 2nd needle was removed and a clamp placed over the site. After the bleeding had stopped, the patient removed the glove, Patient Care Technician (PCT) #1 reinforced tape over the two needle sites, assisted the patient to a wheelchair, and accompanied the patient to the scale. PCT #1 did not offer the patient hand sanitizer or encourage the patient to perform hand hygiene before wheeling the patient out of the treatment room to the waiting room. During an interview on 8/5/24 at 11:53 AM, PCT #1 verified the observation. Review on 8/7/24 at 2:40 PM of the facility policy “Infection Control” revealed information that patients will be educated and encouraged to wear gloves when holding their access sites after needle removal and wash their hands before entering and leaving the patient treatment area.”

“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 policy “G40 Infection Control,” the dialysis facility staff failed to follow standard infection control practices to prevent cross contamination between patients for one of two Registered Nurses (RN) observed. (RN #1) Findings include: On 08/05/2024 at 11:45 AM observations are made in the treatment area. RN #1 is assessing a new patient at Station #7. RN #1 doffed the gloves she/he was wearing and tossed the gloves on top of the dialysis machine, walked away to collect supplies and returned to the patient at Station #7. RN #1 then donned new gloves and began to set up supplies for Central Venous Catheter (CVC) Catheter dressing change. RN #1 did not perform hand hygiene between glove change possibly contaminating CVC dressing supplies. Findings are verified with RN #1 on 08/07/2024 at 12:30 PM. Facility policy, “G40 Infection Control,” reads, “Hands are always washed after gloves are removed and between patient contacts, as well as after touching blood, body fluids, secretions, secretions and contaminated items”.”

“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 review of facility policy, “G40 Infection Control,” the dialysis facility staff failed to prevent potential cross contamination between patients for one of two Registered Nurses (RN’s) observed. (RN #1) Findings are: On 08/05/2024 at 11:45 AM, observations in the treatment area revealed RN #1 assessing a patient at Station #7. RN #1 listened to the patient’s heart and lungs with a stethoscope. After using the stethoscope RN #1 placed the stethoscope around his/her neck. RN #1 then placed the stethoscope on a rolling computer table and is called to another patient to do a post treatment assessment. RN #1 takes the stethoscope from the computer table and uses the stethoscope to listen to the patient at Station #12. After listening to the patient at Station #12, RN #1 places the stethoscope back on the rolling computer table and is called to another patient and does a pre-treatment assessment, listening to heart and lungs, on a new patient at Station #16. RN #1 failed to disinfect his/her stethoscope between patient assessments. Findings are verified with RN #1 on 08/07/2024 at 12:30 PM. Facility policy, “G40 Infection Control,” reads, “27. Reusable supplies will not be shared between patients without being disinfected between each use per the appropriate procedure; this includes blood pressure cuffs and stethoscopes.””

“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: 41879 Based on observation, staff interview and review of facility policy, “IC24 Checking Conductivity & pH of Dialysate,” the dialysis facility staff failed to check conductivity on dialysate before the dialysis treatment for one of three Patient Care Technicians (PCT) observed (PCT #3). Findings include: On 08/07/2024 at 9:10 AM observations are made of the treatment area. PCT #3 is observed setting up the dialysis machine at station #13 for Patient #2. PCT #3 then initiated treatment for the patient post accessing Patient #2’s fistula. PCT #3 was not observed checking the conductivity on the dialysis machine before the treatment started. On 08/07/2024 at 09:35 AM, PCT #3 was asked if the conductivity was checked prior to treatment and she/he responded, “No”. PCT #3 did return to the machine and check the conductivity after treatment was started. Facility Policy, “IC24 Checking Conductivity & pH of Dialysate,” reads, “It is mandatory that independent testing of conductivity of dialysate is performed prior to start of each patient treatment and whenever there is a change in the dialysate during treatment (i.e, physician orders a change in the dialysate bath during the patient’s treatment.)””

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 41879 Based on record review and staff interviews, the dialysis facility failed to obtain cultures for dialysis machines before disinfection for 7 of 22 dialysis machines reviewed. (Machines #9, #10, #11, #12, #13, #14 and #15). Findings include: On 08/06/2024 at 10:30 AM the dialysate cultures for 22 clinic dialysis machines are reviewed. Review of facility yearly culture report revealed the facility bleaches the dialysis machines every Tuesday. Review of the culture report revealed dialysis machines #9-#15 were disinfected on 3/19/2024 with cultures collected on 03/20/2024. Further review revealed machines #9 and #10 were disinfected on 6/11/24 and cultured on 06/12/2024. During an interview with Biomedical Technician (BMT) #1 on 08/06/2024 at 1:00 PM, BMT #1 stated, “I have been covering other clinics and my Biomedical Team here must have collected after disinfection. We should get our cultures before disinfection.””

“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: 28883 Based on observations, interviews, and facility policy review, the dialysis clinic nursing staff failed to ensure expired supplies had been removed from staff access, that training supplies had been labeled, and that medications had been secured. The findings include: Observation on 8/7/24 at 9:43 AM of the in-center lab area on the treatment room revealed (39) vacutainers expired on 6/30/24. During an interview on 8/7/24 at 9:45 AM, Patient Care Technician #3 verified the findings. Observation on 8/7/24 at 12:40 PM to 12:50 PM of the Home Therapy department revealed the following: a lab supply cabinet that contained expired lavender lab tubes used to collect peritoneal dialysis effluent, (1) lab tube expired on 4/1/24 and (22) lab tubes expired on 7/31/24. Observation of the home therapy exam room revealed (10) packages of sterile fields that expired on 10/30/22 and a partially filled drainage bag of fluid attached to a partially filled bag of 1.5% (percent) Dextrose solution, peritoneal dialysate with no label on the fluids to indicate if the supplies were used for training or if it had been used for a patient. Observation of a 2nd exam room revealed a medication refrigerator containing multiple boxes of Mircera (stimulates the body to produce red blood cells) that was unsecured with the lock and key sitting on top of the refrigerator and an unlocked drawer with a key in the lock containing Venofer (Iron) medication. On the exam table were multiple boxes of Venofer with no staff observed in the Home Therapy Department at the time the unsecured medications had been observed. The Home Therapy department including the home therapy exam rooms were able to be accessed by an unlocked door where staff/others coming in the back door through a hallway could access the medications. During a phone interview on 8/7/24 at 1:05 PM, the findings were reviewed with Home Therapy Registered Nurse (HTRN) #1. HTRN #1 stated the home therapy nursing staff had not been in the clinic since last Wednesday (1 week ago). HTRN stated the medication refrigerator and drawers had been locked when they left. HTRN #1 believed someone had stocked the medication refrigerator and drawer and had left the medications unsecured. She/he stated the HTRN had shown a prospective patient/caregiver how peritoneal dialysis worked and had forgotten to remove the used training supplies. HTRN #1 was not aware of the expired supplies. Review on 8/7/24 at 2:35 PM of the facility policy “Medications: Handling, Administration, Storage & Disposal” revealed information that medications must never be left unsecured or unattended. Review on 8/7/24 at 2:40 PM of the facility policy “Infection Control” revealed that no dialysis supplies or medications may be used after the manufacturer expiration date printed on the package.”

“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: 41879 Based on observation and interview, Patient Care Technician (PCT) #2, one of two PCT’s observed initiating a dialysis treatment, failed to program the ordered concentrate settings into the hemodialysis machine prior to the start of treatment. The findings include: On 08/07/2024 at 9:05 AM observations are made of the treatment area. PCT #2 is observed starting a dialysis treatment for a patient at Station # 5. Once the treatment was started, the surveyor asked PCT # 2 to verify the prescription. The dialysis bath was set in the dialysis machine for 3 K (Potassium) and 2.5 Ca (Calcium). Review of physician orders in the computer on wheels revealed the prescribed dialysis prescription for the patient at Station #5 was for 2 K 2.5 Ca bath. The dialysis machine is connected to the wall unit with the correct prescription of 2 K 2.5 Ca. The dialysis staff failed to ensure the dialysis machine was set to the prescribed physician dialysis bath. The findings were verified with PCT #2 on 08/07/2024 at 9:25 AM.”

“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 observations and interviews, Registered Nurse (RN) #1 failed to properly label an antibiotic infusion that was being administered and failed to instill the ordered dose of Heparin into the Central Venous Catheter (CVC) after dialysis treatment for Patient #1, one of one patients observed with an antibiotic infusion and one of two patients observed with a CVC for discontinuation of treatment (Patient #1). The findings include: Observation on 8/5/24 at 11:02 AM revealed RN #1 at machine #7, station #15. Patient #1 was dialyzing when the machine alarmed. RN #1 stated the alarm indicated the need to start the patient’s intravenous antibiotic. There was a 250 milliliter bag of 0.9 Normal Saline hanging and the nurse attached that to the dialysis line and started the infusion. Observation of the normal saline bag revealed no label and/or any detailed information written to on it to indicate what type of antibiotic and/or the dose that had been started. Observation on 8/5/24 at 11:55 AM revealed the patient was getting ready to end treatment and there was still no label on the Normal Saline bag. During an interview on 8/5/24 at 11:55 AM, RN #1 verified the bag of normal saline did not contain a label to indicate required information including the dosage and name of the antibiotic infusing. Review on 8/7/24 at 11:55 AM of the facility policy “Medications: Handling, Administration, Storage & Disposal” revealed “...IV (Intravenous) solutions with medications added shall be labeled with: The name of the medication added to the solution. The dose of medication added to the solution. Date and time of preparation. Initials of nurse preparing the medication...”. Observation on 8/5/24 at 12:02 PM revealed RN #1 discontinuing dialysis treatment for Patient #1 at machine #7, station #15. RN #1 scrubbed the hub with alcohol, flushed the CVC port with saline, injected Heparin into the port, and placed the endcap. For the 2nd CVC port she/he scrubbed the hub with alcohol, flushed the port with saline, and placed the endcap. RN #1 did not instill any Heparin into the 2nd port and placed gauze and tape over the two CVC limbs. At 12:06 PM, the surveyor spoke with RN #1 and informed him/her of the concern about not administering the Heparin lock solution for one of the ports. Observation of the saline syringes/Heparin syringes used for the procedure that were still on the chairside table revealed there were 2 empty saline syringes and only one empty Heparin syringe. RN #1 stated that maybe something had happened to the syringe earlier. Review on 8/7/24 at 2:50 PM of physician orders for Patient #1 revealed the patient was to receive Heparin 1000 units/milliliter (ml), 1.6 ml (milliters) to each port as a pack solution to the catheter each treatment. 41879”