Usrc Holly Tree

“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, interview, and review of the facility’s policy, “Patient Hepatitis B Testing/Vaccination/Seroconversion”, the dialysis clinic nursing staff failed to ensure one of three in-center Hepatitis-B susceptible patients reviewed (Patient #3) received the Hepatitis-B vaccine as indicated. The findings included: The dialysis clinic admitted Patient #3 on 11/22/23 with diagnoses including End Stage Renal Disease. Review on 1/31/24 at 1:30 PM of the laboratory values dated 11/16/23 and 11/28/23 revealed Patient #3 was not immune to the Hepatitis B virus with an antibody level less than 10 and a negative antigen status. The patient had signed a consent to receive the Hepatitis B vaccine on admission on 11/22/23. Review of physician orders/progress notes, nursing notes, and the patient’s care plans dated 12/12/23 and 1/25/24 revealed no documentation to indicate the patient was scheduled for or that the clinic had planned to give the Hepatitis B vaccine. The finding was verified with Facility Administrator #2 during an interview on 1/31/24 at 3:55 PM. Review of the policy, provided by the dialysis clinic, entitled, “Patient Hepatitis-B Testing/ Vaccination/ Seroconversion”, revealed, “...Vaccination: 1. Obtain physician order and offer vaccine to all susceptible patients within three days of receiving lab result. First dose should be given within 30 days of admission...”.”

“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 interdisciplinary team members failed to sign the care plan for 2 of 4 in-center hemodialysis patients. (Patient #1 and #3) The findings included: Review on 1/31/24 at 9:32 AM revealed Patient #1 had a care plan meeting on 1/11/24. There was no signature of the Registered Dietitian participating in the patients plan of care. The finding was verified by Facility Administrator #2 during an interview on 1/31/24 at 3:52 PM. Review on 1/31/24 at 12:54 PM revealed Patient #3 had an initial care plan meeting on 12/12/23. There was no signature of the physician participating in the patient’s plan of care. The finding was verified by Facility Administrator #2 during an interview on 1/31/24 at 3:47 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 policy, “Intradialytic Monitoring of Patient”, the clinic’s nursing staff failed to document safety checks timely for 3 of 4 patient records reviewed for Patient #1, #2, and #4 in-center hemodialysis patients. The findings included: Review on 1/31/24 at 11:37 AM of the dialysis treatment sheets for Patient #1 revealed nursing staff had not documented monitoring of the patient every 30 minutes. A dialysis treatment sheet dated 1/4/24 documented monitoring at 2:05 PM and again at 3:03 PM. A dialysis treatment sheet dated 1/18/24 documented monitoring at 1:30 PM and again at 2:36 PM. Review on 1/31/24 at 12:36 PM of the dialysis treatment sheets for Patient #2 revealed nursing staff had not documented monitoring of the patient every 30 minutes. A dialysis treatment sheet dated 12/20/23 documented monitoring at 9:32 AM and again at 10:33 AM. A dialysis treatment sheet dated 1/12/24 showed monitoring at 7:33 AM and again at 8:38 AM, at 9:17 AM, and again at 10:49 AM. A dialysis treatment sheet dated 1/29/23 showed monitoring at 8:33 AM and again at 9:31 AM. Review on 1/31/24 at 2:49 PM of the dialysis treatment sheets for Patient #4 revealed nursing staff had not documented monitoring of the patient every 30 minutes. A dialysis treatment sheet dated 1/15/24 documented monitoring at 1:33 PM and then again at 2:28 PM. A dialysis treatment sheet dated 1/12/24 showed monitoring at 12:05 PM and again at 1:50 PM, at 2:33 PM, and again at 3:24 PM. A dialysis treatment sheet dated 1/17/24 showed monitoring at 11:37 AM, again at 12:37 PM, at 12:38 PM, and again at 2:38 PM. A dialysis treatment sheet dated 1/26/24 showed monitoring at 10:36 AM, again at 11:42 AM, at 12:07 PM, and again at 2:31 PM. A dialysis treatment sheet dated 1/29/24 showed staff documented patient monitoring at 11:38 AM and again at 12:36 PM. The findings were reviewed with and verified by Facility Administrator #2 during an interview on 1/31/24 at 3:55 PM. Review on 2/1/24 of the facility policy, provided by the dialysis clinic, entitled, “Intradialytic Monitoring of Patient” revealed 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.”