Avera Gregory Healthcare Ctr Dialysis

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 50715 Based on observation, interview, and policy review, the provider failed to ensure: *Two of four observed patients (5 and 6) receiving dialysis in bays 1 and 5 allowed staff full view of the patients’ faces, vascular access sites, and bloodline connections for continuous assessment of their vascular access sits during dialysis treatments. *Patients (3, 4, 5, and 6) who were scheduled for dialysis on 7/30/25 in bays 1 and 5 had an observable view of their faces, vascular access sites, and bloodlines connections by staff at all times during dialysis treatments. Those conditions put all patients at risk for exsanguination (a severe loss of blood) and/or death. This deficient practice represented immediate jeopardy (IJ). IJ is a situation or event that may cause, or is likely to cause, serious injury, harm, impairment, or death to a patient. All patients were at risk. Findings include: 1. Observation during the environmental tour on 7/30/25 at 10:15 a.m. revealed: *The dialysis center had a main treatment area with four dialysis bays and one isolation room for a total of 5 bays each with dialysis machines. *Patient 5 was receiving dialysis in bay 1. *Patient 2 was receiving dialysis in bay 3. *Patient 6 was receiving dialysis in bay 5 (isolation room). *While receiving dialysis in bay 1, patient 5’s face, : -Vascular access site, and bloodline connections were not visible from the nurse’s station due to the obstruction of an opaque(cannot see through) glass. -A clear view of the patient was only obtained by standing directly in front of the bay or at the end of the nurses’ station closest to bay 1. *While receiving dialysis in bay 5, patient 6’s face, : -Vascular access site, and bloodline connections were not visible from the nurse’s station due to the obstruction of solid walls. -A window had been placed in the wall of the room between bay 5 and bay 4. -The window had a glare and was obstructed by a television in bay 4 that was positioned too high to visualize the patient’s face, vascular access site, and bloodline connections. -A clear view of the patient was only obtained by standing directly in front of the room or at the end of the nurses’ station closest to bay 5. *Registered nurses (RN) A and D and patient care technologist (PCT) C were on duty at the time of the observation. RN D was sitting at the nurses’ station and PCT C had been setting up the dialysis machine in bay 4, and the dialysis supervisor had been in and out of her office. *From where the staff were located, patient 5’s and patient 6’s vascular access sites and bloodline connections were not visible. Interview with RN D on 7/30/25 at 11:15 a.m. regarding visualization of patients’ vascular access sites revealed she: *Stated staff should have rounded on patients receiving dialysis every 15 minutes. *Stated staff have certain spots where they would sit while patients were receiving their dialysis treatment to allow for constant visualization. *Agreed, from where she was sitting, there were blind spots in bays 1 and 5. *Agreed the patient receiving dialysis in bay 5 was not visible unless someone had been sitting in front of the door. *Agreed the window placed between bay 5 and bay 4 had not allowed full visualization of patient 6 while receiving dialysis. *Agreed the television in bay 4 was obstructing the window view into bay 5. *Stated, “I was honestly surprised the room was constructed that way because of the blind spots.” Interview with dialysis supervisor A on 7/30/25 at 11:20 a.m. regarding visualization of patient’s 5 and 6 vascular access sites revealed she: *Stated for a patient receiving dialysis in bay 1, staff must sit in the chair at the end of the nurse’s station to visualize the patient. *Stated, “When I’m out on the floor, I always sit in that chair or else you can’t see.” *Agreed patient 5’s and patient 6’s faces, vascular access sites, or bloodline connections could not be visualized, while in bays 1 and 5, from the nurses’ station. *Stated that after the window was placed in bay 5 due to concerns of the visualization of access sites, she was still concerned because the staff could not visualize that patient’s vascular site from the nurses’ station, and that staff must be in the immediate area to see those sites. -Stated, “Staff were not consulted for the changes to bay 5 and I was concerned it wouldn’t pass [an] inspection.” 18559 Interview on 7/30/25 at 12:00 p.m. with dialysis supervisor A and PCT C revealed patients (3 and 4) were scheduled to and would have received dialysis in bays 1 and 5 that day (7/30/25). Notice: On 7/30/25 at 1:18 p.m. administrator B and dialysis supervisor A was notified of the IJ for failure to ensure patients receiving dialysis in bays 1 and 5 faces, vascular access sties, and bloodline connections were always visible during dialysis treatments. An immediate plan of correction (POC) was requested from administrator A on 7/30/25 at 1:18 p.m. Removal Plan: The provider’s immediate POC received and reviewed on 7/31/25 at 8:20 a.m. included: *”Bay 5 (eastern most bay) will no longer be used Until Further Notice (UFN). Staff is [was] notified as of 7/30/25 not to use station 5 until visibility of patients at all times is possible. *The transparent glass in bay 1 was removed on the 30th of July 2025 to further facilitate staff view of the dialysis treatment area. *The administrator will work with Avera Leadership to develop a plan to remodel Bay 5 (eastern most bay) so that the staff will have constant visualization of the access site of patients at all times. Initial plan has been drafted on 7/31/25 and is being sent out to bid through contractors. *Contingency funds will be requested from Avera to complete this project as soon as possible.” The removal plan was approved by the surveyors onsite, and the IJ was removed on 7/31/25 at 8:35 a.m. The deficiency remained at a condition level after the removal of the IJ and compliance with the immediate POC. Review of the provider’s 11/29/23 Hemodialysis: Initiation and Recirculation policy revealed a patient’s face, access site, and bloodline connections should have been visible.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 50915 Based on observation, interview, and policy review, the provider failed to ensure the prescribed dialysis prescription was followed for one of one sampled patient (1). Findings include: 1. Observation on 7/30/25 at 4:35 p.m. of patient 1 during her dialysis treatment revealed: *The dialysate (a fluid that helps clean the blood during dialysis) connected to the machine was 2 K [Potassium], 2.5 Ca [Calcium]. -Patient 1’s prescribed dialysate was 3 K, 2.5 Ca. 2. Interview on 7/30/25 at 4:37 p.m. with registered nurse (RN) D revealed: *She verified the wrong prescribed dialysate was being used for resident 1’s dialysis treatment and immediately changed the dialysate to the correct prescription. *She stated that she performed the machine set-up and attached the wrong dialysate. -She stated patient care technologist C should have also verified the prescription when the dialysis treatment started. -Patient care technologist C was not available for interview on 7/31/25. *She then reported the medication error to her supervisor and completed an incident report. 3. Interview on 7/31/25 at 10:35 a.m. with dialysis supervisor A revealed: *She was aware of the medication error made by RN D on 7/30/25. *She expected that the patient’s prescribed dialysate would be verified by the staff according to the medication administration policy before the dialysis treatment was started. 4. Review of the provider’s 2/2023 medication administration policy revealed: *Section C. Medication administration, “3. The following will be verified at the patient [patient’s] bedside prior to medication administration.” -“a. right patient - no medications are to be administered to patients without proper identification with an ID band, comparing the patient name and birthdate on the ID band with the medication administration record. Recurring outpatient identification is verified by the patient stating his/her name and birthdate.” -“b. right medication - based on the medication order and product label; verify the patient has no allergies or contraindications to the medication.””