Dci East Ridge

“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: 40606 Based on facility policy review, observation and interview, the facility failed to ensure patients, prior to exiting the hemodialysis treatment area, performed disinfection of their hands for 3 of 6 observations. The findings include: Review of the facility policy, “Use of Gloves Including Hand Hygiene,” dated 1/16/2019, revealed “...To provide standard guidance for the use of gloves and hand hygiene in the hemodialysis unit...Hand hygiene will be performed...Before entering and on exiting the patient treatment area.” Observations on 4/28/2025, from 10:30 AM to 12:30 PM, revealed the dialysis treatment area had 16 dialysis treatment stations. Further observation revealed 3 patients had exited their stations after completing their dialysis treatment, weighed and exited the treatment floor without sanitizing their hands. The patients were accompanied by the staff upon their exit, no offer was made by staff to encourage patient hand hygiene. During an interview on 4/30/2025 at 10:45 AM, the interim Clinic Manager confirmed patients were expected to adhere to the facility’s handwashing policy and stated “...Yes...patients were expected to wash their hands prior to exiting the treatment area...””

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 40606 Based on facility policy review, medical record review, observation and interview, the facility failed to ensure the external transducer (a protective barrier from blood contamitation of the dialysis machine) was free of blood for 1 of 8 dialysis machines observed during dialysis treatments for 1 patient (#6) of 16 patients observed. The findings include: Review of facility policy titled, “Intradialytic Patient Assessment and Monitoring,” dated, 9/26/2018, showed “...The dialysis delivery system will be assessed, monitored and documented on at least every 30 minutes for the following...Integrity of the extracorporeal circuit (blood lines which include external transducers)...TMP (Transmembrane pressure-is a value of the difference of the machine calculated data from arterial and venous chamber as it passes through the external transducers)...” Medical record review revealed Patient #6 was admitted to the facility 5/24/2007 with diagnoses including Diabetes and End Stage Renal Disease. During an observation of the treatment area, on 4/28/2022 at 12:05-12:30 PM, showed Patient #6 was seated in station 20 receiving dialysis treatment. During the observation at 12:05 PM, showed the venous transducer was wet with blood. Observation showed Patient Care Technician (PCT) #1 was in the station entering information into the dialysis machine. Continued observation at 12:30 PM, showed Patient#6 was 30 minutes into a 3-hour treatment time. PCT #1 was in the station entering information into the dialysis machine and did not address the wet transducer. Continued observation showed several staff members had entered station #20 to enter information into the dialysis machine, but no staff member changed the wet venous transducer. During an observation on 4/28/2025 at 2:50 PM, at station 20, showed Patient #6’s treatment was completed and the venous transducer remained wet. During an interview on 4/30/2025 at 10:45 AM, the interim Clinic Manager confirmed the wet transducer was to be changed immediately and confirmed the facility staff had not followed the facility policy.”

“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: 40606 Based on facility policy review, medical record review and interview, the facility failed to address 2 patients’ (Patient #1 and Patient #2) fluid volume status within their plans of care of 5 patients reviewed for fluid and blood pressure management. The findings include: Review of the facility policy, “Patient Assessment And Patient Plan of Care,” revised 3/2022, showed “...PURPOSE...To establish an individualized, comprehensive plan of care that addresses the patient’s needs...Assessment criteria...The patient’s comprehensive assessment must include at a minimum...Evaluation of the appropriateness of the dialysis prescription, blood pressure, and fluid management needs...The plan of care must...specify services necessary to address the patient’s needs...include measurable and expected outcomes...” Review of the facility policy, “Post-Treatment Assessment,” dated 9/26/2018, showed “...Routine post treatment assessment will include but not limited to...Respiratory status...Cardiac status...Dry weight...Assessment of vital signs...Any vital sign or assessment...abnormality will be reported to Physician...” Patient #1 was admitted to the facility on 4/19/2022 with diagnoses including Type II Diabetes and End Stage Renal Disease. Review of Patient #1’s Hemodialysis Treatment Sheets dated 4/4/2025-4/25/2025, showed the prescribed estimated dry weight (EDW) was 52.0 kilograms (1 kilogram = 2.2 pounds). Review showed Patient #1’s weight pre-dialysis was 4 to 9 kilograms greater than the physician prescribed EDW for 8 of 9 treatments reviewed. Continued review showed Patient #1’s post dialysis weight on 4/4/2025 was 53.6 kg (kilograms), the closest post dialysis weight to the EDW reviewed for the time frame. On 4/4/2025, the patient left the clinic 1.6 kg heavier than the EDW. Review showed after each of the 9 dialysis treatments, Patient #1’s post weight was between 1.6 kgs and 5.7 kgs (or 12.5 pounds) over the prescribed dry weight with no documentation of Patient #1’s fluid status communicated to the physician. Review of Patient #1’s care plan dated 2/28/2025, showed limited documentation of interventions developed by the IDT team to address Patient #1’s excessive fluid gains between dialysis treatments. No documentation of the avenues explored by the IDT team to curb Patient #1’s excessive fluid gains and return to the prescribed EDW was added to the care plan. Patient #2 was admitted to the facility on 7/19/2020 with diagnoses including End Stage Renal Disease and Type II Diabetes. Review of Patient #2’s Hemodialysis Treatment Sheets dated 4/7/2025-4/25/2025 showed Patient #2’s EDW was 51.5 kilograms. Patient #2’s weight pre-dialysis was 3.8-6.2 kilograms (the goal is to gain 3 kgs or less between treatments) greater than the physician prescribed EDW for 8 of 9 treatments reviewed. Patient #2’s post dialysis weights from 4/7/2025-4/25/2025 ranged from 1.9 kg to 4.5 kg (9.9 pounds) over the prescribed EDW of 51.5 kg. Review of the treatment sheets showed Patient #2 left the clinic consistently heavier than the prescribed EDW. No documentation of Patient #2’s fluid status was communicated to the physician about being 1.9-4.5 kgs above the EDW. Review of Patient #2’s care plan dated 2/28/2025 showed no documented problem or action steps to indicate Patient #2 had excessive fluid gains between dialysis treatments. During an interview on 4/30/2025 at 10:30 AM, the Medical Director (MD) confirmed he was aware Patient #1 had excessive fluid gains between dialysis treatments. The MD confirmed Patient #1’s care plan did not identify and implement actions to aid in improvement of Patient #1’s fluid management. The MD confirmed Patient #2 had ongoing problems with excessive fluid during and between dialysis treatments and Patient #2’s care plan did not indicate Patient #2 had a fluid volume problem. During an interview on 4/30/2025 the interim Clinical Manager stated it is the Interdisciplinary Teams responsibility to implement appropriate care plan interventions to meet the needs of each patient.”