Rcg Martin

“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: 35244 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of potentially infectious bacteria by 1 of 6 (CCHT #1) staff members observed. The findings included: 1. Review of the facility’s “Hand Hygiene” policy (11/6/2023) revealed, “...Hands Will Be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...After contact with inanimate objects near the patient... Review of the facility’s “Access Assessment and Cannulation” policy (5/6/2024) revealed, “...Assessment of Vascular Access...LOOK...LISTEN...FEEL...Remove gloves and perform hand hygiene. Don new gloves...” 2. Observations on the treatment floor on 3/17/2025 at 11:15 AM, revealed CCHT #1 dropped a box of gloves onto the floor. CCHT #1 picked up the box of gloves then donned a pair of gloves. CCHT #1 failed to perform hand hygiene after picking up the potentially contaminated box of gloves. Observations at Dialysis Station #10 on 3/17/2025 at 11:40 AM, revealed CCHT #1 performed AV fistula initiation for RP #1. CCHT #1 assessed the AV fistula site by looking, listening and feeling. CCHT #1 then cleaned the AV fistula site. CCHT #1 failed to perform hand hygiene and don a new pair of gloves after assessing the AV fistula. In an interview on 3/19/2025 at 10:30 AM, the CM verified CCHT #1 should have performed hand hygiene and donned new gloves after assessing the AV fistula site.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 35244 Based on policy review, observation and interview, the facility failed to ensure dialysis stations were appropriately disinfected between patients by 1 of 2 (RN #2) staff members observed. The findings included: 1. Review of the facility’s “Cleaning and Disinfecting the Dialysis Station” policy (9/5/2023) revealed, “...Clean and disinfect any surfaces contaminated with blood or other potentially infectious material immediately or as soon as feasible...” 2. Observations on the treatment floor on 3/17/2025 at 9:45 AM, revealed RN #2 disinfected Dialysis Station #13. RN #2 cleaned the dialysis chair, then removed blood lines from the dialysis machine. The blood lines touched the disinfected dialysis chair. RN #2 failed to re-disinfect the contaminated dialysis chair. In an interview on 3/19/2025 at 10:30 AM, the facility’s CM verified RN #2 should have re-disinfected the dialysis chair after the chair had been contaminated by the blood lines.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 35244 Based on policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed by 1 of 2 (RN #1) nurses observed providing CVC site care and initiation. The findings included: 1. Review of the facility’s,”Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer” policy (5/6/2024) revealed, “...Follow the steps...to disinfect the catheter connections...Threads and end of the luer lock (hub) must be scrubbed with 70% sterile alcohol pad...for 10-15 seconds and any time caps are removed, or bloodlines are disconnected...” 2. Observations on the treatment floor on 3/17/2025 at 10:10 AM, revealed RN #1 performed CVC initiation of dialysis for RP #1 at Dialysis Station #1. RN #1 cleaned the CVC closed system connectors with an alcohol prep pad for 6 seconds. RN #1 failed to clean the connectors for 10-15 seconds per facility policy. In an interview on 3/19/2025 at 9:30 AM, the CM stated the closed system connectors should be scrubbed with alcohol pads for at least 15 seconds.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 35244 Based on policy review, facility document review, medical record review and interview, the facility failed to ensure patients deemed “unstable” were reassessed monthly to determine their needs for 1 of 2 (Patient #3) unstable patients reviewed. The findings included: 1. Review of the facility’s “Comprehensive Interdisciplinary Assessment and Plan of Care” policy (7/3/2023) revealed, “...Unstable patients must be reassessed by the IDT monthly...” 2. Medical record review for Patient #3 revealed an admission date of 5/18/2018 with diagnoses which included HTN and ESRD. Review of a facility document provided on 3/17/2025 revealed Patient #3 was deemed “unstable” due to history of suicide attempts. Review of Patient #3’s “unstable” POC reassessments for October 2024 through March 2025, revealed there was no documentation the IDT reassessed the Patient in December 2024. In an interview on 3/19/2025 at 10:00 AM, the facility’s DO verified there was no documentation of a POC reassessment for Patient #3 for December 2024.”

“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: 51246 Based on policy review, medical record review and interview, the facility failed to ensure staff notified the registered nurse of patients’ elevated blood pressure and pulse rates for 2 of 5 (Patient #1 and #2) sampled incenter hemodialysis patients. The findings included: 1. Review of the facility’s “Patient Assessment and Monitoring” policy (5/1/2023) revealed, “The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed...During Treatment...Report to the nurse...Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury]...Blood Pressure less than or equal to 100 mm/Hg systolic...Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular...” 1. Medical record review for Patient #1 revealed an admission date of 3/14/2023 with diagnoses which included End Stage Renal Disease. Review of the 2/18/2025 Treatment Sheet revealed Patient #1’s pulse rates and blood pressures were as follows: At 8:37 AM, blood pressure was 95/41. At 10:35 AM, blood pressure was 95/41. At 11:00 AM, pulse was 110. At 1:50 PM, pulse was 107. There was no documentation the registered nurse was notified of the elevated pulse rates or low blood pressure readings. Review of the 2/20/2025 Treatment Sheet revealed Patient #1’s pulse rates were as follows: At 9:09 AM, pulse was 105. At 10:05 AM, pulse was 115. At 10:32 AM, pulse was 114. At 11:05 AM, pulse was 115. At 1:32 PM, pulse was 122. There was no documentation the registered nurse was notified of the elevated pulse rates. Review of the 2/22/2025 Treatment Sheet revealed Patient #1’s pulse rates were as follows: At 8:54 AM, pulse was 115. At 9:31 AM, pulse was 106. At 10:03 AM, pulse was 106. At 10:34 AM, pulse was 104. There was no documentation the registered nurse was notified of the elevated pulse rates. Review of the 2/27/2025 Treatment Sheet revealed Patient #1’s pulse rates were as follows: At 9:35 AM, pulse was 59. At 10:02 AM, pulse was 57. There was no documentation the registered nurse was notified of the low pulse rates. Review of the 3/11/2025 Treatment Sheet revealed Patient #1’s pulse rates and blood pressure were as follows: At 9:38 AM, pulse was 111. At 10:05 AM, pulse was 107. At 10:30 AM, pulse was 113. At 2:05 PM, blood pressure was 151/101. There was no documentation the registered nurse was notified of the elevated pulse rates or elevated blood pressure reading. Review of the 3/15/2025 Treatment Sheet revealed Patient #1’s pulse rates were as follows: At 8:36 AM, pulse rate was 104. There was no documentation the registered nurse was notified of the elevated pulse rate. Medical record review for Patient #2 revealed an admission date of 7/5/2021 with diagnoses which included Hypertensive Chronic Kidney Disease. Review of the 2/17/2025 Treatment Sheet revealed Patient #2’s pulse rates and blood pressure were as follows: At 8:33 AM, pulse was 51. At 9:02 AM, blood pressure was 99/48. At 9:36 AM, blood pressure was 97/57. At 10:06 AM, pulse was 49. At 11:32 AM, pulse was 47. There was no documentation the registered nurse was notified of the low pulse rates or low blood pressures. Review of the 2/28/2025 Treatment Sheet revealed Patient #2’s blood pressure was as follows: At 8:35 AM, blood pressure was 98/63. There was no documentation the registered nurse was notified of the low blood pressure. Review of the 3/3/2025 Treatment Sheet revealed Patient #2’s blood pressure and pulse rates were as follows: At 8:00 AM, blood pressure was 96/54. At 10:38 AM, pulse rate was 49. There was no documentation the registered nurse was notified of the low blood pressure and pulse rates. In an interview on 3/19/2025 at 9:30 AM, the CM verified blood pressure and pulse rates outside of policy parameters should be brought to the attention of the RN.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 51246 Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure physician’s orders for BFR and DFR were followed for 3 of 5 (Patient #1, #2, and #4) sampled in-center hemodialysis patients. The findings included: 1. Review of the facility’s “Patient Assessment and Monitoring” policy (5/1/2023) revealed, “...During Treatment...Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow...Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...” 2. Medical record review for Patient #1 revealed an admission date of 3/14/2023 with diagnoses which included End Stage Renal Disease. Review of a 3/13/2025 physician’s order revealed a BFR of 300 and a DFR of 600. Review of the 3/6/2025 Treatment Sheet revealed the DFR was 800 from 8:56 AM until 1:02 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. 3. Medical record review for Patient #2 revealed an admission date of 7/5/2021 with diagnoses which included Hypertensive Chronic Kidney Disease. Review of a 1/22/2025 physician’s order revealed a BFR of 400 and a DFR of 800. Review of the 2/21/2025 Treatment Sheet revealed the BFR was 350 from 9:34 AM until 11:05 AM and 300 from 11:31 AM until 11:57 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 2/24/2025 Treatment Sheet revealed the BFR was 350 from 9:32 AM until 11:51 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 2/26/2025 Treatment Sheet revealed the BFR was 375 from 7:53 AM until 10:34 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 3/10/2025 Treatment Sheet revealed the BFR was 350 from 9:34 AM until 11:03 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 3/12/2025 Treatment Sheet revealed the BFR was 385 from 8:04 AM until 8:30 AM and 350 from 8:31 AM until 11:52 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 3/17/2025 Treatment Sheet revealed the BFR was 300 from 8:32 AM until 11:15 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 4. Medical record review for Patient #4 revealed an admission date of 1/2/2025 with diagnoses which included HTN and ESRD. Review of a 3/1/2025 physician’s order revealed a BFR of 400 and DFR of 800. Review of the 2/22/2025 Treatment Sheet revealed the DFR was 600 from 11:47 AM until 1:33 PM. There was no documentation why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the 2/25/2025 Treatment Sheet revealed the BFR was 300 from 12:24 PM until 3:32 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 3/11/2025 Treatment Sheet revealed the DFR was 600 from 11:58 AM until 3:27 PM. There was no documentation why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. In an interview on 3/19/2025 at 10:30 AM, the facility’s CM verified staff should document the reason BFR and DFR orders were not followed.”