Fmc Millington

“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 and other measures to prevent the spread of infectious bacteria were performed by 1 of 4 (Nurse #1) staff observed during 1 of 1 (11/6/2023) observation days on the dialysis treatment floor. The findings included: 1. Review of the facility’s “Changing the Catheter Dressing Procedure” policy (5/2/2022) revealed, “ ...The patient and caregiver must wear a mask for all procedures that require accessing the catheter ...Step ...Action/Rationale ...2. Apply mask to patient and caregiver to help prevent contamination by airborne nasal bacterial ...5. Inspect and remove the old dressing ...6. Visually inspect the exit site and surrounding areas ...8. Discard dressing and remove gloves. Perform hand Hygiene ...” Review of the facility’s “Access Assessment and Cannulation” policy (7/5/2022) revealed, “ ...Disinfect cannulation site as follows ...70% isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating ...” 2. Observations on 11/6/2023 beginning at 10:50 AM revealed Nurse #1 set up supplies to perform dressing change of a CVC for RP #1. Nurse #1 performed hand hygiene, donned clean gloves, and proceeded to remove the old dressing from RP #1’s CVC site. Nurse #1 then began to clean the CVC exit site without first removing gloves, performing hand hygiene and donning clean gloves. Observations also revealed RP #1’s mask was below his nose for the entirety of the procedure. Observations on 11/6/2023 beginning at 11:55 AM revealed Nurse #1 was performing initiation of dialysis for RP #2 via cannulation of an AV Fistula. Nurse #1 applied antiseptic to the first cannulation site with an alcohol pad for 15 seconds and immediately cannulated, without allowing the site to dry. Nurse #1 then applied antiseptic to the second cannulation site with an alcohol pad for 15 seconds, allowing the site to dry before cannulation. In an interview on 11/8/2023 at 10:30 AM, the DO verified masks should be worn covering the nose, gloves should be changed and hand hygiene performed after removing an old CVC dressing, and verified AV fistula sites should be cleaned for 30 seconds, allowing time to dry before cannulation.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to ensure the IDT revised, updated and individualized interventions to address fluid gains and elevated heart rate for 2 of 5 (Patient #3 and #4) sampled patients. The findings included: 1 Review of the facility’s “Comprehensive Interdisciplinary Assessment and Plan of Care” policy (7/3/2023) revealed, “ ...The patient’s Plan of Care will be guided and developed based on the findings identified in the Comprehensive Interdisciplinary Assessment ...The Plan of Care must include measurable and expected outcomes and an estimated timetable to achieve these outcomes ...If the patient specific expected outcome as determined by the attending physician, IDT and patient for the Plan of Care is not achieved within the identified timeframe: The Interdisciplinary team must adjust the patient’s Plan of Care and document changes made to the POC. Implement the Plan of Care changes to address the identified issues ...” 2. Medical record review for Patient #3 revealed a dialysis start date of 8/30/2023 with diagnoses that included ARF and DM. Review of dialysis treatment sheets beginning 10/13/2023 through 11/3/2023 revealed Patient #3’s pre-treatment heart rate was over 100 bpm for 8 of the 10 treatments. There was no documentation the facility RN made the patient’s physician aware of the elevated pre-treatment heart rates. Review of a 10/25/2023 POC revealed no documentation the IDT addressed the patient’s elevated heart rate pre-treatment. Review of the IDT Comprehensive Assessments beginning August 2023 through October 2023 revealed no documentation of goals or interventions by the IDT related to Patient #3’s elevated pre-treatment heart rate. In an interview on 11/7/2023 at 11:30 AM, the CM verified there were no goals or interventions implemented to address Patient #3’s elevated heart rate pre-treatment. 3. Medical record review for Patient #4 revealed a dialysis start date of 5/29/2020 with diagnoses that included ESRD. Review of dialysis orders beginning 10/13/2023 revealed Patient #4’s dry weight was 96.70 kg. Review of 10 dialysis treatment sheets beginning 10/13/23 through 11/3/23 revealed Patient #4 gained 3.0-5.8 kg between each treatment. Further review of treatment sheets revealed Patient #4 left above the ordered dry weight for 6 of the 10 treatments. Review of a 10/1/2023 POC revealed an area of focus as BP and Fluid Management. There was no documented goal related to fluid management. An intervention in progress was documented as “Educate patient/family/caregiver on fluid control” with further documentation stating the patient verbalized understanding of the importance of fluid control and verbalized understanding of signs and symptoms of fluid overload. Review of clinical notes and IDT progress notes beginning August 2023 through October 2023 revealed no updated, revised or individualized interventions to address Patient #4’s continued fluid gains between treatments. In an interview on 11/7/2023 at 11:30 AM the CM verified there were no additional interventions documented addressing Patient #4’s fluid gains between treatments.”