Dci Waverly

“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: 49570 Based on policy review, observation and interview, the facility failed to ensure dialysis machines were properly cleaned and disinfected between patients by 1 of 1 (PCT #1) staff members observed on the treatment floor. The findings included: 1. Review of the facility’s policy titled, “Standard Precautions and Infection Control”, revised 7/11/2018, revealed, “ ...D. Between patient, clean all equipment with clean towels soaked in bleach water...After each patient treatment, clean and disinfect the dialysis station (chairs, beds, tables, machines, television, clipboard, pen, change over supply buckets, top of sharps containers) and all ancillary equipment (scissors, hemostats, fistula clamps, stethoscopes, blood pressure cuffs)...If there is a dedicated stethoscope for each machine, then the stethoscope need only be cleaned at the end of treatment with the machine...” Review of facility’s policy titled, “Routine Disinfection in the Hemodialysis Unit”, issued 2/01/2023, revealed, “...Failures in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., hepatitis B virus) and other infections from one patient to another in hemodialysis units. Proper cleaning and disinfection of environmental surfaces (including patient chairs or bed surfaces, dialysis equipment surfaces, adjacent tables, and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens...10. Stethoscopes will be cleaned before and after each use. Stethoscopes that are left at the dialysis station will be considered part of the station and cleaned at the end of each patient treatment. 11. Machine supply lines will be disinfected at same frequency of the water distribution disinfection...Procedure: 3. Clean the dialysis machine start at the top of the machine. Ensure that all items from top to bottom are cleaned, including but not limited to: Stethoscope, if left on machine, All components of machine (i.e. air detector, heparin pump, blood pump doors, Hansen connector and tubing), blood pressure cuff and tubing...5. Ensure any ancillary equipment is cleaned with a new cloth/towel that has been saturated with approved disinfectant. Items include but not limited to: Television monitors...” 2. Observations on the treatment floor at Station #4 on 1/22/2025 at 10:07 AM, revealed PCT #1 failed to clean the dialysis hoses, stethoscope, blood pressure cuff, and TV when disinfecting the dialysis station. Observations on the treatment floor at station #15 on 1/22/2025 at 10:40 AM, revealed PCT #1 failed to clean the dialysis hoses, stethoscope, blood pressure cuff, and TV when disinfecting the dialysis station. 3. During an interview on 1/22/2025 at 5:15 PM, the NM confirmed when cleaning/disinfecting dialysis stations that “everything” is to be wiped down. This included but was not limited to the dialysis machine top to bottom, including all hoses on the machine, the entire chair, IV pole, blood pressure cuff, TV and stethoscope.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 33763 Based on review of the package insert titled, “Tuberculin Purified Protein Derivative (Mantoux) Tubersol,” facility policy review, observation and interview, the facility failed to ensure expired medications were not available for use in 1of 1 (medication storage refrigerator) medication storage refrigerators observed. The findings included: 1. Review of the package insert titled, “Tuberculin Purified Protein Derivative (Mantoux) Tubersol,” revealed, “...A vial of Tubersol which has been entered and in use for 30 days should be discarded...do not use after expiration date...” 2. Review of the facility’s policy titled, “Medication Storage” dated 9/21/2021 revealed, “...Medications will not be expired...” 3. Observations in the medication storage refrigerator on 1/21/2025 at 8:35 AM, revealed one open multidose vial of Tuberculin Purified Protein Derivative with an open date of 9/23/2024. The medication had been opened a total of 120 days. 4. During an interview on 1/21/2025 at 8:35 AM, RN #1 confirmed the Tuberculin Purified Protein Derivative was expired. During an interview on 1/22/2025 at 5:48 PM, the NM verified the open multidose vial of Tuberculin Purified Protein Derivative should have been discarded after 30 days.”

“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: 33763 Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure CVC exit site care was completed for 1 of 2 (Patient #5) sampled patients with a CVC and failed to ensure measures to prevent CVC related infections were followed by 2 of 2 (NM and RN #1) nurses observed performing CVC exit site care and initiation of dialysis via CVC. The findings included: 1. Review of the facility’s policy titled, “Central Venous Catheter: Exit Site Care” dated 8/1/2017 revealed, “...To establish a standardized procedure for exit site care to prevent infection...Only a Registered Nurse will perform exit site care and dressing changes on patients with catheters. If using Biopatch and Tegaderm dressing, it should be changed every treatment...Remove old dressing...Disinfect the site...Allow disinfectant to dry...If using Biopatch, open the package and aseptically place around the exit site...aseptically place the sterile gauze over the exit site. Then cover with new dressing (Island or Tegaderm) securing gauze in place. 17. Date, time, and initial dressing...Document dressing change and integrity of catheter on flow sheet...” Review of the facility’s policy titled, “CV Catheter: Connection and Disconnection” dated 8/1/2017 revealed, “...This procedure will be used at the beginning and end of the treatment, and any other time the catheter hubs are open...Definitions...Hub refers to the end of the CVC that connects to the blood lines or cap...Connections...Clamp the catheter limbs and remove cap from limbs one at a time...Scrub the first hub for at least 15 seconds using an appropriate antiseptic...Thirty wrist twists takes about 15 seconds...” 2. Medical record review for Patient #5 revealed an admission date of 10/25/2024 with diagnoses of End Stage Renal Disease and Hypertension. Review of the physician’s orders dated 10/23/2024 and renewed on 1/6/2024 revealed Patient #5 was to receive hemodialysis treatments via CVC three times a week. Review of the Hemodialysis Flowsheet dated 1/13/2025, revealed no documentation CVC exit site care was completed. Review of the Hemodialysis Flowsheet dated 1/15/2025, revealed no documentation CVC exit site care was completed. During an interview on 1/22/2025 at 5:22 PM, the NM verified there was no documentation CVC exit site care was completed on Patient #5 on 1/13/2025 and 1/15/2025. 3. Observations on the treatment floor at Station #6 on 1/22/2025 at 11:41 AM, revealed the NM was performing exit site care and initiation of dialysis to Patient #5. The NM failed to date, time, and initial the new sterile CVC dressing after performing CVC exit site care. The NM was observed scrubbing Patient #5’s CVC hubs for 4 seconds instead of at least 15 seconds per facility policy prior to connecting the sterile syringes to each port during initiation of treatment. Observations on the treatment floor at Station #17 on 1/22/2025 at 12:15 PM, revealed RN #1 was performing exit site care and initiation of dialysis to Patient #1. RN #1 failed to date, time, and initial the new sterile CVC dressing after performing CVC exit site care. 4. During an interview on 1/22/2025 at 5:22 PM, the NM stated CVC exit site care and dressing changes should be performed every treatment. When asked if the dressing should be labeled with the date, time, and initials, the NM stated, “We don’t because we change them every time they are here.” The NM stated facility policy is for staff to label the dressings with date, time, and initials when applied.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 33763 Based on facility policy review, observation and interview, the facility failed to ensure visibility of hemodialysis access sites during treatment for 5 of 15 (Random Patient #1, #2, and #3, and sampled Patient #4, and #5) patients observed on the treatment floor on 1 of 1 (1/22/2025) observation days. The findings included: 1. Review of the facility’s policies titled, “Cannulation of Established AV Fistula” dated 8/1/2027” and “Preparation & Cannulation of the New or Existing Arteriovenous Graft (AVG)” revised 10/28/2019, revealed, “...ensure that vascular access site, needle tubing, and bloodlines are visible at all times...” 2. Observations on the treatment floor on 1/22/2025 at 8:31 AM, 8:41 AM, 9:02 AM, and 9:12 AM, revealed Random Patient #1 receiving hemodialysis. Random Patient #1’s hemodialysis access site was covered by a blanket and not visible. 3. Observations on the treatment floor on 1/22/2025 at 8:36 AM, 8:40 AM, 9:02 AM, and 9:52 AM, revealed Random Patient #2 receiving hemodialysis. Random Patient #2’s hemodialysis access site was covered by a blanket and not visible. 4. Observations on the treatment floor on 1/22/2025 at 8:34 AM and 9:02 AM, revealed Random Patient #3 receiving hemodialysis. Random Patient #3’s hemodialysis access site was covered by a blanket and not visible. 5. Observations on the treatment floor on 1/22/2025 at 2:22 PM and 3:38 PM, revealed Patient #4 was receiving hemodialysis. Patient #4’s hemodialysis access site was covered by a blanket and not visible. 6. Observations on the treatment floor on 1/22/2025 at 12:12 PM, 2:21 PM, and 3:16 PM, revealed Patient #5 was receiving hemodialysis. Patient #5’s hemodialysis access site was covered by a quilt and not visible. 7. During an interview on 1/22/2025 at 5:47 PM, the NM confirmed hemodialysis access sites should be visible at all times when the patient is receiving hemodialysis.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49570 Based on policy review, medical record review, and interview, the facility failed to ensure physician’s orders for heparin administration were followed for 3 of 5 (Patient #3 and Patient #4 and Patient #5) sampled hemodialysis patients, and failed to ensure measures to prevent exposure of potential infectious bacteria during cannulation and de-cannulation of an AV fistula were followed by 3 of 3 (PCT #1, RN#1 and the NM) staff observed providing direct patient care on the treatment floor. The findings included: 1. Review of facility policy, “Systemic Heparinization” issued 11/30/2017, revealed, “Document the amount of Heparin given on the flow sheet.” 2. Medical record review for Patient #3 revealed an admission date of 11/19/2021 with diagnoses which included End Stage Renal Disease. Review of the physician’s orders dated 12/23/2024 revealed Patient #3 was to undergo hemodialysis treatments for 3 hours and 30 minutes via a AVF 4 days a week. A physician’s order dated 1/26/2024 and renewed on 1/06/2025 revealed Patient #3 was to receive “...Heparin Porcine Load 1000 Units, Hourly 500 Units x 3h...” (Heparin infusion ordered to run for 3 hours each treatment for a total of 2500 units of heparin infusion). Review of the Hemodialysis Flowsheet dated 1/03/2025 revealed Patient #3 received a total of 1000 units of heparin instead of 2500 units as prescribed. There was no documentation why Patient #3 was not given the extra 1500 units of heparin. Review of the Hemodialysis Flowsheet dated 1/17/2025 revealed Patient #3 received a total of 1000 units of heparin instead of 2500 units as prescribed. There was no documentation stating why Patient #3 was not given the extra 1500 units of heparin. During an interview on 1/22/2025 at 5:15 PM, the NM verified staff should document the total amount of heparin given at the end of each treatment. The NM confirmed there was no documentation why Patient #3 was not administered the prescribed dose of heparin on 1/3/2025 and 1/17/2025. 3. Medical record review for Patient #4 revealed an admission date of 7/5/2024 with diagnoses which included End Stage Renal Disease. Review of the physician’s orders dated 7/5/2024 and renewed on 1/6/2025 revealed Patient #4 was to undergo hemodialysis treatments for 4 hours via an AVG 3 days a week. A physician’s order dated 11/18/2024 revealed Patient #4 was to receive “...Heparin...Load 1000 Units, Hourly 1000 Units x 3h...IV...” (The heparin infusion was ordered to run for 3 hours each treatment for a total of 4000 units of heparin infusion). Review of the Hemodialysis Flowsheet dated 1/15/2025 revealed Patient # 4 received a total of 4500 units of heparin instead of 4000 units as prescribed. There was no documentation stating why Patient #4 was given the extra 500 units of heparin. During an interview on 1/22/2025 at 5:12 PM, the NM verified staff should document the total amount of heparin given at the end of each treatment. The NM confirmed there was no documentation why Patient #4 was given 500 extra units of heparin on 1/15/2024. 4. Medical record for Patient #5 revealed an admission date of 10/25/2024 with diagnoses of End Stage Renal Disease and Hypertension. Review of the physician’s orders dated 10/23/2024 and renewed on 1/6/2025 revealed Patient #5 was to undergo hemodialysis treatments for 4 hours via a CVC 3 days a week. A physician’s order dated 10/23/2024 and renewed on 1/6/2025 revealed Patient #5 was to receive “...Heparin...Load 1000 Units, Hourly 1000 Units x 4h...IV...” (The heparin infusion was ordered to run for 4 hours each treatment for a total of 5000 units of heparin infusion). Review of the Hemodialysis Flowsheet dated 12/26/2025 revealed Patient #5 received a total of 1000 units of heparin instead of 5000 units as prescribed. There was no documentation stating why Patient #5 was not given the extra 4000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/15/2025 revealed Patient #5 received a total of 1000 units of heparin instead of 5000 units as prescribed. There was no documentation stating why Patient #5 was not given the extra 4000 units of heparin. During an interview on 1/22/2025 at 5:22 PM, the NM verified staff should document the total amount of heparin given at the end of each treatment. The NM confirmed there was no documentation Patient #5 received the ordered 4000 units of heparin infusion on 12/26/2024 and 1/15/2025. 5. Review of the facility policy titled, “Cannulation of Established AV Fistula” dated 8/1/2017, revealed, “...Ensure that the patient goes to the sink and washes his access arm and hands with soap and water before beginning procedure. If patient is unable to or does not do this, then wash his access with soap at the chair side...Clean sites with antiseptic and allow to air dry...If area is touched for any reason after initial cleaning, re-cleanse site...” Review of the facility’s policy titled, “Preparation & Cannulation of the New or Existing Arteriovenous Graft (AVG) policy revised 10/28/2019, revealed, “...Patients that are physically able should be encouraged to wash hands and vascular access site prior to entering the treatment area; if the patient is physically unable, staff should complete this step chairside...Ensure that the patient goes to the sink and washes his access arm and hands with soap and water before beginning procedure. If patient is unable to or does not do this, then wash his access with soap at the chair side...Clean sites with antiseptic and allow to air dry...If area is touched for any reason after initial cleaning, re-cleanse site...” Review of the facility’s policy titled, “Use of the [named medical device manufacturer] Masterguard Anti-Stick Needle protector” dated 11/10/2010, revealed, “...Upon completion of dialysis, don PPE and rinse back and assess patient...Gently remove tape from first needle. Place a folded sterile gauze, stopper, or band aid over the insertion site...While maintaining appropriate pressure on the cannulation site, pull the tubing so that the needle exits the cannulations site...When hemostasis is achieved, apply sterile gauze, stopper, or band aid and clean gauze over exit site...” 6. Observations on the treatment floor on 1/22/2025 at 9:12 AM, revealed the NM discontinued Random Patient #3’s treatment via an AVF/AVG. Random Patient #3 held pressure to the insertion sites until active bleeding was stopped; however, the patient had some blood visible on her skin between the two dressings and the arterial dressing had an area of bright red blood visible. The NM failed to clean the blood off the patient’s skin and instead, covered the area with a piece of paper tape. The NM also failed to ensure Random Patient #3 left the facility with a clean, dry dressing in place. During an interview on 1/22/2025 at 5:37 PM, the NM stated all visible blood should be cleaned from the patient’s skin. When asked if it was acceptable to let the patient leave with a blood stained dressing in place, the NM stated all access sites should have a clean dressing on top with no visible blood “so they [patients] will know if they bleed afterwards.” 7. Observations on the treatment floor on 1/22/2025 at 10:41 AM, revealed PCT #1 escorted Random Patient #4 to the treatment floor and to the assigned chair. Random Patient #4 was not observed washing the access site with soap and water prior to walking to the treatment chair. PCT #1 began the cannulation procedure without washing the patient’s access site with soap. During the cannulation procedure, a small amount of blood oozed from the cannulation site. PCT #1 did not clean the blood off the patient’s skin. During an interview on 1/22/2024 at 11:01 AM, Random Patient #4 confirmed she did not wash her access site while she was in the facility. During an interview on 1/22/2025 at 5:37 PM, the NM stated staff were expected to clean access sites with soap when patients were unable to do so prior to cannulation. 8. Observations on the treatment floor on 1/22/2025 at 11:00 AM, revealed RN #1 prepared to cannulate Patient #3’s vascular access site. RN #1 cleaned the access site with antiseptic and allowed the site to air dry when Patient #3 repositioned herself in the chair and rubbed the access site against her shirt. RN #1 did not re-cleanse the access site prior to cannulation. During an interview on 1/22/2025 at 5:37 PM, the NM stated if access sites come into contact with anything while the antiseptic used to clean the site was drying, the site should be re-cleaned with antiseptic and allowed to air dry prior to cannulation. When asked if it was acceptable to leave blood visible on the patient’s skin, the NM confirmed all visible blood should be cleaned from the patient’s skin.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 33763 Based on review of manufacturer’s instructions for use, observation and interview, the Medical Director failed to ensure facility staff stored blood glucose testing strips according to manufacturer’s instructions for use in 1 of 1 laboratory (lab)preparation (prep) areas observed. The findings included: Review of the manufacturer’s instructions for use on [named medical supply company] Pro Test Strips revealed, “CAUTION: Always close the vial with the cap immediately after use.” Observations in the lab prep areaon 1/22/2025 at 9:01 AM, revealed one bottle of glucose monitoring strips stored on the counter. The cap on the bottle was open. During an interview on 1/22/2025 at 5:15 PM, the NM confirmed caps were supposed to be closed on the blood glucose monitoring strips when not in use.”