Usrc Cool Springs Dialysis

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed by 2 of 2 (RN #1 and RN #2) nurses on 1 of 1 observation days (3/24/2025) performing direct patient care to patients with CVCs before and after hemodialysis. The findings included: 1. Review of facility policy, “Accessing and De-Accessing the Dialysis Catheter” revised 06/2024 revealed, “...Supplies: (Accessing)...at least 4 packages alcohol prep pads...Supplies: (De-accessing)...(1) Underpad (replace underpad beneath the catheter for preparation of termination/disconnection)...8. Disinfect the hub with an alcohol prep pad...” 2. Observations on the treatment floor on 3/24/2025 at 9:59 AM, revealed RN #2 discontinued dialysis with a CVC on Random Patient #4. RN #2 failed to follow facility policy by not changing out the field under the CVC ports before disconnecting the lines. 3. Observations on the treatment floor on 3/24/2025 at 10:24 AM, revealed RN #2 discontinued dialysis with a CVC on Random Patient #5. RN #2 failed to follow facility policy by not changing out the field under the CVC ports before disconnecting the lines, and failed to ensure both hubs were scrubbed with an alcohol prep pad for a minimum of 20 seconds each. RN #2 scrubbed each hub with an alcohol prep pad for a maximum time of 9 seconds. 4. Observations on the treatment floor on 3/24/2025 at 11:11 AM, revealed RN #2 discontinued dialysis with a CVC on Random Patient #3. RN #2 failed to follow facility policy by not changing out the field under the CVC ports before disconnecting the lines. 5. Observations on the treatment floor on 3/24/2025 at 12:15 PM, revealed RN #1 initiated dialysis with CVC on Random Patient #1. RN #1 failed to ensure both hubs were scrubbed with an alcohol prep pad for a minimum of 20 seconds each by scrubbing one hub for 5 seconds and the other hub for 3 seconds before initiating treatment. 6. During an interview on 3/25/2024 at 12:37 PM, the FA stated the field (underpad) should be changed after hemodialysis treatment has ended, but before the disconnection of the lines from the CVC. The FA stated nursing staff were expected to scrub the CVC hubs with an alcohol prep pad for a minimum of 20 seconds each.”

“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: 49570 Based on facility policy review, medical record review, and interview, the facility failed to ensure 2 of 5 (Patient #1 and #2) sampled patients received the prescribed dialysis prescription for BFR and/or DFR during in-center hemodialysis. The findings included: 1. Review of facility policy, “Initiation of Dialysis Treatment” revised 07/2024, revealed, “ ...verify all prescribed orders are followed ...If unable to follow any part if the patient’s prescription after troubleshooting, notify charge nurse and document notification ...Charge nurse will notify physician if indicated and document any follow up or new orders ...Blood flow rate is at prescribed rate ...Correct dialysate flow rate ...” Review of facility policy, “Intradialytic Monitoring of Patient” policy revised 07/2024, revealed, “ ...Delivery of dialysis prescription: review prescribed treatment orders against actual machine settings ...” 2. Medical record review for Patient #1 revealed an admission date of 12/24/2023 with diagnoses that included ESRD. A physician’s order dated 2/24/2025 revealed dialysis 3 times per week for 3 hours and 45 minutes with a BFR of 400 and a DFR of 600. Review of the 2/26/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 7:17 AM when treatment began to 11:01 AM when treatment ended. There was no documentation that stated why the BFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/3/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 7:01 AM when treatment began to 8:01 AM and 325 from 9:30 AM to 10:42 AM when treatment ended. There was no documentation that stated why the BFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/7/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 7:30 AM to 8:00 AM. There was no documentation that stated why the BFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. 3. Medical record review for Patient #2 revealed an admission date of 11/15/2024 with diagnoses that included Hypertensive Chronic Kidney Disease Stage 5 or ESRD. A physician’s order dated 2/21/2025 revealed dialysis 3 times per week for 3 hours and 30 minutes with a BFR of 400 and a DFR of 600. Review of the 2/24/2025 Hemodialysis Flowsheet revealed the DFR was 500 from 11:59 AM to 3:00 PM when treatment ended. There was no documentation that stated why the DFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the DFR not being administered at the prescribed rate. Review of the 3/5/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 12:11 PM to 3:00 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/19/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 2:01 PM to 3:22 PM. The DFR was 500 from 11:42 AM to 3:22 PM at the end of treatment. There was no documentation that stated why the BFR or DFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the BFR or DFR not being administered at the prescribed rate. Review of the 3/21/2025 Hemodialysis Flowsheet revealed the DFR was 500 from 11:36 AM to 3:04 PM at the end of treatment. There was no documentation that stated why the DFR was not administered as prescribed, and no documentation the charge nurse or the physician was notified of the DFR not being administered at the prescribed rate. 4. During an interview on 3/25/2025 at 12:37 PM, the FA stated the BFR and DFR should run at the prescribed rate. If unable to run at the prescribed rate, there must be documentation of why the prescribed rate could not be reached and notification of the charge nurse and physician on the hemodialysis flowsheets.”

“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 facility policy review, observation, and interview, the facility failed to ensure appropriate measures were taken by 1 of 2 (RN #1) staff members on 1 of 1 (03/24/2025) observation days to reduce the risk of infection during cannulation of an AVF and/or AVG prior to initiation of hemodialysis. The findings included: 1. Review of the facility policy, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” revised 10/2023 revealed, “ ...Established AVF: A. Patient must wash access with soap and water prior to disinfection and cannulation. B. If unable, staff will wash patient’s access with soap and water (rinsing and drying afterwards ...3. Access preparation ...C. Disinfect each access site separately with one of the below options: Alcohol Prep Pad ...utilize a rubbing motion for at least 30 seconds ...” 2. Observation at Station #6 on 3/24/2025 at 11:16 AM, revealed RN #1 initiated hemodialysis on Random Patient #2 via an AVF/AVG. RN #1 failed to clean the access site per facility policy by not ensuring the access site was cleaned with soap and water prior to disinfection and cannulation and failed to clean the access sites per facility policy by scrubbing each access site with an alcohol prep pad for 3 seconds each instead of at least 30 seconds each per facility policy. 3. During an interview on 3/24/2025 at 12:47 PM, the FA confirmed staff were expected to follow the facility policy for initiation of dialysis with an AVG/AVF. She stated the access sites should be washed with soap and water before disinfection and cannulation and that each site should be cleaned with an alcohol prep pad for at least 30 seconds before cannulation is attempted.”