Fresenius Medical Care Amarillo High Plains

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 43999 Based on observation and staff interviews the facility failed to ensure staff followed their policies in the care of patients. These practices have the potential to harm patients and staff due to cross contamination. The cumulative effects of this deficient practice resulted in the facility’s inability to comply with the condition of Participation: Patient Assessment. This deficient practice placed all patients receiving treatment in the facility at an increased risk of significant health problems. Findings: The facility failed to evaluate and assess patient needs for 2 of 8 patient’s reviewed. The direct patient care staff (PCT) did not report significant changes in patient health status while receiving hemodialysis to the charge nurse; and/or the charge nurse failed to reassess the patient when significant changes occurred during treatment, notifying the physician when appropriate and/or administering medication as ordered for patients.Based on record review and staff interview, the facility staff failed to ensure direct care staff were reporting patient vital signs that fell outside of the facility’s set parameters to the CN (charge nurse) for further assessment and intervention on 4 (# 1 # 2 # 6 # 8) of 4 patient charts reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. Based on observation and policy review the facility failed to ensure staff followed their own policies when terminating and perparing central venous catheter for patient discharge and assessing blood pressure needs of the patients which can lead to patient harm. Cross reference tags: V0147, V504”

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 43999 Based on observation, interviews and documentation reviewed, the facility is not in compliance with applicable State regulatory licensing requirements, Texas Administrative Code 117.45(d)(6)(B), when there was not sufficient direct care staff on site to meet the needs of the patients. During treatment of eight, but not more than twelve patients, the registered nurse functioning as charge nurse was assigned as direct care staff. Findings include: During review of patient/staff assignments for patient care July 27, 2024 and August 10, 17 & 24, 2024, there were two nurses assigned to provide patient care with no CN (charge nurse) assigned that is not assigned pt care when 8 or more patients are receiving treatments. In an interview with nurse (staff # 2) on 8/27/24, it was stated, “All nurses provide direct patient care,sometimes our CM (clinic manager) assist with care, but its not scheduled. On most, if not all, Saturday shifts, there is only two nurses and they both provide direct patient care that include all nursing responsibilities: initiation and termination of all CVC (central venous catheter) patients throughout the two shifts, as well as administration of all patient ordered medications, assessments, and other CN duties.” In an interview with staff #1 (Clinic Manager) on 8/27/24, it was confirmed all nurses provide direct patient care when there is no other scheduled nurse to be in Charge. Texas Administrative Code 117.45(d)(6)(B) states, “(6) Sufficient direct care staff, as defined in §117.2(25) of this title (relating to Definitions), shall be on site to meet the needs of the patients, and at least one licensed nurse shall be available on site for every twelve patients or portion thereof. ...(B) During treatment of eight but not more than twelve patients, the registered nurse functioning as charge nurse shall not be assigned as direct care staff...””

“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: 43999 Based on record review and interview, the facility staff failed to include and/or adhere to catheter care when catheter care was not done after treatment prior to discharge for 1 of 1 patients (patient # 1). This practice placed all patients in the facility for high risk of infection. Findings : Facility Procedure titled “ Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer dated 02/07/2022 partly stated, “Termination: Preparing Catheter for Patient Discharge... 1- Open the arterial catheter limb clamp, and flush limb. 2- Remove empty saline syringe from a catheter limb and immediately attach the heparin, or other prescribed locking agent filled syringe. 3-Open catheter limb clamp and gently flush limb with heparin or other prescribed locking agent. Close the catheter clamp. Flushing quickly and closing the catheter clamp, as the last solution is instilled, helps to maintain a positive pressure within the catheter. This prevents blood from backing up into lumens that could then lead to clotting. 4- Apply a sterile cap on the end of the lumen maintaining aseptic technique. Tighten the end cap securely. Sterile caps prevent infection and provide protection between treatments. 5- Repeat steps 1 through 4 for the venous catheter limb. If patient requires saline after any heparin, or other prescribed locking agent has been instilled into the catheter limbs, aspirate 5 mL of blood from the catheter limb prior to systemic administration of saline. After saline has been administered, perform scrub the hub procedure prior to re- instilling heparin, or other prescribed locking agent. 6- If preferred, gauze may be wrapped around the catheter limbs for patient comfort. Avoid placing tape directly on the catheter as micro - organisms may adhere to tape residue. Never use scissors near a CVC to avoid accidental cutting. “ Patient # 1: The treatment sheets dated 7/29/24 documented patient received catheter care and/or catheter Heparin lock care after treatment, signed and completed by staff #3. There were orders for Catheter Care Every Treatment and Heparin sodium 1,000 units/ml. catheter lock venous blue port and 1600 units/mL in arterial red port post dialysis every treatment. In an interview with staff # 1 on 8/26/24, the patient returned to the facility 7/30/24 and had syringes attached to catheter ports instead of sterile caps. The finding was confirmed with staff #1 during interview. When asked how often the catheter care and Heparin lock care should be performed on patients, she replied, “Our policy is every treatment.””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 43999 Based on observation and staff interviews the facility failed to ensure staff followed their procedures in the assessment and care changes in patients blood pressure during treatment. This practice has the potential to cause patient harm. Findings: Facility procedure titled : “Patient Assessment and Monitoring 05/01/2023 partly stated: Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LP note any changes or abnormal findings in the patient ’ s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. · The RN will notify the patient ’ s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. Blood Pressure pre,during and post treatment; Record blood pressure. · Recheck blood pressures after a drop that requires interventions such as administering normal saline. · Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: · Systolic blood pressures greater than 180 mm/Hg · Diastolic blood pressure greater than 100 mm/Hg · Blood Pressure less than or equal to 100 mm/hg systolic Review of 2 of 2 patient treatment sheets revealed direct care staff did not report out-of-parameter blood pressures findings to the Charge Nurse/RN for assessment and further evaluation and instruction. Patient # 1 Date: 8/5/24 0807 AM: BP (blood pressure) - 164/108 PCT (staff # 11)did not notify RN, no intervention taken 0832 AM BP- 152/115 LPN (staff # 3) did not notify RN, q 15 min BP, no intervention taken 0917 AM: BP- 181/137 LPN (staff # 3) did not notify RN, q 15 min BP, no intervention taken 0931 AM BP- 178/114 LPN (staff # 3) did not notify RN, q 15 min BP, no intervention taken 0948 AM: BP- 153/115 PCT(staff # 11) did not notify RN, q 15 min BP,no intervention taken Date: 8/9/24---- 1001 AM: BP(blood pressure) - 119/104 LPN(staff # 14) did not notify RN,no intervention taken 1037 AM: BP-155/125 PCT (staff #16) did not notify RN, q 15 min BP,no intervention taken 1042 AM: BP- 149/102 PCT(staff #16) did not notify RN, no intervention taken 1116 AM: BP- 134/106 PCT(staff #16) did not notify RN, BP,no intervention taken 1159 AM: BP- 144/108 RN (staff #15) discharged, no intervention taken Patient # 16 Date: 8/22/24 0618 AM: BP (blood pressure) - 161/131 RN (staff #12) initiated treatment, no intervention documented 0649 AM BP- 203/120 PCT(staff # 11) did not notify RN, q 15 min BP, no intervention taken 0719 AM: BP- 170/120 PCT (staff # 11) did not notify RN, no intervention taken 0730 AM BP- 192/105 LPN (staff # 14) did not notify RN, q 15 min BP, no intervention taken 0746 AM: BP- 223/117 LPN(staff # 14) did not notify RN, q 15 min BP,no intervention taken 0803 AM: BP- 164/110 PCT (staff # 11) did not notify RN, q 15 min BP,no intervention taken Date: 8/27/24- 0735 AM: BP(blood pressure) -209/135 PCT (staff #13) did not notify RN,no intervention taken 0801 AM: BP-205/146 PCT(staff #13) did not notify RN, q 15 min BP,no intervention taken 0819 AM: BP- 200/151 PCT (staff #13) did not notify RN, no intervention taken 0830 AM: BP- 205/139 PCT(staff #13) did not notify RN, BP,no intervention taken 0901 AM: BP- 220/151 RN (staff #12) discharged, no intervention taken The above findings were confirmed in an interview with the Clinic Manager 8/27/24 , the staff did not follow facility blood pressure parameters for documentation and reporting changes in the patient condition to the charge nurse/RN.”