Usrc Arlington

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 50181 A review of the facility form, “AED/Emergency Crash Cart Daily Checklist” revealed that the facility failed to ensure the emergency equipment was checked daily. Findings include: The following dates were not recorded for the month of January 202401/12/202401/18/202401/30/202401/31/2024 The following dates were not recorded for the month of February 202402/05/202402/07/202402/12/2024 For the months of January, February, March and April 2024 the logs do not have the AED model name and serial number recorded. The above findings were reviewed with the Clinic Coordinator (Staff #2) on 05/14/2024.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 30377 Based on observation, policy and procedure review and staff interview, the facility staff failed to ensure a clean and sanitary environment was monitored and maintained to minimize the transmission of infectious agents in the in-center treatment area. This deficient practice had the likelihood to result in the transmission of infectious agents within the unit and between patients, staff members, and members of the public. Findings included: During a tour of the facility on 5/14/24 the following infection control issues were observed: In-Center Treatment Area Observations conducted on 5/14/2024 from 09:35AM to 10:48AM revealed: 1 out of 4 patient treatment chairs observed with a visible tear in the vinal arm rest that made cleaning impossible and cross contamination likely. 2 of 4 Sharps Containers observed with dried brown stains that appeared to be dry blood splatter on the top of the containers. Review of the facility’s policy titled, Infection Control and Precautions for All, published 07/2023 indicated, in part: #15: Clean and Disinfect: Clean and disinfect the dialysis station (e.g., chairs, beds, tables, keyboards, dialysis machines, ancillary equipment) after the patient has vacated the station. Give special attention to surfaces that are frequently touched and potentially contaminated with patients’ blood. During an Interview on 05/14/2024 with the facility’s clinical coordinator, staff # 2 confirmed the above infection control concerns and acknowledged the findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50181 Based on record review, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The specific BFR/DFR is needed to ensure that the blood pump is at constant speed to push the patient’s blood through the dialyzer and back into the patient’s body and is a part the patient’s dialysis prescription. Review of Patient #8 treatment record for 05/13/2024 revealed the BFR was ordered to run at 350mL/min. Review of the intradialytic records revealed the BFR ran at 400mL/min for the duration of the treatment 15:47-18:59 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 05/10/2024 revealed the DFR was ordered to run at 700 mL/min. Review of the intradialytic records revealed the DFR ran at 600mL/min for the duration of the treatment 11:07-15:06 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the 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: 50181 Based on record review, the facility staff failed to ensure direct patient care (DPC) staff were reporting patient vital signs that fell outside of the facility’s set parameters to the CN (charge nurse) for further assessment, interventions, and physician notification, if required. This deficient practice had the likelihood to cause harm and delay in care to all in-center hemodialysis patients receiving care at the facility. Findings Include: A review of C-FORMS-0081, “Reportable Parameters to the Charge Nurse” revealed, “PRE-DIALYSIS Weight: No weight gain or gain >4.5kg B/P Systolic: >180 or <100 B/P Diastolic: >100 Pulse: <60 or >100 beats per minute Nurse must complete assessment before treatment initiated if any parameters not met INTRA-DIALYSIS B/P Systolic: >180 or <100 Diastolic: >100 Pulse: <60 or >100 beats per minute POST DIALYSIS B/P Systolic: >180 or <100 Diastolic: >100 Pulse: <60 or >100 Weight: >1kg above or below EDW” Patient #3 A review of the treatment sheet dated 05/09/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 07:18 Blood Pressure 196/109 note reads, “Cleaned two sites with aseptic technique. Cannulated two sites without difficulty. Treatment started without problems. Lines and needles taped and secure. Saline line double clamped.” A review of the treatment sheet dated 05/07/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 08:01 Blood Pressure 186/88 10:04 Blood Pressure 187/83 10:38 Blood Pressure 184/88 A review of the treatment sheet dated 05/04/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 08:30 Blood Pressure 213/125 09:03 Blood Pressure 236/87 Pulse 105 09:33 Pulse 105 10:02 Blood Pressure 200/105 Pulse 108 10:30 Blood Pressure 204/121 11:00 Blood Pressure 200/101 Pulse 101 13:27 Blood Pressure 192/107 Patient #4 A review of the treatment sheet dated 05/11/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 11:50 Blood Pressure 198/74 11:55 Blood Pressure 207/73 13:02 Blood Pressure 208/82 A review of the treatment sheet dated 05/09/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 11:35 Blood Pressure 204/77 11:37 Blood Pressure 210/77 14:00 Blood Pressure 187/78 14:06 Blood Pressure 204/76 14:30 Blood Pressure 192/72 A review of the treatment sheet dated 05/07/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 11:48 Blood Pressure 185/72 12:02 Blood Pressure 183/68 14:00 Blood Pressure 191/71 14:16 Blood Pressure 191/71 14:47 Blood Pressure 187/73 15:02 Blood Pressure 185/70 A review of the treatment sheet dated 05/02/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 12:29 Blood Pressure 211/99 13:01 Blood Pressure 200/46 14:18 Blood Pressure 191/31 15:26 Blood Pressure 182/65 16:27 Blood Pressure 194/73 A review of the treatment sheet dated 04/30/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 13:19 Blood Pressure 192/78 14:32 Blood Pressure 203/74 14:55 Blood Pressure 205/77 Patient #8 A review of the treatment sheet dated 05/10/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 15:45 Pulse 102 16:59 Pulse 102 18:00 Pulse 105 18:30 Pulse 106 19:00 Pulse 108 A review of the treatment sheet dated 03/23/2024 revealed the following vital signs documented by the DPC staff during treatment without documentation to support the CN was notified of the out of parameter findings. 08:00 Pulse 102 08:30 Pulse 102 09:00 Pulse 106 09:30 Pulse 112 10:00 Pulse 107 10:30 Pulse 103 11:00 Blood Pressure 171/102 Pulse 104 11:13 Blood Pressure 168/103 Pulse 104 11:18 Pulse 102”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 50181 Based on record review and interview, the facility failed to ensure the interdisciplinary team completed the plan of care assessment prior to the plan of care meeting date. Findings include: Patient #1Plan of Care meeting date: 05/02/2022RN CIPA Completion Date: 05/11/2022 Social Worker CIPA Completion Date: 05/05/2022 Patient #4Plan of Care meeting date: 10/06/2023RN CIPA Completion Date: 11/24/2023 Patient #5 Plan of Care meeting date: 08/28/2023 RN CIPA Completion Date: 08/31/2023 Social Worker CIPA Completion Date: 09/08/2023 Patient #6Plan of Care meeting date: 03/29/2024 RN CIPA Completion Date: 03/30/2024Social Worker CIPA Completion Date: 04/19/2024 The above findings were discussed with the Clinic Coordinator (Staff #2) and Group FA (Staff #3) both confirmed and acknowledged the above findings.”