Bayshore Dialysis Center

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 28297 Based on observations, interviews, and policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) (refers to wearable equipment used to protect workers from serious injuries or illnesses while doing their jobs. Personal protective equipment acts as a barrier between infectious materials and the skin, mouth, nose, or eyes (mucous membranes) as required during disconnection of dialysis treatment via fistula/graft for one of three survey days. The failure to wear appropriate PPE had the potential for staff to be exposed to Bloodborne Pathogens (infectious microorganisms in human blood that can cause disease in humans. These pathogens include, but are not limited to, hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) and this could affect 116 in-center. Findings include: Observation on 02/03/25 at 4:15 PM revealed Certified Clinical Hemodialysis Technician (CCHT) 1 was at Station #15 completing discontinuation of dialysis treatment for Patient (P) 14 CCHT1’s eye protection of goggles were on top of his/her head. Observation on 02/03/25 at 4:16 PM revealed CCHT2 was at Station #11 completing discontinuation of dialysis treatment for P15 CCHT2’s eye protection of a face shield was on top of his/her head. During interviews on 02/03/25 at 4:18 PM both CCHT 1 and 2 acknowledged and confirmed they did not have eye protection as required when completing vascular access care via the patient’s fistula because there was a risk of splash if the patient’s access had started bleeding. Observation on 02/03/25 at 4:59 PM revealed Registered Nurse (RN) 2 was at Station #19 completing discontinuation of dialysis treatment for P13RN2 was wearing personal glasses that were not consider eye protection for the task. During an interview on 02/03/25 at 5:00 PM RN2 confirmed he/she did not have the correct eye protection for the risk of blood splash if the patient’s access had started bleeding. During an interview on 02/05/25 at 2:50 PM the Clinic Manager confirmed staff should have eye protection that prevents exposure to blood splashes when discontinuing the dialysis treatment via fistula/graft. Review of the facility policy “Personal Protective Equipment” revised 11/06/23 indicated the following: “ ...Personal protective equipment including a full face-shield or mask and protective eyewear with full side shield, fluid resistant gowns, and gloves, must be worn to protect employees from blood or other potentially infectious material (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood).””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 28297 Based on interview, medical record review, facility document and policy review the facility failed to ensure an unstable Assessment and Plan of Care was completed for one of 10 sampled patients (P3). The failure to complete an unstable Assessment and Plan of Care had the potential for missed opportunities for improved care and this could affect 116 in-center patients. Findings include: Review of the medical record face sheet for Patient (P) 3 indicated the facility admitted the P3 on 03/15/23 with diagnosis including end stage renal disease (ESRD). Review of the hospital records for P3 indicated the patient was hospitalized from 10/21/24-11/13/24 with a diagnosis of “Intercranial Hemorrhage” [life threatening brain bleed]. Review of the most recent care plan provided by the facility indicated the facility completed an annual Assessment and Plan of Care on 10/22/24 while P3 was in the hospital, however there was no unstable Assessment and Plan of Care when P3 returned from an extended hospital stay of 22 days for an “Intercranial Hemorrhage.” During an interview on 02/04/25 at 11:11 AM, the Clinic Manager stated an unstable Assessment and Plan of Care was not completed for P3. He/she stated the computer program did not trigger the patient to complete an unstable Plan of Care however there should have been an unstable Assessment and Plan of Care completed for P3 for an extended hospitalization. During an interview on 02/05/25 at 2:00 PM, the Social Worker stated there was a computer dashboard that indicated when Assessments and Plan of Care’s were due and that the Clinic Manager was responsible for initiating an Unstable Assessments and Plan of Care. Review of the policy “Comprehensive Interdisciplinary Assessment and Plan of Care”, revised 07/03/23 indicated the following: “ ...Unstable patients must be reassessed by the Interdisciplinary Team (IDT) monthly ...The following are unstable criteria: Extended or frequent hospitalization: Hospitalization of more than 15 days with discharge occurring within the last 30 days, or More than 3 admissions in the last 30 days or ...””

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 28297 Based on interviews, medical record review, facility document and policy review, the facility failed to ensure an initial Assessment and Plan of Care was completed in a timely manner for one of 10 sampled patients (P) 1The failure to complete an initial assessment and plan of care had the potential to create missed opportunities for improved care and this could affect 116 in-center patients. Findings include: Review of the medical record for P1 revealed the facility admitted the patient on 12/07/24 with diagnosis including end stage renal disease (ESRD). Review of the initial assessment and plan of care completed by the facility revealed it was not completed until 01/29/25, 22 days late. In addition, there was no patient signature on the plan of care that indicated the patient was involved with the plan of care and the facility could not provide documentation that an invitation was given to the patient indicating the day of the plan of care meeting of 01/29/25. Review of the dialysis treatment summary report provided by the facility revealed the patient had completed his/her 13 treatments at the facility by 01/04/25. An interview could not be completed during this survey with P1, as the patient was in the hospital for a planned procedure. During an interview on 02/04/25 at 10:05 AM, the Clinic Manager confirmed he/she could not locate an invitation for the Plan of Care Meeting for P1. During an interview on 02/05/25 at 2:50 PM the Clinic Manager confirmed P1’s Assessment and Plan of Care was late and should have been completed by 30 days after P1’s admission to the facility, or after the first 13 treatments. Review of the facility policy “Comprehensive Interdisciplinary Assessment and Plan of Care,” revised 07/03/25 indicated the following: “ ...an initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patients new to dialysis within the latter of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session ...The timeline for both the completion of the initial comprehensive assessment and the beginning of the implementation of the initial patient plan of care is the latter of 30 days from the date of admission or 13 hemodialysis treatments at the facility ...””