Medical Center Kidney Clinic

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders in 3 of 17 sampled patients and closed records: Patient #s 3, 4 and 13. Findings: Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265, published 11/06/2023 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Patient #3 On 06/20/2024 at 7:03 a.m., Patient #3 was observed seated at station #5 machine #21 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 800 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: 2 potassium, 2.5 calcium, 35 bicarbonate, 137 sodium. Observation in the chairside computer revealed a physician’s order dated 03/30/2024 for Bicarbonate setting: 32.0 mEq/L. Review of the hemodialysis treatment time revealed the start time was 5:45 a.m. Interview on 06/20/2024 at 7:20 a.m. with the direct care staff assigned to the patient, Patient Care Technician (B): The Surveyor informed him that the dialysate bicarbonate setting was not set on the hemodialysis machine as prescribed by the physician. Patient Care Technician (B) said, “Oh” and then he corrected the setting on the hemodialysis machine. Patient #4 On 06/20/2024 at 7:15 a.m., Patient #4 was observed seated at station #27 machine #12 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 800 mL/min via right central venous catheter. The patient was utilizing an Optiflux 180 non reuse dialyzer. Treatment sheet dated 06/14/2024 Review of the patient’s treatment sheet dated 06/14/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of 350 mL/min from 6:40 a.m. - 9:40 a.m. There was no justification documented for the blood flow rate of 350 mL/min. Interview with Clinical Coordinator (E), the Surveyor informed her that the patient was not administered the blood flow rate prescribed by the physician. Clinical Coordinator (E) said, “I’m not sure when it changed to 400, I will have to check.” Patient #13 Review of the patient’s clinical record (demographic data) on 06/20/2024 revealed the patient was admitted to the facility 08/04/2023. Treatment sheet dated 05/16/2024 Review of the patient’s treatment sheet dated 05/16/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 12:09 p.m.- 12:35 p.m. and 13:30 p.m.- 14:45 p.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Interview with Clinical Manager (G), the Surveyor informed her that the patient was not administered the dialysate flow rate prescribed by the physician. Clinical Manager (G) said, “I’m not sure why.””

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review patient’s attending nephrologists failed to complete monthly comprehensive progress notes on patients addressing adequacy, vascular access, anemia management, nutritional status, bone mineral metabolism and treatment response in 1 of 17 sampled patients and closed records: Patient #s 6 Findings: Patient #6 Observation on 06/20/2024 at 6:33 a.m., revealed Patient #6 was observed at station #31, hemodialysis machine #34 receiving hemodialysis treatment at a blood flow rate of 500 mL/min and dialysate flow rate of Autoflow 2.0 (800 mL/min) via a left upper arm vascular access. Review of the patient’s clinical record (CMS 2728) revealed the patient was admitted to the facility on 05/17/2022 with diagnosis of other cardiac disease, hypertension and end stage renal disease, on in-center hemodialysis three times weekly. Review of the patient’s clinical record (Physician Progress Note) revealed the most current documentation of a physician progress note was on 04/25/2024. There was no documentation of a physician progress note for May 2024. Review of the Facility’s Absence and Hospitalization report revealed Patient #6 was not absent or hospitalized during May 2024. Interview with Clinical Manager (G) at 4:45 p.m. confirmed the physician progress note on 04/25/2024 was the last one the facility had available in their records.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 30124 Based on observation and interview with the facility manager, staff ID #A facility failed to maintain a safe environment for its employees, patients, and visitors. Policy reviewed: Review of the facility’s current policy along with the facility manager titled “General Cleanliness and Infection Control Guidelines”, Published: 02/07/2022; Reference Number: 47685; Version: 6. Purpose: The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staff and visitors. Responsibility: All staff. Contaminated Needles and Sharps Containers: Contaminated needles/sharps are not to be recapped, bent, sheared or broken. During use, sharps containers shall be: Easily accessible and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. Maintained upright throughout use; replaced routinely and not be allowed to overfill. Contaminated sharps shall be discarded immediately or soon as feasible in containers that are: Clearly identifiable as sharp’s container. Designed to close. Puncture resistant. Leak proof on the sides and bottom. Labeled in accordance with OSHA Bloodborne Standard 1910.1030. Designed to prevent anyone from reaching into the container. All containers for storage or disposal needles/sharps shall be replaced on a regular schedule basis or when no more thatn 2/3 or ¾ full. The containers must be closed prior to being full and prior to being disposed. Findings: Observation on 01/09/2024 of the facility’s treatment area revealed 3 of 15 bio-hazard sharps containers were observed to be open and available for use were filled past the required replacement line marked on the containers with previously used open needles. Observation of the medication area revealed 1 bio-hazard sharps container was observed filled past the required replacement line marked on the container with previous used open needles. Interview with staff ID #A on 01/09/2024 at 15:45 PM confirmed the above finding. Staff ID #A confirmed the bio-medical sharps containers should have been changed out and she would take care of it.”