Usrc Webster Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to perform hand hygiene according to policy: 1 of 6 staff observed: Patient Care Technician (B) Findings: Review of the facility’s current policy and procedure: Hand Hygiene directs the staff as follows: Hand Hygiene will be performed: 8. After touching patient surroundings (e.g., dialysis machine, and any items in the dialysis area or chairside computers 9. After gloves are removed 10. Before and after touching PPE 11. After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station Patient Care Technician (B) Observation on 09/24/2024 at 10:57 a.m., revealed Patient Care Technician (B) at station #33 disinfecting the wall box behind machine #5 with bleach towels after the hemodialysis treatment. Patient Care Technician (B) discarded the contaminated bleach towels and with the same gloves reached into the bleach bucket to grabbed new bleach towels with his contaminated gloves. Patient Care Technician (B) then used the bleach towels to disinfect the stethoscope hanging on the intravenous pole of machine #5. The Surveyor immediately notified Patient Care Technician (B) that he failed to remove his contaminated gloves and perform hand hygiene before reaching into the bleach bucket for new bleach towels. Patient Care Technician (B) said, “Okay, I should have removed my gloves and wash my hands.””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean blood from the prime bucket in a timely manner in 1 of 6 sampled staff: Patient Care Technician (E) Patient #5 Findings: Patient Care Technician (E) Patient #5 On 09/24/2024 at 08:06 a.m., Patient #5 was observed at station #9 machine #10 receiving a sequential ultrafiltration (SEQ) treatment at a blood flow rate of 350 mL/min and dialysate flow rate of SEQ. Observation revealed frank blood in the prime bucket. Prior to approaching the patient’s station, the Surveyor observed the direct care staff member assigned to the patient leave the treatment floor. The Surveyor began to write down the hemodialysis machine settings when another direct care staff member removed the prime bucket stated, “she forget to clean it.” The direct care staff member confirmed that Patient Care Technician (E) left the blood in the prime bucket. Review of the patient’s treatment record in the chairside computer revealed that the patient’s vascular access was cannulated at 7:23 a.m. Interview with Patient Care Technician (E) revealed that one of Patient #5’s vascular access needles was not functioning properly, so she removed the needle from the patient’s arm and drained it into the prime bucket to check for blood clots. She confirmed that she left the blood in the prime bucket and did not dispose of it in a timely manner.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s governing body failed to: ensure expired medications are not stored and ready for use on the emergency cart. B) ensure expired supplies are not stored and in use for calibration and quality control testing of the blood glucose monitoring device. Findings: Observation on 09/24/2024 at 8:23 a.m. revealed a single-use ampule of Epinephrine Injection USP 1 mg/mL in the top drawer both Lot # 230204A, expiration date of 08/2024. Review of the Facility’s Emergency Cart Contents log for June and July 2024 revealed the expiration date for the Epinephrine Injection was documented as 8/2024. The documentation for August 2024 revealed and documented expiration date of 8/2029. The Surveyor notified Registered Nurse (A) of the expired Epinephrine Injection on the emergency cart. Registered Nurse (A) stated, “Let me take that and throw it away.” 30124 Observation on 9/24/2024 at 0855 AM along with registered nurse staff ID #A the following was observed: 1. One opened container of Medline EvenCare G2 glucose control testing solution for low testing was not labeled with an open date per manufactory recommendations, Lot #16822092109, Expiration Date 09/08/2024. 2. One opened container of Medline EvenCare G2 glucose control testing solution for high testing was not labeled with an open date per manufactory recommendations, Lot #16822092209, Expiration Date 09/28/2024. Manufactory instruction “Use within 3 months after first opening, or the expiration date.” 3. One opened container of EvenCare G2 Blood glucose test strips, Lot #16823072009, manufactory expiration date 04/04/2025 did not have an open date on the container. Manufactory instructions: “Use within 6 months after first opening or before expiration date”. Interview on 09/24/2024 at 0900 AM with staff ID #A confirmed the above findings.”

“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 2 of 23 sampled patients and closed records: Patient #s 5 and 6 Findings: Patient #5 On 09/24/2024 at 08:06 a.m., Patient #5 was observed at station #9 machine #10 receiving a sequential ultrafiltration (SEQ) treatment at a blood flow rate of 350 mL/min and dialysate flow rate of SEQ. Review of the patient’s clinical record on 09/25/2024 revealed no documentation of a physician progress note for the current month of September 2024. There was no documentation of a physician progress note for the month of August 2024. The most recent physician progress note was documented on 07/22/2024. Review of the facility’s grievance log revealed dated 09/25/2024 revealed the patient notified the RN that he wanted to switch to another physician “because he doesn’t see his doctor often.” Interview with the Clinical Specialist on 09/25/2024 confirmed there were no attending physician visits after 07/22/2024 for Patient #5. Patient #6 On 09/24/2024 at 08:31 a.m., Patient #6 was observed at station #19 machine #36 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 600 mL/min. Review of the patient’s clinical record on 09/25/2024 revealed no documentation of a physician progress note for the current month of September 2024. The most recent physician progress note was documented on 08/20/2024. Interview with the Clinical Specialist on 09/25/2024 confirmed there were no attending physician visits after 08/20/2024 for Patient #6.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on record review and interview the facility’s Medical Director failed to ensure nursing staff followed the facility’s policy and procedure to prevent or reduce complications pre, during or post treatment in that: 1. Selected patient records reviewed found the facility’s nursing staff failed to provide hemodialysis treatment as ordered by the physician in 1 of 23 records reviewed. (Patient ID #3) 2. Selected patient records reviewed contained no hemodialysis prescription verification by a second staff member within the first hour of hemodialysis treatment in 5 of 23 records reviewed. (Patient ID #9, 12, 13, 8, 14) 3. Selected patient records reviewed found no document a nurse re-assessment/intervention was completed by the facility’s nursing staff after abnormal finding outside of patient parameters were identified during treatment to see if clinical interventions were necessary in 3 of 23 records reviewed. (Patient ID #12, 14, 7) B) Based on observation, interview and record review facility’s registered nurse failed to follow facility’s policy during administrator of Venofer in 2 of 12 patients observed during administration of intravenous Venofer: Patient #’s 6 and 7 Policies Reviewed: Review of the current policy and procedure titled “Initiation of Dialysis Treatment”; Policy # C-TI-0010; Last revision 07/2024. Purpose: To provide guidance to prevent complications related to initiation of the hemodialysis treatment. 5. Two staff members must verify and document on the flow sheet indicating the following items are correct prior to initiation of treatment: d. Correct prescription (e.g., dialyzer, acid concentrate, bicarbonate, sodium, temperature, heparin (if ordered), and any Special Instructions. Procedure: 13. Prior to walking away from patient’s dialysis machine, verify all prescribed orders are followed. If unable to follow any part of 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. Prescription orders and safety measures include, but are not limited to verifying the following: a. Blood flow is at prescribed rate. b. Heparin pump (if used) is turned on and delivering the correct dose. c. Correct dialysate flow rate. _____________ Policy Reviewed: Review of the current policy and procedure titled “Nursing Staff”; Policy # C-AD-0120; Last revision 01/2020. Purpose: To define the responsibilities of the registered nurse and licensed vocational/practical nurse. Policy: Registered nursing staff will be responsible for: 1. Administration of patient medications as prescribed. 2. Administration of dialysis prescription as ordered. 3. Conducting comprehensive admission nursing assessments. 4. Conducting assessments of a patient when indicated by a question relating to a change in patient’s status or at the patient’s request. 5. Participating in team review of patient’s progress. 6. Recommending changes in treatment based on the patient’s current needs. ____________ Policy Reviewed: Review of the current policy and procedure titled: Reportable Parameters to Charge Nurse (CN)”; Policy # C-Forms-0082; Revision Date: 01/2020. PCT/CCHT/LPN: Report to Charge Nurse Pre-Dialysis - B/P - Systolic > 180 or <90, Diastolic <50 Intra-Dialysis - B/P - Systolic > 180 or <90, Diastolic <50 Post Dialysis - B/P - Systolic > 180 or <90, Diastolic <50 Policy Reviewed: Review of the facility’s current policy and procedure: Iron Protocol and Administration (policy # C-MA-0620, revision date 09/2022) directs the staff as follows: “PROCEDURE 5. CombiSet/Nipro bloodlines: d. Aseptically attach syringe securely to the medication Y-port. e. Push Venofer slowly with over 2 to 5 minutes as recommended by manufacturer f. Follow Venofer with 1mL of air to ensure entire dose is administered ...” Findings: Review of patient ID #9’s hemodialysis records: 08/26/2024 treatment initiated at 05:01 AM, there was no additional second verification by staff that the patient was receiving their prescribed hemodialysis treatment orders. 09/07/2024 treatment initiated at 12:10 PM, there was no additional second verification by staff that the patient was receiving their prescribed hemodialysis treatment orders. Review of patient ID# 12’s hemodialysis records: 09/17/2024 treatment initiated at 10:19 AM, there was no additional second verification by staff that the patient was receiving their prescribed hemodialysis treatment orders. 09/19/2024 hemodialysis treatment sheet reviewed documented at 12:29 PM, pre-treatment blood pressure 172/77, pulse 75. Treatment was initiated by Licensed Vocational Nurse (LVN) at 12:31 PM, with BP 165/74, pulse 72. At 15:00 PM, LVN noted BP 198/64, pulse 65, “BP high, CN (charge nurse) notified, 0.1 mg clonidine given at 15:19 PM. Patient resting, and eyes closed. Dialysis in progress. Respirations regular. Access visualized and lines secure.” At 15:38 PM LVN documented BP 189/64, pulse 64, “BP high CN (charge nurse) notified. No documentation was found of a re-assessment or intervention by the registered nurse with BP levels above the parameters set for patient. Review of patient ID #3’s hemodialysis record: Review of hemodialysis orders for patient Id #3 documented as: treatment time 3.5-hour, dialysate solution 2.0 K, 2.5 Ca, 140 Na, blood flow 350 ml/min, dialysate flow 600 ml/min via right internal jugular central venous catheter. Review of patient ID #3’s hemodialysis treatment sheet dated 09/14/2024 documents initiated of treatment by the nurse at 07:02 AM with a blood flow of 400 ml/min and continued to run at a blood flow rate of 400 ml/min during the entire length of treatment. No documentation was found as to why the blood flow was run at a higher rate. Review of patient ID #3’s hemodialysis treatment sheet dated 09/17/2024 documents initiated of treatment by the nurse at 06:51 AM with a blood flow of 400 ml/min and continued to run at a blood flow rate of 400 ml/min during the entire length of treatment. No documentation was found as to why the blood flow was run at a higher rate. Interview and record review on 09/25/2024 along with the facility’s Clinical Specialist, staff ID #J confirmed the above listed finding during record review. 48020 Prescription Verification and Nursing Assessment: Patient #13 Review of the patient’s clinical record (demographic data) on 09/24/2024 revealed the patient was admitted to the facility on 09/21/2022 with the diagnoses of end stage renal disease and diabetes mellitus, on incenter hemodialysis three times a week. Review of the patient’s treatment sheet dated 05/10/2024 revealed the patient’s treatment was initiated at 10:50 a.m. and there was no documented second verification of the patient hemodialysis prescription. Patient #8 Review of the patient’s clinical record (demographic data) on 09/25/2024 revealed the patient was admitted to the facility on 03/11/2021 with the diagnoses of end stage renal disease and hypertension, on incenter hemodialysis three times a week. Review of the patient’s treatment sheet dated 09/18/2024 revealed the patient’s treatment was initiated at 16:04 p.m. and there was no documented second verification of the patient hemodialysis prescription. Review of the patient’s treatment sheet dated 09/23/2024 revealed the patient’s treatment was initiated at 16:22 p.m. and there was no documented second verification of the patient hemodialysis prescription. Patient #14 Review of the patient’s clinical record (demographic data) on 09/25/2024 revealed the patient was admitted to the facility on 12/02/2019 with the diagnoses of end stage renal disease and diabetes with renal manifestations on incenter hemodialysis three times a week. Review of the patient’s treatment sheet dated 09/18/2024 revealed the patient’s treatment was initiated at 14:05 p.m. and there was no documented second verification of the patient hemodialysis prescription. Review of the patient’s treatment sheet dated 09/23/2024 revealed the patient’s treatment was initiated at 15:57 p.m. and there was no documented second verification of the patient hemodialysis prescription. 15:59 p.m.: documented blood pressure of 91/58 and pulse rate of 52 beats per minute- PCT documented, “UF OFF DUE bp trending low, nurse notified.” The RN did not document an assessment until 18:38 p.m. which is the same time the Pre-dialysis Assessment was signed off. The Pre-dialysis Assessment was documented greater than one hour after the hemodialysis treatment was initiated. Patient #7 On 09/24/2024 at 08:36 a.m., Patient #7 was observed seated at station #16 machine #17 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 133/70 pulse 63. Review of the patient’s treatment sheet dated 09/19/2024 revealed the following findings: 09:34 a.m.: documented blood pressure of 92/58 and pulse rate of 74 beats per minute- PCT documented, “BP low; UF turned off; RN notified...” 10:01 a.m.: documented blood pressure of 101/84 and pulse rate of 73 beats per minute- PCT documented, “BP still low; UF remains off ...” 10:31 a.m.: documented blood pressure of 110/67 and pulse rate of 69 beats per minute- PCT documented, “BP still low; UF remains off ...” There was no assessment by the registered nurse during the dialysis treatment to determine the need to have the patient’s UF turned off. Interview and record review with Clinical Coordinator (D) on 09/25/2024 confirmed second verification of the hemodialysis prescriptions and reassessments by the registered nurses were not performed in the above findings. Venofer administration: Patient #6 On 09/24/2024 at 08:31 a.m., Patient #6 was observed at station #19 machine #36 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 600 mL/min. Observation revealed residual Venofer was observed in the venous chamber medication Y-port. Review of the patient’s treatment sheet dated 09/24/2024 revealed documentation by Registered Nurse (F) that Venofer 50 mg, was administered at 6:58 a.m. although residual medication was left in the venous chamber medication Y-port. Subsequent observation at 11:15 a.m. revealed Patient Care Technician (E) removed the blood lines from the hemodialysis machine with the residual Venofer remaining in the medication Y-port and discarded them into the biohazard. The patient did not receive the complete dose of Venofer. Patient #7 On 09/24/2024 at 08:36 a.m., Patient #7 was observed at station #16 machine #17 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min. Observation revealed residual Venofer was observed in the venous chamber medication Y-port. Review of the patient’s treatment sheet dated 09/24/2024 revealed documentation by Registered Nurse (F) that Venofer 50 mg, was administered at 09:45 a.m. although residual medication was left in the venous chamber medication Y-port. Subsequent observation at 11:12 a.m. revealed Patient Care Technician (G) returning the blood after the hemodialysis treatment. Patient Care Technician (G) then removed the blood lines from the hemodialysis machine with the residual Venofer remaining in the medication Y-port and discarded them into the biohazard. The patient did not receive the complete dose of Venofer. The Surveyor immediately notified Registered Nurse (F) that Patient #’s 6 and 7 did not receive the complete dose of Venofer because of the residual dose left in venous chamber medication Y-port. Registered Nurse (F) said, “Okay.””