Fmc Dialysis Services of Pearland

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, facility’s clinical manager failed to maintain the Emergency Disaster Patient Contact List as directed by the facility’s policy. Findings: Review of the facility’s current policy on Emergency and Disaster Responsibility Guidelines published 08/02/2017 directs the staff as follows: Action: Maintain current listings of patients and staff including local contact, emergency contact and evacuation contact information. Responsible Party: Clinical Manager On 08/14/2024 - 08/15/2024 during the survey patients were observed receiving care and services in the facility. Observation of the Emergency Supply Box on 08/14/2024 revealed the facility’s current Emergency Disaster Patient Contact List had a Report Creation Date of 1/8/2024. The report directs the staff to keep the list in the Emergency Supply Box or Cart. Review of the Facility’s Patient List of current patients provided by the Clinical Manager revealed a Report Creation Date of 8/14/2024. When the Surveyor compared Patient List to the current Emergency Disaster Patient Contact List, 20 patients on the Patient List were not found on the Emergency Disaster Patient Contact List. Interview with Clinical Manager Facility Administrator (G) on 08/15/2024 confirmed the Emergency Disaster Patient Contact List was not maintained as required by the policy.”

“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 and disinfect the blood pressure cuff holders, wall boxes, dialysate lines chase cabinets behind the dialysis stations in 2 of 3 sampled staff: Float Registered Nurse (C) and Patient Care Technician (B) B) the facility’s governing body failed to ensure the floor tiles on the treatment floor were cleaned and disinfected: Station #s 2 and 3 Findings: Review of facility’s current policy and procedure on cleaning and disinfecting the dialysis station published 09/05/2023, reference number 47806 version 14 directs staff as follows: “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day, and it is critical that these items be thoroughly cleaned and disinfected between uses.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty.” Float Registered Nurse (C) Station #11 - hemodialysis machine #10 Observation on 08/14/2024 at 10:25 a.m. revealed Float Registered Nurse (C) terminally cleaning station #11 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #10 at station #11, Registered Nurse (C) failed to clean the dialysate hoses, wall box, and chase cabinet. Station #10 - hemodialysis machine #13 Subsequent observation on 08/14/2024 at 11:21 a.m. revealed Float Registered Nurse (C) terminally cleaning station #10 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #13 at station #10, Registered Nurse (C) failed to clean the dialysate hoses, wall box, and chase cabinet. The Surveyor notified Float Registered Nurse (C) at 12:26 p.m. that he failed to clean and disinfect the dialysate hoses, wall boxes, and chase cabinets at stations #11 and #10. Float Registered Nurse (C) said, “Okay.” During the notification, the Surveyor observed a cobweb below the windowsill behind station #10 and dead insects on the chase countertop behind stations #10-11. The Surveyor immediately notified the Clinical Manager of the cobweb and dead insects on top of the chase cabinets behind stations #10-11. The Clinical Manager said, “Okay.” Patient Care Technician (B) Station #7 - hemodialysis machine #11 Observation on 08/14/2024 at 11:32 a.m. revealed Patient Care Technician (B) terminally cleaning station #7 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #11 at station #7, Patient Care Technician (B) failed to clean the IV pole, stethoscope, dialysate hoses, wall box, and chase cabinet. The Surveyor notified Patient Care Technician (B) at 1:05 p.m. that she failed to clean and disinfect the IV pole, stethoscope, dialysate hoses, wall box, and chase cabinet at stations #7. Patient Care Technician (B) said, “Okay, I’ll clean them.” Observation of the treatment floor: Stations #2 and #3 Observation on 08/14/2024 of the treatment floor revealed floor tiles with black buildup at stations #2 and #3. The Surveyor pointed out the floor tiles to the Clinical Manager who was rounding with the Surveyor. The Clinical Manager said, “Okay.””

“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 1 of 8 sampled patients: Patient #1 Findings: Review of the facility’s current Policy and Procedure on Pre-Treatment Safety Checks; Policy #47798, published 02/06/2023 directs staff as follows: Policy The clinician initiating treatment must verify the prescribed set up matches the patient: “ Patient’s identity per policy “ Prescription o Dialyzer o Dialysate composition o Dialysate flow rate o Time o Goal set o Needle size o Temperature “ Special attention orders are followed “ Na modeling (SVS) and/or UFR profiling if applicable “ Heparin dose. If a heparin pump is used check to see if it is primed, turned on and set at the proper prescribed infusion rate. “ OLC volume “ Blood pressure and parameters are set Patient #1 On 08/14/2024 at 7:02 a.m., Patient #1 was seated at station #6 machine #1 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min via left lower arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: potassium 2.0 mEq/L, calcium 2.5 mEq/L, bicarbonate 33 mEq/L , sodium 137 mEq/L. Observation of the patient’s physician’s order located in the chairside computer revealed an order for bicarbonate 35.0 mEq/L Review of the patient’s clinical record revealed a physician’s order dated 08/12/2024 for Bicarbonate setting: 35.0 mEq/L Subsequent review of the patient’s clinical record located in the chairside computer revealed the hemodialysis treatment began at 6:23 a.m. Interview on 08/14/2024 at 7:10 a.m. with Patient Care Technician (B) who was rounding with the Surveyor and responsible for setting up the patient hemodialysis machine: the Surveyor informed her that the dialysate bicarbonate setting was not set on the hemodialysis machine as prescribed by the physician. Patient Care Technician (B) said, “I’ll change it.””

“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: 48020 Based on observation, record review and interview: the facility’s registered nurses failed to conduct post treatment assessment on patients when patients experienced a change in condition during hemodialysis treatment in 2 of 8 sampled and closed patients: Patient #s 2 and 7 B) the facility’s governing body failed to ensure the oxygen concentrator air filters are being cleaned weekly. Findings: Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment The comprehensive assessment is the first step, and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN ’ s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual ’ s performance and activity.5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN ’ s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: ’ “Lung sounds, edema, heart sounds. The registered nurse will assess/ reassess post treatment as indicated During Treatment “ Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. “ Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations. Follow the steps below for monitoring patient and machine parameters during treatment: Step 1 Blood Pressure- Action/Rational: 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” Patient #2 On 08/14/2024 at 7:02 a.m., Patient #1 was seated at station #11 machine #10 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 700 mL/min via a right central venous catheter. Vital signs were as follows: blood pressure 176/101 pulse 92. Review of the patient’s clinical record on 08/15/2024 revealed the following: Treatment sheet dated 08/14/2024: Review of treatment sheet dated 08/14/2024 revealed the following documentation: 06:40 a.m.: registered nurse documented the pretreatment assessment which revealed “AAOx3. BP high but asymptomatic. Clonidine 0.1 mg PO PRN given. Denies SOB, NVD, chest pain. UFG set to 3 L PPR or as Pt tolerates. Machine setting checked and verified. Will continue to monitor closely. Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: bilateral” 10:11 a.m.: registered nurse documented the post treatment assessment which revealed “BP resolved. Tx completed. Tol tx well. Total removed 3 L. Pt denies any new c/o post tx. Pt left above edw, MD aware. Fluid limitations reinforced. Pt receptive to education. Pt left unit stable, ambulatory at discharge.” The edema reassessment was not documented. Review of the patient’s treatment sheets dated 07/19/2024 and 08/09/2024 revealed the registered nursed did not document a reassessment of edema found during the pretreatment assessment. Treatment sheet dated 08/05/2024: Review of treatment sheet dated 08/05/2024 revealed the following documentation: 07:08 a.m.: documented blood pressure of 183/105 and pulse rate of 90 beats per minute - PCT did not document any notes 07:31 a.m.: documented blood pressure of 188/115 and pulse rate of 91 beats per minute - PCT documented “UF on; Resting Comfortably; Access Visible; Denies Complaints; Patient Alert” 08:01 a.m.: documented blood pressure of 176/107 and pulse rate of 92 beats per minute - PCT documented “ ...Denies Complaints; Patient Alert” 08:32 a.m.: documented blood pressure of 179/105 and pulse rate of 92 beats per minute - PCT documented “ ...Denies Complaints; Patient Alert” 09:02 a.m.: documented blood pressure of 205/114 and pulse rate of 94 beats per minute - PCT documented “ ...Denies Complaints; Patient Alert” 09:32 a.m.: documented blood pressure of 180/109 and pulse rate of 95 beats per minute - PCT documented “ ...Denies Complaints; Patient Alert” 10:00 a.m.: documented blood pressure of 165/79 and pulse rate of 91 beats per minute - RN documented “UF on; Access Visible; Resting Comfortably; Access Visible; Denies Complaints; Patient Alert; All lines secured” The Patient Care Technician (PCT) monitored the patient for the majority of the hemodialysis treatment and did not report the elevated blood pressure to the registered nurse as required by the facility’s policy. The registered nurse did assess the patient’s blood pressure during the hemodialysis treatment. Patient #7 Review of the patient’s clinical record on 08/15/2024 revealed the patient was admitted to the facility 09/12/2016. Treatment sheet dated 03/18/2022: Review of the patient’s treatment sheet dated 03/18/2022 revealed the following documentation: 06:14 a.m.: documented blood pressure of 101/55 and pulse rate of 72 beats per minute 06:36 a.m.: documented blood pressure of 109/49 and pulse rate of 67 beats per minute 07:16 a.m.: documented blood pressure of 111/57 and pulse rate of 71 beats per minute 07:34 a.m.: documented blood pressure of 93/42 and pulse rate of 55 beats per minute - PCT documented “Denies Complaints; UF Off; Patient Alert; BP Low, feet elevated, UF off, RN notified” 08:04 a.m.: documented blood pressure of 106/59 and pulse rate of 64 beats per minute 08:38 a.m.: documented blood pressure of 124/60 and pulse rate of 69 beats per minute 09:06 a.m.: There was no documented blood pressure or pulse rate - PCT documented “Denies Complaints; Patient Alert” 09:37 a.m.: documented blood pressure of 112/60 and pulse rate of 60 beats per minute 10:15 a.m.: documented blood pressure of 117/58 and pulse rate of 64 beats per minute 10:15 a.m.: registered nurse documented the post treatment assessment which revealed “tx completed, pt tolerated tx well, no issues to address, pt denies symptoms or complaints, discharged in stable condition, fluid restrictions reinforced, advised to ER if symptoms arise.” The Patient Care Technician (PCT) monitored the patient for the majority of the hemodialysis treatment and did not report that the UF was turned off due to the decreased blood pressure to the registered nurse as required by the facility’s policy. The registered nurse did not assess the patient’s blood pressure during the hemodialysis treatment or the need to have the UF turned off. The post assessment by the registered nurse said the patient had “no issues to address” during treatment. Interview with the Clinical Manager on 08/15/2024 confirmed the patient care technicians were not reporting unusual findings to the registered nurses which would prompt them to do an assessment during dialysis. Oxygen Concentrators: Observation on 08/14/2024 of the facility’s oxygen concentrators revealed Respironics Everflo Oxygen Concentrator #4 with the serial number of 0620672 and Respironics Everflo Oxygen Concentrator #5 with the serial number of 0620660. Review of on 08/15/2024 of the Facility’s O2 Concentrator(weekly) logs revealed the filters were not cleaned weekly as follows: Serial Number 0620660: “ March 2024- the filter was cleaned on 3/6/2024, 3/13/2024, 3/21/2024, and 3/29/2024. The filter was not cleaned weekly (every seven days) on 3/20/2024 and 3/28/2024. “ April 2024- the filter was cleaned on 4/5/2024, 4/12/2024, 4/19/2024, 4/23/2024. The filter was not cleaned weekly (every seven days) on 4/30/2024. “ May 2024- the filter was cleaned on 5/1/2024, 5/9/2024, 5/16/2024, 5/23/2024, and 5/30/2024. The filter was not cleaned weekly (every seven days) on 5/8/2024. “ June 2024- the filter was cleaned on 6/4/2024, 6/11/2024, 6/19/2024, and 6/26/2024. The filter was not cleaned weekly (every seven days) on 6/18/2024. “ August 2024- the filter was cleaned on 8/6/2024 and 8/14/2024. The filter was not cleaned weekly (every seven days) on 8/13/2024. Serial Number 0620672: “ March 2024- the filter was cleaned on 3/6/2024, 3/13/2024, 3/21/2024, and 3/29/2024. The filter was not cleaned weekly (every seven days) on 3/20/2024 and 3/28/2024. “ April 2024- the filter was cleaned on 4/5/2024, 4/12/2024, 4/19/2024, 4/23/2024. The filter was not cleaned weekly (every seven days) on 4/30/2024. “ May 2024- the filter was cleaned on 5/1/2024, 5/9/2024, 5/16/2024, 5/23/2024, and 5/30/2024. The filter was not cleaned weekly (every seven days) on 5/8/2024. “ June 2024- the filter was cleaned on 6/4/2024, 6/11/2024, 6/19/2024, and 6/26/2024. The filter was not cleaned weekly (every seven days) on 6/18/2024. “ August 2024- the filter was cleaned on 8/6/2024 and 8/14/2024. The filter was not cleaned weekly (every seven days) on 8/13/2024. Observation on 08/15/2024 at 10:18, Random Patient #6 was seated at station #10 machine #13 receiving hemodialysis treatment. The patient was connected via nasal cannula to the Respironics Everflo oxygen concentrator #4 serial number 0620672. Interview with Biomedical Technician (D) on 08/15/2024 at 12:15 p.m. confirmed the oxygen concentrators filters were not being cleaned weekly. He also confirmed that “weekly” means every seven days.”