Liberty Dialysis College Station

“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: 22676 Based on observations, interview, and policy review, the facility failed to ensure staff performed hand hygiene (sanitizing with an alcohol-based hand rub or washing with soap and water) after removing gloves, after touching patient care equipment (dialysis machines and bloodlines), and before contact with the patient, during one of three survey days. Failure to remove gloves and perform hand hygiene provided a mode of cross contamination, with the potential spread of infection, which could negatively impact the 68 patients receiving incenter dialysis treatments in this facility. Findings include: During an observation of the hemodialysis treatment area on 12/06/23 from 9:45 AM to 12:30 PM revealed, Patient Care Technician (PCT) 12 was observed disconnecting at Station 12 at 10:45 AM. PCT12 removed his/her gloves and failed to perform hand hygiene. PCT12 then donned (put on) new gloves without performing hand hygiene. PCT12 then went into Station 9 and touched the dialysis machine and assisted the Nurse. Wearing the same gloves, PCT12 left Station 9 and opened the clean supply cabinet to obtain supplies. PCT 12 was observed numerous times removing gloves at the biohazardous container at the nursing station without using hand sanitizer or washing with soap and water after removing gloves. During an interview on 12/06/2023 at 12:12 PM PCT12 confirmed the above findings. PCT12 stated he/she was new to dialysis and forgot. During an observation of the hemodialysis treatment area on 12/06/23 at 11:30 PM revealed, Registered Nurse (RN) 10 scrub the patients Central Venous Catheter (CVC) hubs and connected the syringes. RN 10 then set the machine settings. RN10 was then observed connecting the dialysis lines to the CVC without changing gloves and sanitizing hands. During an interview on 12/06/23 at 12:30 PM staff RN 10 confirmed he/she failed to change gloves and use hand sanitizer after touching the machines and before making the connection to the Patients CVC line. During an interview on 1206/23 at 1:40 PM, the Administrator confirmed that after removing gloves and donning new gloves hand hygiene should be performed. The Administrator confirmed the CVC connection should be made after sanitizing hand and donning new gloves. Review of the facility’s policy titled, “Hand Hygiene,” revision dated 11/06/23 revealed, “Immediately after removing glove. After contact with body fluids or excretion .... after contact with inanimate objects near patient, when moving from a contaminated body site to clean body site of the same patient. After contact with other objects within the patient station.””

“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: 22676 Based on observation, interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure that the wall boxes (dispensing outlets) at all 16 dialysis stations were clean and free of a build-up of white crystals and yellow substance. This deficient practice had the potential to cause bacteria to grow in the wall boxes and cause harm by infecting the 68 patients receiving in-center hemodialysis at the facility. Findings include: Observation of all wall boxes on 12/06/23 at 9:45 AM, at all 16 dialysis stations revealed a dark yellow sediment with white sediment build-up on the wall boxes. During an interview on 12/06/23 at 10:00 AM, Biomedical Technician 6 stated that he/she did not know when the wall boxes were to be cleaned. He/She confirmed all 16 wall boxes were visibly dirty with white sediments and dark yellow build up. During an interview on 12/06/26 at 12:30 PM, the Certified Clinical Hemodialysis Technician (CCHT) 13 stated they were told today the closing staff would clean them each night. CCHT 13 stated he/she did not know when the wall boxes were cleaned last. Review of the facility policy titled “Cleaning and Disinfection of the Dialysis Station” dated 09/05/23 “Dialysis wall boxes and the area/wall around the wall box must be routinely cleaned at the end of each treatment day or immediately if splattered with blood. All surfaces shall be surface disinfected with 1:100 bleach solution. Special attention should be given to removing build-up and/or cleaning splatter and spray of concentrate solution. If concentrate leaks are noted at the wall box, staff should notify biomedical services for repair.” Review of the “CDC Dialysis Safety” located on the CDC website at www.cds.gov titled “Wall boxes and Drains” indicated, “All box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). Cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during patient care activities ... ... More than one disinfectant wipe or application may be needed to ensure all wall box surfaces are visibly wet with disinfectant to achieve contact time specified by the manufacturer.””

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 22676 Based on observation, interview, review of the “Daily Water Treatment Logs,” and review of the facility’s policy, the facility failed to ensure the staff monitored the end of day hardness of water as required by the regulations and facility policy, for one of 42 days reviewed. This deficient practice had the potential to affect the safety of the all 68 in-center hemodialysis patients receiving treatment and staff at this facility. Findings include: Review of the facilities paper “Daily Water Treatment Logs” from 10/01/23 through 11/30/23 located in the electronic waterlogs, revealed the facility failed to conduct the end of day hardness on one of 2 days reviewed. It was noted on 11/08/23 the area to document the end of the day hardness was left blank. During an interview on 12/06/23 at 2:00 PM, Biomedical Staff 7 confirmed the staff are required to conduct and document, the end of day hardness (a test to confirm the water hardness does not exceed the required limits) on the daily water treatment log at the end of each treatment day. Biomedical Staff 7 confirmed on 11/08/23 the log was blank A review of the facility’s policy titled, “Water Softener” dated 05/03/23, Hardness levels post water softener at the beginning of each operational day and at the end of each operational day.””

“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: 22676 Based on record reviews, interview, and review of the facility’s policy, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for six of seven sampled in-center patients (Patient (P) 1, P2, P3, P4, P6 and P7). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 68 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1’s electronic medical record (EMR) revealed a prescribed blood flow rate (BFR) 450 milliliters per min (ml/min) and a dialysate flow rate (DFR) of 1.5 (the BFR) (675) ml/min. Review of one of six “Post Treatment” flowsheets from 11/22/23 through 12/05/23, in the EMR indicated the following: On 12/05/23, the BFR was documented at 400 ml/min and the DFR at 600 ml/min from 9:30 AM through the end of treatment at 12:44 PM. There was no documented rationale for the change to the prescribed DFR. 2. Review of P2s EMR revealed a prescribed BFR of 400 ml/min and a DFR of 1.5 (the BFR) (600) ml/min. Review of one of six “Post Treatment” flowsheets from 11/20/23 through 12/07/23, in the EMR indicated the following: On 11/20/23 the DFR was documented at 800 ml/min from 6:14 AM through 9:30 AM. 3. Review of P3s EMR revealed a prescribed DFR of 500 ml/min. Review of one of six “Post Treatment” flowsheets from 11/20/23 through 12/05/23, in the EMR indicated the following: On 12/05/23 the DFR was documented at 800 ml/min from 12:10 PM through 1:04 PM and 600 ml/min from 1:04 PM through 4:03 PM. There was no documented rationale for the change to the prescribed BFR and DFR. 4. Review of P4s EMR revealed a prescribed DFR of 600 ml/min. Review of one of six “Post Treatment” flowsheets from 11/24/23 through 12/06/23, in the EMR indicated the following: On 11/28/23 the DFR was documented at 800 ml/min from 11:03 AM through 1:44 PM. 5. Review of P6’s EMR revealed a prescribed BFR of 400 ml/mi and a DFR of 1.5 (the BFR) (600) ml/min. Review of one of six “Post Treatment” flowsheets from 11/24/23 through 12/06/23, in the EMR indicated the following: On 12/06/23, the DFR was documented at 700 ml/min from 11:04 AM through the end of treatment at 2:44 PM. There was no documented rationale for the change to the prescribed DFR. 6. Review of P7s EMR revealed a prescribed BFR of 400 ml/min. Review of one of six “Post Treatment” flowsheets from 11/22/23 through 12/05/23, in the EMR indicated the following: On 12/05/23 the BFR was documented at 400 ml/min from 11:22 AM through 1:23 PM. There was no documented rationale for the change to the prescribed BFR and DFR. There was no documented rationale for the change to the prescribed BFR. During an interview on 12/07/23 at 2:45 PM, the Administrator confirmed the above findings and confirmed that staff did not follow the facility’s policy. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, revealed, “Check the prescribed blood flow rate is being achieved or the reason is documented in the medical record if unable to meet prescribed flow rate. Check dialysate flow rate setting is correct, and the correct prescribed flow is being ...””