Kidney Care Center Lubbock

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 43999 Based on observation, interviews and documentation reviewed, the facility is not in compliance with applicable State regulatory licensing requirements. The Charge Nurse(CN) provided direct patient care duties contrary to Texas ESRD Rules and Regulations. Findings include: During observation on the patient treatment floor on 11/20/23, it was observed the two RNs both provided patient care to patients that include assessments , medication administration and catheter care as required . Review of the treatment sheets for 11/20/23 identified the CN initiating and terminating treatment. Based on observation, interviews and documentation reviewed, the facility is not in compliance with applicable State regulatory licensing requirements. The Charge Nurse(CN) provided direct patient care duties contrary to Texas ESRD Rules and Regulations. In an interview with staff #8 it was acknowledged that the CN (charge nurse) provides direct patient care routinely that include medication administration, and other charge nurse responsibilities.”

“TRAINING DOCU INCLUDES MED DIR CERT CFR(s): 494.50(b)(1) 5.2.2 Documentation: includes med dir certification Each person performing procedures for the multiple use of dialyzers shall have successfully completed the dialysis facility’s training course relevant to that person’s task and demonstrated competence in the area covered by his or her training. Successful completion of training shall be certified by the medical director or his or her designated representative and recorded in the trainee’s personnel file along with verification of the trainee having received the instruction. Retraining is necessary when new procedures are undertaken. Annual review of competence is required with appropriate retraining if deficiencies are found. This Standard is not met as evidenced by: 43999 Based on record review and interview, the facility failed to ensure facility staff, citing 4 of 8 unlicensed staff did not have the Medical Director delegation to perform specific clinical procedures. Findings included: Review of employee files for staff # 9, 11, 12 & 13 did not provide documentation to administer Lidocaine, Normal Saline, Heparin, and Oxygen. On 11/221/23 at 1500pm, staff # 1 & 2 confirmed the 4 of 8 staff did not have the required delegation by the facilities Medical.”

“MAINTENANCE PER DFU OR 2X/YR;RECORD CFR(s): 494.50(b)(1) 7.2.3 Maintenance: per DFU or semiannual/maintenance record Written maintenance procedures and a schedule of preventive maintenance activities designed to minimize equipment malfunctions should be established. In the case of purchased reprocessing equipment or safety equipment, the recommendations of the vendor should be followed unless documented experience supports alternative approaches. If the manufacturer’s recommendations are not available, reuse equipment and safety equipment should be inspected on a semiannual basis. 4 Records 4.3 Equipment maintenance record Records shall be maintained of the dates of preventive maintenance procedures and the results of scheduled testing in order to ensure the proper functioning of reprocessing equipment, environmental-control equipment, safety equipment, or other equipment. 4 Records A place should be provided for the signature or other unique mark of identification of the person ...performing preventative maintenance procedures. This Standard is not met as evidenced by: 43999 Based on record review and interview, the facility failed to ensure that all equipment was maintained in accordance with the manufacturer’s recommendations a a record of all maintenance and repairs be maintained at facility. Findings included: The facility was unable to provide documentation of completed annual Preventive Maintenance (PM) on the 14 machines for 2022 and 2023. There was no documented evidence that the Annual Preventive Maintenance was performed on the facility 14 machines according to the manufacturer’s recommendations. In an interview on 11/21/23 at 1400pm, the Biomed ( staff #5) and DO,staff #1 confirmed the above findings.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 43999 Based on an onsite visit, record review and interview it was determined that the facility failed to ensure the plans of care (POC) were updated/completed and shared with the patient or patient’s designee. Findings include: As of 11/21/2023, review of tracking tools to identify , implement and complete facility patient plan of care (POC) within 15 days of completion revealed there were 17 plans of care that were past due from 4/01/2023 through 11/21/2023. It was acknowledged on 11/21/23 in an interview with the Director of Operations , staff #1 the 17 patient’s care plans were past due.”