Bma - Nassawadox

“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: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff perform hand hygiene after glove removal for one (1) of three (3) Staff Members (SM), SM # 4; and failed to ensure staff have fingernail length 1/4 inch or less for one (1) of one (1) SM, SM # 3. The findings include: On May 14, 2024 between 9:00 a.m. and 12:00 p.m. the following were observed in the treatment area during initiation and termination of treatments: At 9:18 a.m., SM # 3 was observed in the treatment area with fingernails greater than 1 inch in length. At 9:20 a.m. SM # 4 was observed during treatment initiation at Station # 12. SM # 4 removed dirty gloves and failed to perform hand hygiene before donning clean gloves. At 9:35 a.m. SM # 4 was observed at Station # 14. SM # 4 removed during gloves and donned clean gloves without performing hand hygiene and going to Station # 10. On May 15, 2024, a review of the facility’s policy titled “Hand Hygiene” reads in part “Natural fingernail length shall be kept to 1/4 inch or less. Hand will be decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves.” On May 15, 2024 at 1:00 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff wear and/or wear correctly personal protective equipment (PPE) when in the treatment area during initiation and termination of treatments for three (3) of five (5) Staff Members (SM), SM # 4, # 6 and # 10. The findings include: On May 14, 2024 between 9:00 a.m. and 12:00 p.m. the following were observed in the treatment area during initiation and termination of treatments: At 9:00 a.m., SM # 1 and # 3 provided a gown and face shield to the surveyor to wear before the initial tour and observations in the treatment area. At 9:10 a.m., SM # 10 was observed at Station # 5 not wearing a gown or face shield while in the treatment area where patient treatments were being initiated and terminated. At 9:45 a.m., SM # 10 was observed at Station # 10 talking with the Patient. SM # 10 was not wearing a face shield while in the treatment area where patient treatments were being initiated and terminated. At 9:55 a.m., SM # 6 was observed at Station # 14 touching the dialysis machine. SM # 6 failed to wear a gown or face shield while in the treatment area where patient treatments were being initiated and terminated. At 10:11 a.m. SM # 6 was observed at Station # 8 touching the dialysis machine. SM # 6 failed to wear a gown or face shield while in the treatment area where patient treatments were being initiated and terminated. At 10:35 a.m. SM # 4 was observed at Station # 2 with the face mask below the chin. SM # 4 then pulled the face mask up above the nose. On May 15, 2024 at 12:30 p.m., an interview with SM # 1 and # 2 indicated “All staff should wear PPE when in the treatment area while patient treatments are initiated and terminated.” On May 15, 2024, a review of the facility’s policy titled “Personal Protective Equipment” reads in part “Personal protective equipment including full face shield or mask and protective eyewear with full side shield, fluid resistant gowns and gloves must be worn to protect employees from blood or other potentially infectious materials. Facemasks are single use only and must be discarded after the task for which they were needed is complete.” On May 15, 2024 at 1:00 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure staff keep clean supplies clean for one (1) of one (1) Staff Member (SM), SM # 4. The findings include: On May 14, 2024 between 9:00 a.m. and 12:00 p.m. the following was observed in the treatment area during initiation and termination of treatments: At 9:20 a.m. SM # 4 was observed during treatment initiation at Station # 12. SM # 4 removed dirty gloves and failed to perform hand hygiene before entering the clean supply storage with dirty hands. On May 15, 2024, a review of the facility’s policy titled “Hand Hygiene” reads in part “Hands will be washed with antimicrobial soap and water before gathering supplies.” On May 15, 2024 at 1:00 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure staff clean stethoscopes after use for one (1) of one (1) Staff Member (SM), SM # 4. The findings include: On May 14, 2024 between 9:00 a.m. and 12:00 p.m. the following was observed in the treatment area during initiation and termination of treatments: At 9:20 a.m., SM # 4 was observed during treatment initiation at Station # 12. SM # 4 failed to clean the stethoscope after use before placing the stethoscope around neck. On May 15, 2024, a review of the facility’s policy titled “”Access assessment and cannulation” “ reads in part “clean stethoscope after assessing a patient.” On May 15, 2024 at 1:00 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility staff failed to obtain treatment data to include blood pressure at least every forty-five (45) minutes during the dialysis treatment for three (3) of seven (7) Patients (P), P # 2, # 5 and # 6. The findings include: On May 15, 2024 between 9:00 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 2- The flowsheet dated May 13, 2024 revealed there were no document treatment data to include blood pressure between 9:36 a.m. and 10:45 a.m. (greater than 45 minutes). P # 5- The flowsheet dated May 13, 2024 revealed there were no document treatment data to include blood pressure between 7:00 a.m. and 8:30 a.m. (greater than 45 minutes). P # 6- The flowsheet dated May 13, 2024 revealed there were no document treatment data to include blood pressure between 12:33 p.m. and 1:39 p.m. (greater than 45 minutes). On May 15, 2024, a review of the facility’s policy titled “Patient Assessment and Monitoring” reads in part “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes.” On May 15, 2024 at 1:00 p.m., the findings were discussed with Staff Members # 1 and # 2 during the exit interview.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility staff failed to ensure staff complete a comprehensive reassessment within fifteen (15) days of the revision of the plan of care for one (1) of seven (7) Patients (P), P # 5. The findings include: On May 15, 2024 between 9:00 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 5- The annual stable plan of care dated October 11, 2023 indicated the last Registered Nurse (RN) comprehensive reassessment was performed January 1, 2023, greater than fifteen (15) days prior to the plan of care completion. On May 15, 2024, a review of the facility’s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” reads in part “The plan of care must be implemented within 15 days of the reassessment.” On May 15, 2024 at 1:00 p.m., the findings were discussed with Staff Members # 1 and # 2 during the exit interview.”