Renal CARE Group - Martinsville

“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: 46466 Based on observations and facility document review, facility staff failed to wear proper attire while caring for patients on the treatment floor. The findings include: On 6/3/24 at 12:45 p.m., the surveyor observed one (1) staff member on the treatment floor, caring for patients while wearing Croc’s (Croc’s are a rubberized shoes that have open holes throughout the shoe). A review of the facility’s policy “Employee Dress Code”, effective date 6/18/21, stated in part: “...When in a patient care or lab area, footwear must be worn that meets the following safety requirements...has a solid foot-box (no holes or vents)...”. The findings were discussed with Staff Members #1, #3, #4, #5, #6 and #7 on 6/4/24 at 2:00 p.m..”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 46466 Based on observations and facility document review, the facility staff failed to maintain a safe environment for dialysis patients by not discarding expired medications. The findings include: On 6/3/24 at 12:35 p.m., a vial of Tubersol with a written opened date of 5/1/24 and a written expiration date of 5/27/24 was found inside the refrigerator. The Tubersol package insert reads in part, “A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date”. A review of the facility’s policy “Medication Preparation and Administration”, published 2/6/23, stated in part “...Expiration dates for all stored medications are to be monitored on a monthly basis. -Expired medications are to be discarded...Any open multi dose vials must be discarded 28 days after opening or per manufacturers expiration date...”. The findings were discussed with Staff Members #1, #3, #4, #5, #6 and #7 at the exit conference on 6/4/24 at 2:00 p.m.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 46466 Based on observations and document review, the facility staff failed to maintain aseptic technique for a CVC (central venous catheter) dressing change. The findings include: On 6/4/24 at 1:15 p.m., the surveyor observed one (1) staff member performing CVC exit site care at patient station #24. The patient was wearing a t-shirt where the collar was tucked under CVC hubs. The staff member removed the old dressing, disposed of the old dressing, donned new gloves then disinfected the exit site. After disinfecting, the patient’s t-shirt collar moved back into the disinfected exit site area and was touching the bottom of the exit site. A review of the facility’s policy “Changing the Catheter Dressing Procedure”, published 2/5/24, stated in part: “...Applying the Dressing...using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing with gloved hands or to any surface...”. The findings were discussed with Staff Members #1, #3, #4, #5, #6 and #7 on 6/4/24 at 2:00 p.m..”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 19883 Based on clinical record review and staff interview, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) for one (1) of ten (10) patients included in the survey sample. The findings included: During the survey ten (10) clinical records were reviewed. Patient #10, a Home Hemodialysis patient, had a physician’s order for four (4) treatments per week and a BFR (Blood Flow Rate) of 400 milliliter’s per minute (Ml/min). Review of Patient #10’s daily treatment flow sheets from 5/14/24 through 6/3/24 evidenced a documented BFR of 300 Ml/Min, with no documentation to indicate why the prescribed flow rate was not followed. On 6/4/24 at approximately 10:09 AM, during an interview with Staff Member #2, they indicated they are respondible for the daily review of the treatment flow sheets of the Home Hemodialysis patients. Staff Member #10 verified that Patient #10’s BFR should have run at 400 Ml/Min, and that there should have been documentation to show why the physician’s orders were not followed for a BFR of 400 Ml/Min. Staff Member #2 stated, “I just missed it.” A review of the facility’s policy “Patient Assessment and Monitoring”, published 5/1/23, stated in part: “...3. Machine Parameters and Extracorpeal Circuit - Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow...”. The findings were discussed with Staff Member #’s 1, 2, 3, 4, 5, 6, and 7 on 6/4/24 at 2:00 PM.”