Artificial Kidney Center - Suffolk

“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 reviews and interviews, it was determined that the facility staff failed to ensure facemasks are worn correctly while in the treatment area for four (4) of seven (7) Staff Members (SM), SM # 2, # 3, # 4 and # 6. The findings include: On June 25, 2024 between 9:30 AM and 12:00 PM, observations in the treatment area during initiation and termination of treatments were performed and the following was observed: At 10:25 AM, SM # 6 was observed wearing the facemask below the nose at Station #2. SM # 6 was observed touching the front of the facemask and not performing hand hygiene before continuing patient care. At 10:40 AM, SM # 4 was observed touching the front of the facemask and not performing hand hygiene before continuing patient care at Station #10. At 10:50 AM, SM # 2 was observed touching the front of the facemask and not performing hand hygiene before continuing patient care at Station #16. At 11:20 AM, SM # 3 was observed touching the front of the facemask and not performing hand hygiene before continuing patient care at Station #3. At 3:00 PM, an interview with SM # 1 revealed the front of the facemask is considered “dirty”. On June 26, 2024 at 2:30 PM, a review of the facility’s policy titled “Guidance on dialyzing and infection control practices” reads in part “Reinforce training with putting on, using and taking off personal protective equipment (PPE) such as gowns, gloves, facemasks and face shields.” On June 26, 2024 at 2:45 PM, SM # 1 provided an inservice on “Wearing PPE appropriately” signed by SM # 2, # 3, # 4 and # 6, dated March 1, 2024. Center for Disease Control (CDC) guidelines include: “Masks are worn to help stop droplets from being spread by the person wearing the mask. They also keep splashes or sprays from reaching the mouth and nose of the person wearing the mask. The mask should fully cover the nose, mouth and chin to prevent fluid penetration. When wearing the mask, ensure that the mask fits snugly over the face; the color side of the mask faces outward, with the metallic strip uppermost, the strings or elastic bands are positioned properly to keep the mask firmly in place, the mask covers the nose, mouth and chin, and the metallic strip mould to the bridge of the nose. Hands should be washed before applying mask and after removing the mask.” On June 26, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 7, # 9, # 10 and # 12 during the exit interview.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 34452 Based on observations, document reviews and interviews, it was determined that the facility staff failed to ensure stethoscopes taken to the dialysis station were cleaned and disinfected after use for one (1) of one (1) Staff Member (SM), SM # 2. The findings include: On June 25, 2024 between 9:30 AM and 12:00 PM, observations in the treatment area during initiation and termination of treatments were performed and the following was observed: At 10:25 AM and 10:46 AM, SM # 2 was observed cleaning the stethoscope by wiping hand sanitizer on the bell of the stethoscope after use. On June 26, 2024 at 9:00 AM, an interview with SM # 1 revealed staff are expected to clean the stethoscope with a disinfectant or 1:100 bleach. On June 26, 2024 at 2:30 PM, a review of the facility’s policy titled “Cleaning and disinfecting the Dialysis station” reads in part “After use, any non-disposable equipment and supplies brought into the dialysis station (ex. stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before removed from the dialysis station.” CDC guidelines include: “noncritical surfaces (e.g. dialysis bed or chair, countertops, external surfaces of dialysis machines and equipment [scissors, hemostats, clamps, blood pressure cuffs, stethoscopes]) should be disinfected with an EPA registered disinfectant.” On June 26, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 7, # 9, # 10 and # 12 during the exit interview.”

“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: 34452 Based on document reviews and interviews, it was determined that the facility staff failed to evaluate and ensure the dialysis prescription was administered as ordered by the Physician for eight (8) of nine (9) Patients (P), P # 1, # 2, # 3, # 4, # 5, # 6, # 7 and # 8. The findings include: On June 26, 2024 between 9:00 AM and 2:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 25, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 6:11 AM through 7:01 AM revealed the BFR was 300; from 7:38 AM through 10:30 AM the BFR was 425. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 2- The flowsheet dated June 25, 2024 revealed the Physician ordered BFR was 400. Documentation at 7:12 AM revealed the BFR was 250; from 7:32 AM through 8:34 AM the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 3- The flowsheet dated June 20, 2024 revealed the Physician ordered BFR was 450. Documentation at 6:33 AM and 8:06 AM revealed the BFR was 400; from 8:34 AM through 9:06 AM the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 22, 2024 revealed the Physician ordered BFR was 450. Documentation from 7:32 AM through 8:37 AM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 25, 2024 revealed the Physician ordered BFR was 450. Documentation from 8:01 AM through 8:31 AM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 4- The flowsheet dated June 20, 2024 revealed the Physician ordered BFR was 400. Documentation from 6:02 AM through 8:33 AM revealed the BFR was 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 5- The flowsheet dated June 15, 2024 revealed the Physician ordered BFR was 450. Documentation from 7:38 AM through 10:31 AM revealed the BFR was 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 25, 2024 revealed the Physician ordered BFR was 450. Documentation from 9:03 AM through 10:38 AM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 6- The flowsheet dated June 15, 2024 revealed the Physician ordered BFR was 400. Documentation from 8:03 AM through 8:50 AM revealed the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 20, 2024 revealed the Physician ordered BFR was 400. Documentation from 6:59 AM through 9:51 AM revealed the BFR was 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 7- The flowsheet dated June 15, 2024 revealed the Physician ordered BFR was 400. Documentation from 11:38 AM through 2:32 PM revealed the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 25, 2024 revealed the Physician ordered BFR was 400. Documentation from 12:00 PM through 2:49 PM revealed the BFR was 250. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. P # 8- The flowsheet dated June 19, 2024 revealed the Physician ordered BFR was 400. Documentation from 6:15 AM through 10:03 AM revealed the BFR was 300; from 7:32 AM through 8:34 AM the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. The flowsheet dated June 21, 2024 revealed the Physician ordered BFR was 400. Documentation from 7:31 AM through 9:06 AM revealed the BFR was 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. There was no documented treatment prescription verification by the RN. On June 26, 2024 at 2:30 PM, a review of the facility’s policy titled “Patient assessment and monitoring” reads in part “During treatment... 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.” Facility’s policy titled “Nursing Supervision and Delegation” reads in part “The registered nurse must evaluate each patient preferably within an hour ... to: review patient treatment prescription and equipment parameters to verify correct settings and if dialysis prescription is being followed”. On June 26, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 7, # 9, # 10 and # 12 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 reviews and interviews, it was determined that the facility staff failed to ensure standing blood pressure were obtained pre and post treatment for two (2) of nine (9) Patients (P), (P # 4 and # 8); and treatment data to include blood pressures were documented at least every 45 minutes during the treatment for five (5) of nine (9) Patients, (P # 1, # 4, # 6, # 7 and # 8). The findings include: On June 26, 2024 between 9:00 AM and 2:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 18, 2024 revealed there was no treatment data to include blood pressure between 8:33 AM and 9:32 AM. (greater than 45 minutes). The flowsheet dated June 20, 2024 revealed there was no treatment data to include blood pressure between 8:04 AM and 9:07 AM. (greater than 45 minutes). P # 4- The flowsheet dated June 15, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The post treatment standing blood pressure was documented as 100/58. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. The flowsheet dated June 18, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The post treatment standing blood pressure was documented as “cannot assess”. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. The flowsheet dated June 20, 2024 revealed there was no treatment data to include blood pressure between 6:59 AM and 8:33 AM. (greater than 45 minutes). P # 6- The flowsheet dated June 20, 2024 revealed there was no treatment data to include blood pressure between 7:29 AM and 8:30 AM. (greater than 45 minutes). P # 7- The flowsheet dated June 25, 2024 revealed there was no treatment data to include blood pressure between 1:32 PM and 2:29 PM. (greater than 45 minutes). P # 8- The flowsheet dated June 17, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The post treatment standing blood pressure was documented as 204/108. The nursing evaluation documented ambulation status as “Ambulates w/assistive device”. The flowsheet dated June 21, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The post treatment standing blood pressure was documented as 130/72. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. There was no treatment data to include blood pressure between 7:59 AM and 9:00 AM. (greater than 45 minutes). On June 26, 2024 at 2:30 PM, a review of the facility’s policy titled “Patient assessment and monitoring” reads in part “During Treatment... Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes” and “Pre treatment ... obtain blood pressure. post treatment ... obtain blood pressure.” On June 26, 2024 at 3:00 PM, the findings were discussed with Staff Members (SM) # 1, # 7, # 9, # 10 and # 12 during the exit interview. SM # 7 indicated that staff are expected to obtain standing and sitting BP pre and post treatment all Patients.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 34452 Based on document reviews and interviews, it was determined that the facility staff failed to ensure there was a current evaluation of psychosocial needs by a social worker for one (1) of nine (9) Patients (P), P # 6. The findings include: On June 26, 2024 between 9:00 AM and 2:00 PM, clinical record reviews revealed the following: P # 6- The plan of care meeting dated October 31, 2023 failed to have a current evaluation of the psychosocial needs by a social worker. The last social worker update was dated November 30, 2022. On June 25, 2024 at 9:30 AM, an interview with Staff Members (SM) # 1 and # 7 indicated the facility had identified there was documentation that was lacking and they were working to update the information. The facility did not provide any updated comprehensive assessment by the social worker. On June 26, 2024 at 2:30 PM, a review of the facility’s policy titled “Comprehensive interdisciplinary assessment and plan of care” reads in part “The comprehensive interdisciplinary assessment (CIA) and plan of care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, ... qualified master’s degree level social worker ... . CIA and modifications to the Plan of Care must be conducted 12 months after the completion of the 3 month assessment and then reassessed annually thereafter on all stable patients.” On June 26, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 7, # 9, # 10 and # 12 during the exit interview.”