Bma - Franklin County

“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: 33906 Based on observation and document review, facility staff failed to a) complete exit site care for a CVC (central venous catheter) according to policy for one of one observations and b) failed to provide documentation of visual audits of personnel infection control practices while provided care to patients. The findings include: a) At 11:15 AM on 6/24/2025, Staff #10 was observed providing exit site care for Patient #7. After removing and discarding the old exit site dressing, Staff #10 performed hand hygiene and donned clean gloves. Staff #10 (using a swabstick) cleaned the area above the exit site in a side to side motion, while moving farther away from the site. Staff #10 failed to clean under or to the sides of the catheter’s exit site. Staff #10 allowed the site to dry and then applied a sterile dressing. Review of facility document “Changing the Catheter Dressing Procedure” published 5/02/2025 revealed in part “Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry. . . “ b) During review of the facility’s QAPI (quality and performance improvement) program, Staff #1 was unable to provide evidence that personnel had been observed for infection control practices when providing care to patients. Although audits had been completed, Staff #1 had failed to document the name(s) of staff observed. The above observation was shared with Staff #1 prior to exit.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 33906 Based on observation and interviews, facility staff failed to ensure aisles on the treatment floor allowed room for staff access to allow for emergency care of the patient. The findings include: Surveyor observations on 6/23/2025 and 6/24/2025 found: The treatment floor has 16 stations with 4 stations each along the left and right walls, and the remaining 8 stations placed along a half-wall in the center of the room. The general appearance of the treatment floor is cluttered. The aisle between the dialysis stations along the right wall (looking out with the nursing station to your back) and the center half-wall has the following items lined up down the center of the aisle: a large trash can, biohazard box, patient wheelchair, cart with clean supplies, a stool, cart with cleaning supplies, biohazard box, patient wheelchair and a large trash can. There are no openings to allow staff to easily and quickly move between patients along the half-wall and the outer-wall. Additionally, it was noted that stools were being used to “prop-up” the footrest of dialysis chairs for some patients. The chair’s reclining function was operational and the surveyor observed the foot rest remained elevated when the stool was removed. The practice of putting stools under the chairs’ footrest creates an additional hazard to be navigated in the case of an emergency. The above findings were discussed with the management team and the medical director prior to exit. - A dialysis machine separates stations 5 and 6. The sharps container on the machine is touching chair 6, posing a contamination risk and sharps hazard for the patient in chair 6. -Dialysis chairs in stations 7 and 8 are approximately 3” apart when the side tables are in use, increased risk of blood splatter and cross contamination. -Stations 5, 6, 7 and 9 do not have sufficient space to allow staff to reach both sides of the chairs. There is not enough space chair side to allow for emergency equipment and/or treatment of medical emergencies. - The dialysis chair in Station #9 is positioned within 14” of an access panel that is labeled “danger - high voltage keep out” “warning electrical panel keep clear up to 36 inches”. -Stations 5, 6, 7, 8 and 9 do not have the space to allow staff to reach both sides of the chairs. There is not enough space chair side to allow for emergency equipment and/or treatment of medical emergencies. The above findings were reviewed with Staff Members #1, 4 and 6 prior to exit on 5/9/2024. See V-0401”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 33906 Based on observations and interviews, it was determined the facility staff a) failed to ensure patients’ skin over their access sites were washed with soap and water or an antibacterial scrub before proceeding with skin antisepsis and b) touched access site after antisepsis without repeating antisepsis. For two of two observations. The findings include: The facility staff failed to ensure Patient #4 and Patient #8’s access site was cleaned with soap and water or an antibacterial scrub prior to proceeding with skin asepsis. The surveyor conducted observations of Staff #11 (a Hemodialysis technician) initiating the hemodialysis treatment for Patient #11 on 06/24/25 at 10:00 AM. The surveyor observed the patient enter the treatment floor, weigh and then proceed to the dialysis chair. Patient #11 was in the chair at the dialysis station waiting for Staff #11 to began to initiate the treatment. Staff #11 did not ask the patient about whether he/she had cleaned his/her access site with soap and water. Staff #11 did not wash the access site with soap and water or an antibacterial scrub. Staff #11 evaluated the access site and proceeded to apply the antiseptic. After performing antisepsis, Staff #11 was observed touching the site with a gloved finger before inserting the catheter. Antisepsis was not performed again after touching the site. The surveyor conducted observations of Staff #10 (a Hemodialysis technician) initiating the hemodialysis treatment for Patient #1 on 06/24/25 at 10:10 AM. The surveyor observed the patient enter the treatment floor, weigh and then proceed to the dialysis chair. Patient #1 was in the chair at the dialysis station waiting for Staff #10 to began to initiate the treatment. Staff #10 did not ask the patient about whether he/she had cleaned his/her access site with soap and water. Staff #10 did not wash the access site with soap and water or an antibacterial scrub. Staff #10 evaluated the access site and proceeded to apply the antiseptic. After performing antisepsis, Staff #10 was observed touching the site with a gloved finger three times before inserting the catheter. Antisepsis was not performed again after touching the site. The surveyor reviewed the facility’s procedure for “Access Assessment and Cannulation” on 05/05/25. The procedure included, in part, the following: “Prior to treatment, ask your patient to wash access area with liquid soap for one minute, rinsing well. Dry with clean paper towel. Wash access (per above) if patients unable to clean their access.” “70% isopropyl alcohol pad: Using gentle friction, clean the access site...and allow to dry before cannulating.” and “Do not touch cannulation sites after skin disinfection.” The above findings were shared with Staff #1 prior to exit.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 33906 Based on interview and review of documentation of the facility quality program it was determined facility staff failed to ensure all patient deaths were reviewed for cause, analyzed and trended by the quality team. The findings include: Review of mortality was discussed with Staff #1 during the QAPI (Quality Assessment Performance Improvement) review on 6/24/2025. The surveyor asked to review the analysis of the death of Patient #6. Patient #6 expired on 9/25/2024, the cause of death was listed as “cardiac arrest”. Review of the facility’s documentation of patient deaths found no review had been conducted. Staff #1 stated all deaths are discussed during quality meetings but was unable to provide evidence the death of Patient #6 was reviewed, analyzed or trended by the quality team. The above findings were reviewed with the management team prior to exit.”