Bma - Crystal Spring

“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: 19883 Based on observations and facility document review, the facility staff failed to properly perform hand hygiene between donning and doffing gloves per policy. The findings include: On March 3, 2025, while providing care to a patient who was receiving dialysis, Staff Member #2 removed their gloves but did not perform hand hygiene before donning clean gloves. After donning the gloves, Staff Member #2 adjusted their eye glasses, then picked up a clean clamp and placed it on the patient’s chairside tray. Staff Member #2 proceeded to hang a bag of fluid, and adjusted the dialysis tubing on the patient’s arm, then removed the arterial and venous needles from the patient, while wearing the same pair of gloves. A review of the facility’s policy “Hand Hygiene”, published 11/6/23, indicated in part: “...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Immediately after removing gloves...”. 46466 On March 3, 2025 at 1:35 PM, 1:37 PM, 1:41 PM, 2:05 PM and 2:10 PM, the surveyor observed Staff Member #2 doffing and donning new gloves without performing hand hygiene between the glove changes.”

“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 observation and facility document review, two (2) facility staff failed to wear proper attire while caring for patients on the treatment floor. The findings include: On March 3, 2025 at 1:20 PM, two (2) staff members were observed wearing Croc’s (rubberized shoes with open holes throughout) on the treatment floor while caring for patients. A review of the facility’s policy “Employee Dress Code”, effective date 6/18/21, indicated 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)...”.”

“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: 46466 Based on observation and facility document review, the facility failed to disinfect or dispose of items used at multiple patient dialysis stations. The findings include: On March 3, 2025 at 2:05 PM, Staff Member #3 was observed using a stylus pen on the dialysis keyboard of patient station #5. When finished typing, Staff Member #3 placed the pen underneath their left arm. Staff Member #3 did not disinfect the stylus pen after using it at station #3. Staff Member #3 then went to station #8, removed the pen from under their arm and used it on the keyboard. A review of the facility’s policy “Cleaning and Disinfecting the Dialysis Station”, published 9/5/23, indicated in part: “...If equipment is brought into the patient station or becomes contaminated, follow cleaning and disinfecting procedures...”.”

“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: 46466 Based on observations and facility document review, it was determined that the facility staff failed to clean and disinfect contaminated surfaces of the medical devices and equipment per policy. The findings included: On March 3, 2025 at 1:00 PM, Staff Member #2 was observed disinfecting patient station #12. Staff Member #2 only disinfected the front and top of the dialysis machine. Staff Member #2 did not disinfect the sides of the dialysis machine, and did not empty or disinfect the prime waste bucket. The prime waste bucket was observed with approximately two (2) to three (3) inches of fluid inside. As Staff Member #2 set up the machine, Staff Member #2 was observed placing the ends of the bloodlines into the prime waste bucket and submerging the ends into the remaining fluid. Staff Member #2 left the station then returned to continue disinfecting the chair. Staff Member #2 disinfected the chair back, arms and sides but did not push the side tables down to disinfect between the arms and the tables. After disinfecting the chair, Staff Member #2 placed the dirty blood pressure cuff on top of the disinfected seat and began to disinfect the cuff front and back. Staff Member #2 failed to disinfect the blood pressure tubing, the wall behind the station, and the television. Staff Member #2 left the station area, then returned with dry paper towels and began to wipe the wet disinfected chair down to dry. Staff Member #2 did not pick up the medical debris left on the floor at the dialysis station. A review of the facility’s policy “Cleaning and Disinfecting the Dialysis Station”, published 9/5/23, indicated in part: “All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glisteningly wet and let air dry unless otherwise specified by the manufacturer...If equipment is brought into the patient station or becomes contaminated, follow cleaning and disinfecting procedures...Procedure...3. Use a cloth wetted with 1:100 bleach solution or EPA- approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind chair)...4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by the manufacturer. 5. Give special attention to the cleaning control panel on the dialysis machine and other surfaces that are frequently touched and potentially contaminated with patient’s blood and/or body fluids...6. Pick up all trash or visible medical debris from around the patient chair...”.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 46466 Based on observations, interview and facility document review, the facility failed to ensure a safe environment for all staff, visitors and patients while on facility property. The findings include: On March 3, 2025 at 1:14 PM, the surveyors observed a small water puddle underneath the chair of patient station #11 and in front of the dialysis equipment at patient station #12. There were two (2) wet floor caution signs placed in front of and near the stations, however, the water spill had not been cleaned as of 2:10 PM. On March 4, 2025 at 10:10 AM, an interview was conducted with Staff Member #5. Staff Member #5 stated that a water spill on the treatment floor should be cleaned up as soon as feasibly possible. Staff Member #5 stated that they did not have a specific policy regarding the cleaning of water spills but provided an internal document. A review of the facility’s internal document regarding “Precautionary Measures”, with no date indicated in part: “...Clean up spills immediately...”.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46466 Based on clinical record and facility document review, the facility failed to properly assess patients during treatment for three (3) of eleven (11) patients included in the survey sample. (Patient # 4, #6 and #8) The findings include: On March 4, 2025 a review of eleven (11) patient medical records was conducted. Patient #4: Six (6) treatment records from February 18, 2025 through March 1, 2025 were reviewed. On February 22, 2025, Patient #4’s blood pressure was documented at 7:00 AM and not documented again until 8:03 AM. Patient #5: Six (6) treatment records from February 17, 2025 through February 28, 2025 were reviewed. On February 19, 2025, Patient #5’s blood pressure was documented at 6:13 AM and not documented again until 7:03 AM. On February 21, 2025, Patient #5’s blood pressure was documented at 1:30 PM and not documented again until 2:30 PM. The blood pressure was documented at 3:00 PM and not documented again until 4:30 PM. On February 26, 2025 Patient #5’s blood pressure was documented at 2:33 PM and not documented again until 3:34 PM. Patient #8: Five (5) treatment records were reviewed from February 26, 2025 through March 3, 2025. On March 3, 2025, Patient #8’s blood pressure was documented at 6:04 AM and not documented again until 7:07 AM. A review of the facility’s policy “Patient Assessment and Monitoring”, published 5/1/23, stated in part: “...During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations...”.”

“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 medical record review, and facility document review, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) and/or DFR (dialysis flow rate) for five (5) of eleven (11) in-center dialysis patients included in the survey sample. (Patient #1, #4, #5, #8 and #9) The findings included: Patient #1: The surveyor reviewed six (6) dialysis treatment records with treatment dates of 02/18/25 through 03/01/25. Patient #1 had a prescribed BFR of 400 ml/min and a prescribed DFR of 2.0 autoflow. (Autoflow sets the DFR to 1.5 times the blood flow rate. Therefore a patient dialyzing with a 400 ml/min blood flow would have a reduced dialysis fluid flow of 600 ml/min. Source: https://map.sustainablehealthcare.org.uk). Patient #1’s prescribed autoflow rate for their DFR should have been 600 ml/min. Review of Patient #1’s dialysis treatment record revealed that Patient #1’s DFR was 800 ml/min on 02/15/25, 02/22/25 and 03/01/25. On 02/20/25, Patient #1’s DFR was 300 ml/min. On 02/27/25, Patient #1’s DFR was 500 ml/min. There was no documentation in any of the aforementioned dialysis treatment records to indicate why Patient #1’s prescribed DFR of a 2.0 autoflow rate, (equivalent to a DFR of 600 ml/min) was not followed. Patient #9: The surveyor reviewed six (6) dialysis treatment records with treatment dates of 02/14/25 through 02/19/25. Patient #9 had a prescribed BFR of 400 ml/min, and a prescribed DFR of 2.0 autoflow. Patient #9’s autoflow rate for their DFR should have been 600 ml/min (1.5 times the BFR). On 2/12/25, 02/10/25, and 02/07/25, Patient #9’s DFR was 700 ml/min. On 02/09/25, Patient #9’s DFR was 400 ml/min. There was no documentation in any of the aforementioned dialysis treatment records to indicate why Patient #9’s prescribed DFR of a 2.0 autoflow rate (Equivalent to a DFR of 600 ml/min) was not followed. Review of the facility’s policy titled “Patient Assessment and Monitoring” with a published date of 05/01/23 reads in part: ...”Check prescribed dialysate flow rate setting is correct, and the prescribed flow is being delivered.” and ...”Document any findings and interventions in the medical record.” 46466 Patient #4: The surveyor reviewed six (6) dialysis treatment records from February 18, 2025 through March 1, 2025. The treatment sheets evidenced an order for a BFR of 400. On February 18, 2025, the BFR was documented as 325. On February 22, 2025, the BFR was documented as 350. On February 25, 2025, the BFR was documented as 350. On February 27, 2025, the BFR was documented as 350. On March 1, 2025, the BFR was documented as 300 and 350. Patient #4’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed. Patient #5: The surveyor reviewed six (6) dialysis treatment records from February 17, 2025 through February 28, 2025. The treatment records evidenced an order for a BFR of 450 and a DFR of autoflow 2.0. On February 26, 2025, the BFR was documented as 400 and the DFR was changed from 800 to 500. Patient #5’s clinical record failed to contain evidence of documentation explaining why the BFR and/or DFR was not being administered as prescribed. Patient #8: The surveyor reviewed six (6) dialysis treatment records from February 26, 2025 through March 3, 2025. The treatment records evidenced an order for a BFR of 350. On February 21, 2025, the BFR was documented as 400. On March 1, 2025, the BFR was documented as 400. On March 3, 2025, the BFR was documented as 300. Patient #8’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed.”