Rai - Churchland-Chesapeake

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 41450 Based on staff interview and documentation review, the facility staff failed to maintain documentation of emergency preparedness training for one (1) staff member in a survey sample of three (3) staff members. The findings include: On 7/2/24 at approximately 2:00 PM, an interview was conducted with Staff Member #1 (SM #1) regarding the facility’s emergency preparedness (EP) training for all staff members. Documentation of EP training was requested for 3 randomly chosen staff members. Review of SM #4’s training documentation revealed no evidence of facility-specific EP training. SM #1 confirmed there was no record of SM #4 having any facility-specific EP training since date of hire on 2-12-24. SM #1 stated, “It is my expectation that all staff members receive training on facility-specific emergency procedures before they begin working with our clients”. Review of the facility’s policy titled, “Guidelines for Emergency Preparedness”, published date 07/03/2023, subtitle “Purpose”, page 1 read, “The purpose of this policy is to provide guidelines for emergency preparedness of In-center and Home Therapies facilities to help protect patients and staff in emergency situations” and subtitle “Staff Training”, page 6 read, “Staff will be trained on emergency disaster preparedness such as fire drills, emergency disconnection, and emergency evacuation”.”

“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 reviews and interviews, it was determined that the facility staff failed to ensure hand hygiene was performed before and after glove removal and after touching masks for one (1) of four (4) Staff Members (SM), SM # 4. The findings include: On July 1, 2024 between 1:00 PM and 3:00 PM the following were observed during initiation and termination of treatments: At 2:25 PM, SM # 4 was observed donning and doffing gloves at Station # 7 without performing hand hygiene. At 3:25 PM, SM # 4 was observed donning and doffing gloves at Station # 7 without performing hand hygiene. At 3:27 PM, SM # 4 was observed at the nursing station removing facemask and not performing hand hygiene. Center for Disease Control (CDC) guidelines include: “Hands should be washed before applying mask and after removing the mask”. On July 2, 2024 at 2:30 PM, a review of the facility’s policy titled “Hand Hygiene” reads in part “Decontaminate using alcohol-based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves”. On July 2, 2024 at 3:00 PM, the findings were discussed with SM # 1 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 items (tape) taken into the dialysis station are disposed of and not taken to a common clean area for one (1) of four (4) Staff Members (SM), SM # 5. The findings include: On July 1, 2024 between 1:00 PM and 3:00 PM the following was observed during initiation and termination of treatments: A 3:05 PM, SM # 5 was observed taking a roll of tape to Station # 16. SM # 5 tore multiple pieces of tape and placed them on the chairs table. SM # 5 then took the roll of tape back to the designated clean area and placed the tape on the counter with clean supplies. On July 2, 2024 at 2:30 PM, a review of the facility’s policy titled “Dialysis Precautions” reads in part “Clean area: an area designated for clean and unused equipment, supplies and medications.” On July 2, 2024 at 3:00 PM, the findings were discussed with SM # 1 during the exit interview. SM # 1 indicated tape should be discarded and not returned to clean area after taken to the chairside.”

“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 two (2) of four (4) Patients (P), P # 1 and P # 3. The findings include: On July 2, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 19, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 12:55 PM through 3:23 PM 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 24, 2024 revealed the Physician ordered blood BFR was 450. Documentation from 12:41 PM through 1:48 PM revealed the BFR was 350; 1:48 PM through 3:32 PM the BFR was 300. There was no documentation of the reason for the decreased BFR or that the RN or Physician was notified. There was no documented treatment prescription verification by the RN. P # 3- The flowsheet dated June 24, 2024 revealed the Physician ordered BFR was 400. Documentation from 11:19 AM through 12:54 PM revealed the BFR was 350. There was no documentation of the reason for the decreased BFR or that the RN or Physician was notified. There was no documented treatment prescription verification by the RN. On July 2, 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 July 2, 2024 at 3:00 PM, the findings were discussed with SM # 1 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 four (4) Patients (P), P # 1 and # 2; and treatment data, to include blood pressures, were documented at least every 45 minutes during the treatment for four (4) of four (4) Patients, P # 1, # 2, # 3 and # 4. The findings include: On July 2, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 24, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. The post treatment standing blood pressure was documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. The flowsheet dated July 1, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. The post treatment standing blood pressure was documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. There was no treatment data to include blood pressure between 12:39 PM and 3:14 PM. (greater than 45 minutes). P # 2- The flowsheet dated June 21, 2024 revealed the pre treatment standing blood pressure documented as “cannot assess”. The post treatment standing blood pressure was documented as 115/58. There was no documentation of why the pre treatment standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. The flowsheet dated July 1, 2024 revealed the pre treatment standing blood pressure documented as 108/51. The post treatment standing blood pressure was documented as “cannot assess”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulates w/o assistance”. P # 3- The flowsheet dated June 26, 2024 revealed there was no treatment data to include blood pressure between 12:32 PM and 2:03 PM. (greater than 45 minutes). P # 4- The flowsheet dated June 24, 2024 revealed there was no treatment data to include blood pressure between 5:28 AM and 7:41 AM. (greater than 45 minutes). On July 2, 2024 at 2:30 PM, an interview with Staff Member (SM) # 2 indicated P # 1 is ambulatory. On July 2, 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 July 2, 2024 at 3:00 PM, the findings were discussed with SM # 1 during the exit interview.”