Bma - Greater Norfolk

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to provide a sanitary environment to minimize the transmission of infection by having tears in the dialysis treatment chairs for four (4) of six (6) chairs at four treatment stations, Station # 10, # 13, # 14 and # 23. The findings include: On January 9, 2024 at approximately 10:55 a.m., a tour of the facility revealed the following: Station # 10 had a treatment chair with an one (1) inch tear in the right arm. Station # 13 had a treatment chair with an one (1) to two (2) inch tear in the right arm. Station # 14 had a treatment chair with one (1) to two (2) inch tears in the right and left arms. Station # 23 had a treatment chair with an one (1) to two (2) inch tear in back of the chair. On January 10, 2024 at 11:30 a.m., a review of the facility policy titled “Infection Control” reads in part “the purpose of this policy is to provide guidance on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staff and visitors.” On January 10, 2024 at approximately 12:30 p.m., the findings were discussed with Staff Members (SM) # 1 and # 2.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to keep clean areas clean for one (1) of two (2) clean sinks (Sink # 1), and label medication syringes for one (1) of one (1) syringe. The findings include: On January 9, 2024, a tour of the facility revealed the following: At 10:58 a.m., the clean sink (Sink # 1) near Station # 12 had a dirty paper towel laying on the counter. When asked if the paper towel was dirty, Staff Member (SM) # 3 stated “I don’t know” and threw the paper towel in the trash. At 11:00 a.m., Station # 12 was observed with a syringe containing a clear liquid with no label. On January 10, 2024 at 11:30 a.m., a review of the facility policy titled “Infection Control” reads in part “the purpose of this policy is to provide guidance on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staff and visitors.” The facility policy titled “Medication Preparation and Administration” reads in part “all medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication.” On January 10, 2024 at approximately 12:30 p.m., the findings were discussed with Staff Members (SM) # 1 and # 2.”

“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 review and interview, it was determined that the facility failed to: have an RN (Registered Nurse) verify the treatment prescription for seven (7) of seven (7) ICHD (In center hemodialysis) Patients (P), P # 1, # 2, # 3, # 4, # 5, # 6 and # 7; have an RN assess the Patient within one (1) hour of the initiation of the treatment for two (2) of seven (7) ICHD Patients, P # 6 and # 7; and assess and document at least every 45 minutes treatment data to include blood pressures for one (1) of seven (7) ICHD Patients, P # 1. The findings include: On January 10, 2024 between 9:00 a.m. and 11:30 p.m., clinical record reviews revealed the following: Patient # 1- The flowsheet dated December 30, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 31, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 5, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 8, 2024 revealed there was no documentation of treatment data to include blood pressure between 7:39 a.m. and 8:31 a.m. (more than 45 minutes). Patient # 2- The flowsheet dated December 28, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. Patient # 3- The flowsheet dated December 26, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 30, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 2, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 6, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. Patient # 4- The flowsheet dated December 28, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. Patient # 5- The flowsheet dated December 26, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 30, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. Patient # 6- The flowsheet dated December 27, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 31, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 3, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 5, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 8, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The treatment was initiated at 5:44 a.m., the RN assessment was documented at 7:40 a.m. (more than one (1) hour). Patient # 7- The flowsheet dated December 26, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 28, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated December 30, 2023 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 2, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The treatment was initiated at 10:23 a.m., the RN assessment was documented at 12:37 p.m. (more than one (1) hour). The flowsheet dated January 4, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. The flowsheet dated January 6, 2024 revealed there was no documentation by the RN that the treatment prescription was verified. On January 10, 2024 at 11:30 a.m., a review of the facility policy titled “Pre-intra-post treatment data collection, monitoring and nursing assessment” reads in part “The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes.” On January 10, 2024, the findings were discussed with Staff Members # 1 and # 2 during the exit interview.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to have signed Plan of Care by the interdisciplinary team (IDT) including the Patient for two (2) of seven (7) Patients (Patients # 5 and # 6). The findings include: On January 10, 2024 between 9:00 a.m. and 11:30 a.m., Clinical Record review revealed the following: Patient # 5- The Patient’s Plan of Care meeting was documented as November 9, 2023. There was no signature for the Physician to reflect participation in the Plan of Care meeting. Patient # 6- The Patient’s annual Plan of Care meeting was documented as December 28, 2023. There was no signature for the Physician to reflect participation in the Plan of Care meeting. On January 10, 2024 at 11:30 a.m., a review of the facility policy titled “Comprehensive Interdisciplinary Assessment an Plan of Care” reads in part “The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the Patient or Patient’s designee ... The Plan of Care must be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting.” On January 10, 2024 at approximately 12:30 p.m., the findings were discussed with Staff Members (SM) # 1 and # 2.”