Rai - Airline-Portsmouth 7253

“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 and interview, it was determined that the facility failed to ensure staff perform hand hygiene after touching the face mask for one (1) of four (4) Staff Members (SM), SM # 8, observed. The findings include: On April 22, 2025 at approximately 11:05 AM, SM # 8 was observed during the initiation of dialysis. SM # 8 was observed wearing the face mask below the chin. SM # 8 pulled the face mask up above nose and failed to perform hand hygiene after touching the face mask. On April 23, 2025 at approximately 1:30 PM, an interview with SM # 7 revealed the facility follows the CDC (Center for Disease Control and Prevention) guidelines. CDC guidelines include “be sure to wash your hands or use sanitizer before putting on a mask. Do not touch the mask when wearing it. If you touch the mask be sure to wash your hands or use sanitizer.” On April 23, 2025 at approximately 2:00 PM surveyor reviewed a facility’s policy titled “Personal Protective Equipment”, which reads in part “Practice hand hygiene after mask removal to prevent cross-contamination.””

“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 and interview, it was determined that the facility failed to ensure one (1) of four (4) Staff Members (SM), SM # 8, wore face masks correctly during patient care. The findings include: On April 22, 2025 at approximately 10:50 AM, SM # 8 was observed in the patient care area wearing the face mask below the chin. At approximately 11:05 AM, SM # 8 was observed pulling the face mask up above nose. At approximately 11:35 AM, SM # 8 was observed pulling the face mask down below the chin. On April 23, 2025 at approximately 1:30 PM, an interview with SM # 7 revealed the facility follows the CDC (Center for Disease Control and Prevention) guidelines. CDC guidelines include “Face masks should completely cover your nose and mouth and fit snuggly against the sides of your face and without gaps. Do not touch the mask when wearing it.” On April 23, 2025 at approximately 2:00 PM, the surveyor reviewed the facility’s policy titled “Personal Protective Equipment”, which read in part “Face masks are single use only and must be discarded after the task for which they were needed is completed.””

“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 review and interview, it was determined that the facility failed to ensure the Patient’s treatment blood flow rate (BFR) was as prescribed by the Physician for one (1) of eleven (11) Patients (P), P # 8. The findings include: On April 23, 2025, the clinical record review revealed the following: P # 8- The flowsheet dated April 16, 2025 revealed the BFR was documented as 350 the entire treatment (5:11 AM to 8:30 AM). The Physician ordered BFR was 400. There was no documentation of the reason why the BFR was altered and that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. The flowsheet dated April 18, 2025 revealed the BFR was documented between 300 and 350 the entire treatment (5:03 AM to 8:23 AM). The Physician ordered BFR was 400. There was no documentation of the reason why the BFR was altered and that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. The flowsheet dated April 21, 2025 revealed the BFR was documented between 300 and 350 the entire treatment (5:00 AM to 8:00 AM). The Physician ordered BFR was 400. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. On April 23, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Patient Assessment and Monitoring” revealed in part “Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow.” On April 23, 2025 at approximately 12:00 PM, an interview with Staff Members # 1, # 7 and # 9 revealed “staff are expected to follow the policy.””

“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 ensure: the Registered Nurse (RN) performed and documented the nursing assessment within one (1) hour of the treatment initiation per facility policy for one (1) of eleven (11) Patients (P), P # 5; Staff obtained a standing blood pressure (BP) per facility policy for two (2) of eleven (11) Patients, P # 5 and # 7; and Staff obtained machine parameters and vital signs to include BFR and blood pressure at least every 30 minutes for four (4) of eleven (11) Patients, P # 5, # 6, # 7 and # 8. The findings include: On April 23, 2025, the clinical record review revealed the following: P # 5- The flowsheet dated April 18, 2025 revealed the treatment was initiated at 5:01 AM and ended at 8:47 AM. The Registered Nurse (RN) assessment was documented at 6:07 AM (greater than one (1) hour). The flowsheet dated April 21, 2025 revealed there was no standing BP on the pre treatment assessment. Mobility was documented as “ambulatory”. The post treatment BP was documented as 158/89. There were no documented machine parameters and vital signs to include BFR and blood pressure between 7:02 AM and 8:03 AM (greater than 30 minutes). P # 6- The flowsheet dated April 18, 2025 revealed there were no documented machine parameters and vital signs to include BFR and blood pressure between 7:31 AM and 9:09 AM (greater than 30 minutes). P # 7- The flowsheet dated April 22, 2025 revealed there was no standing BP on the pre treatment assessment. Mobility was documented as “ambulatory”. The post treatment BP was documented as 137/68. There were no documented machine parameters and vital signs to include BFR and blood pressure between 8:29 AM and 9:32 AM (greater than 30 minutes). P # 8- The flowsheet dated April 16, 2025 revealed there were no documented machine parameters and vital signs to include BFR and blood pressure between 5:11 AM and 6:34 AM (greater than 30 minutes). On April 23, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Patient Assessment and Monitoring” revealed in part “blood pressure and pulse rate every 30 minutes or more as needed and documented machine parameters and safety checks every 30 minutes or more often as needed. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Standing BP and weight are obtained pre and post dialysis by the licensed nurse or PCT (Patient Care Technician).” On April 23, 2025 at approximately 12:00 PM, an interview with Staff Members # 1, # 7 and # 9 revealed “staff are expected to follow the policy.””

“GOV-ADM RESP FOR RELATIONSHIP W/ESRD NW CFR(s): 494.180(a)(3) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (3) The relationship with the ESRD networks; This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to have documentation of cooperation with the End Stage Renal Disease (ESRD) Network from November 2024 to the date of survey, April 23, 2025. The findings include: On April 23, 2025 at 12:00 PM, a review of the facility’s Quality meetings minutes revealed there was no documentation of the ESRD Quality Improvement Report discussions, progress to achieving network goals or goals for Patient engagement from November 2024 to present. On April 23, 2025 at 12:30 PM, an interview with Staff Member (SM) # 7 revealed that “sometimes the facility is not receiving information from the network. The facility will communicate with the network regarding these goals. The facility intends to cooperate with the network to achieve goals.” The facility did not provide a policy related to cooperation with the ESRD network..”