Fmc - Prince William County Dialysis

“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: 49355 Based on four (4) infection control observations, interview and documentation review, it was determined that facility staff failed to follow the facility’s policy on hand hygiene and glove use. Findings: On 02/12/2024 at 11:24 a.m., the surveyor observed Staff Member (SM)5 moving between station #16, which the SM had just finished cleaning, to the nurses’s desk, wearing the same gloves. SM5 returned to station #16, wearing the same gloves, and started programming the machine. At 11:26 a.m., SM5 removed that pair of gloves and donned a new pair, without performing hand hygiene. SM5 then proceeded to visit several other stations, touching machines and checking on a patient at station #15, still wearing the same gloves. At 12:09 p.m., SM14 was observed discarding their gloves and donning new gloves, without performing hand hygiene. At 12:21 p.m. and 12:24 p.m., SM5 was observed removing and discarding their gloves and donning a new pair, without performing hand hygiene. On 02/13/2024 between 10:50 a.m. and 12:25 p.m., SM5 was observed on four (4) occasions removing and donning a new pair of gloves without performing hand hygiene in between. An interview with SM1 on 02/13/2024 confirmed the need to perform hand hygiene before donning a new pair of gloves and the need to change gloves per policy. A review of the facility’s policy titled, “Hand Hygiene” published 11/06/2023, reference number 47664, version 8 reads, in part: ...”Hands will be... ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water... ... Immediately after removing gloves.” A review of policy entitled, “Personal Protective Equipment” published 11/06/2023, reference number 47663, version 6 reads, in part: ... “Gloves... ... Staff must remove gloves and wash hands after: ... Patient care ... Exposure to blood and body fluids ... Touching any surfaces within the patient station. ... Always perform hand hygiene after glove removal.” The above concern was discussed at the exit conference on 02/14/2024 at 1:09 p.m. with SMs #1, 11, 12 and 17.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 42725 Based on two (2) infection control observations and facility policy review, it was determined the facility staff failed to place the access needles in the sharps container upon removal for two (2) of two (2) observations. Findings: On 2/12/24 at 1:21 p.m., a surveyor observed SM14 discontinue treatment for a patient at station #12. The surveyor observed SM14 remove an access needle for the patient. Upon removal, SM14 capped the needle and laid it down on the tray. SM14 proceeded to apply gauze to the access site. Once completed, SM14 picked up the capped needle and disposed of it in the sharps container. SM14 repeated the same process for the second access needle. At 1:30 p.m., the surveyor observed SM13 remove an access needle for a patient at station #2. Upon removal, SM13 capped the needle and laid it down on the tray. SM13 proceeded to apply gauze to the access site. Once completed, SM13 picked up the capped needle and disposed of it in the sharps container. SM13 repeated the same process for the second access needle removal. The facility’s policy regarding discontinuing treatment for a patient with a fistula or graft and needle removal was requested and provided by SM1. The policy titled, Post Treatment Fistula Needle Removal, was reviewed and reads, in part: “...Procedure... 6. Carefully remove the needle... Engage the safe needle device per manufacturer’s instructions for use. Discard needle in sharps container... 9. Remove the second needle following steps 4-8...”. The finding was discussed with SM1 during the day on 2/14/24 and again at the exit conference in the afternoon of 2/14/24 with SMs 1, 11, 12 and 17.”

“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: 42725 Based on observations and facility policy review, it was determined the facility staff failed to follow facility policy for cleaning and disinfecting the dialysis station for two (2) of two (2) observations. Findings: On 2/12/24 at 1:45 p.m., the surveyor observed SM13 cleaning station #4. SM13 did not wipe under the side trays of the chair or the counter space behind the chair. On 2/13/24, the surveyor observed SM5 cleaning station #7. SM5 did not wipe the dialysate hoses, under the trays on both sides of the chair, inside of the prime waste container or the counter space behind the chair. In the afternoon of 2/13/24, the surveyors discussed the findings with SM1. The facility’s policy titled, Cleaning and Disinfection of the Dialysis Station, was reviewed and reads, in part: “... Procedure... 3. Use a cloth wetted with 1:100 bleach solution of 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...”. During the exit conference in the afternoon of 2/14/24, the findings were reviewed with SMs 1, 11, 12 and 17.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 49355 Based on two (2) observations, interviews, and document review, it was determined the facility staff failed to perform conductivity testing as per the facility’s policy and the manufacturer’s instructions. Findings: On 02/12/2024 at 11:20 a.m., the surveyor witnessed Staff Member (SM) 13 perform a conductivity and pH test on dialysate using the Myron L D6 meter. Upon completing the test, SM13 returned the meter to the counter without rinsing the cells of the meter out. At 11:35 a.m. on 02/12/2024, the surveyor witnessed SM6 perform a conductivity and pH test on dialysate, using the Myron L D6 meter. SM6 poured the sample into two (2) cells on the meter, one to measure conductivity and the other to measure pH. SM6 then took the readings for each value from the single sample. SM6 then called SM15 to come over and look at the display on the meter, showing SM15 the values for pH and conductivity visible on the screen. The contents of the meter cells were then dumped down the sink and the meter was returned to the counter. On 02/13/2024, the above observations were discussed with SM1, who confirmed these practices were not within expectations of usage of the Myron L D6 meter. A review of the facility’s policy entitled “Checking Conductivity and pH of Final Dialysate,” published 04/11/2022, reference number 25912, version 9, reads, in part: ... “Test Verification Prior to Treatment ... Incenter setting: ... 2 staff members will verify the conductivity and pH parameters prior to treatment. ... All Modalities ... To verify conductivity and pH readings, both staff (or patient/care partner) watch the test being performed at the same time or if the test is not performed and results observed by both people at the same time, the second person (staff or care partner) must perform an additional test to verify the initial test results are within acceptable limits stated in this policy.” A review of the facility’s policy entitled “Myron L D6 Measuring Procedures,” published 06/14/2017, version 1, reads, in part: ...”Measuring Dialysate Conductivity and pH ... perform measurements according [to] the D6 meter’s IFU (instructions for use]” A review of the “Myron L Company Digital Dialysate Meter Operation Manual 04 October 11” reads, in part: ... “V. Rules of Operation ... A. Operation ... Rinse the pH/ORP sensor well (D-6) and/or conductivity cell with test solution 3 times and refill. ... VI. After using the Dialysate Meter ... A. Maintenance of the Conductivity Cell ... Rinse out the conductivity cell with clean water ... VII. Specific Recommended Measuring Procedures for Con/Res/TDS measurements: ... The conductivity cell MUST be rinsed and filled at least 3 times with sample before each measurement is taken. ... For pH/ORP measurements: ... Both the pH/ORP sensor well and the conductivity cell MUST be rinsed and filled at least 3 times with sample before each measurement is taken.” The above findings were discussed at the exit conference on 02/14/2024 at 1:09 p.m. with SMs 1,11, 12 and 17.”

“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: 49355 Based on observation, interview and document review, it was determined the facility staff failed to close and lock the treatment floor doors. Findings: Upon entering the facility on 02/12/2024 at 10:09 a.m., the door separating the patient waiting room from the treatment area was propped open with a rubber wedge door stop. After crossing the treatment floor with Staff Member (SM) 1, the door separating the treatment area from the staff offices and home training rooms was propped open with a rubber wedge door stop as well. During a meeting with SM1 on 2/13/2024, this issue was discussed. SM1 agreed that the doors should not be left open. During COVID, the charge nurse would screen patients for symptoms in the waiting room before allowing them onto the treatment floor and keeping the door propped open made it easier for the charge nurse to meet the patients in the waiting room and then bring them onto the treatment floor, without having to deal with the keypad lock on the door. This screening procedure has worked so well, the facility has continued doing it. SM1 would like to continue the practice of screening patients in the waiting room, but will brainstorm with other staff members to figure out a method that works, without leaving the doors propped open. A review of the facility’s policy “Physical Security and Facility Access,” published 09/05/2023, reference number 25825, version 3 reads, in part: ... “Purpose To ensure a secure and safe environment for all staff, visitors, and patients while on FKC properties. ... Physical Security ... Doors from the waiting area to the the treatment area should remain closed and locked at all times while still allowing emergency access/exit.” The above concern was discussed at the exit conference on 02/14/2024 at 1:09 p.m. with SMs 1, 11, 12 and 17.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49355 Based on observations, interview and policy review, it was determined the facility staff failed to ensure that the access sites for five (5) patients were visible during their dialysis treatment. Findings: 02/12/2024 observations: At 10:54 a.m., the surveyor observed the access site for the patient at station #4 was covered. The site remained covered until 11:45 a.m., when the patient’s treatment ended. At 11:00 a.m., the access site for the patient at station #12 was covered by the patient’s sweatshirt jacket. The site was uncovered by Staff Member (SM) 1 at 11:28 a.m. At 11:06 a.m., the access site for the patient at station #9 was covered by a blanket and the patient’s jacket. At 1:00 p.m., the patient’s site at station #7 was covered. The surveyor never observed a SM uncover the site before the surveyor exited the treatment floor at 1:15 p.m. 02/13/2024 observation: At 11:25 a.m., the surveyor observed the access site of the patient at station #11 was covered. At 12:25 p.m., when the surveyor rounded the treatment area again, the site remained covered. During an interview in the afternoon of 02/12/2024, SM1 stated that the expectation was that access sites would remain uncovered and visible throughout the treatment period and that this issue was frequently discussed with staff and patients. A review of the facility’s policy entitled “Patient Assessment and Monitoring,” published 05/01/2023, reference number 45284, version 4, states, in part: ... “Access ... Ensure access remains uncovered throughout the treatment.” During the exit conference on 02/14/2024, the surveyors reviewed the findings with SMs 1, 11, 12 and 17.”

“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: 49355 Based on medical record reviews and document review, it was determined the facility staff failed to document pulse (PL) readings and estimated dry weight (EDW) that were not within facility guidelines in four (4) out of eight (8) in-center hemodialysis patient records reviewed. Findings: The six (6) most recent flow sheets for eight (8) in-center hemodialysis patients were reviewed on 02/13/2024 and 02/14/2024. Four (4) of eight (8) sampled patients were missing documentation on the flow sheets of notification to the charge nurse (CN) concerning discrepancies in EDW and post treatment weights, and/or pulse (PL) readings and the CN’s post treatment assessment notes failed to mention these discrepancies upon review of the treatment period. Patient (P) 1: On 02/05/2024 - P1’s PL was less than 60 beats per minute (bpm) for the entire four (4) hour treatment. There was no documentation on the flow sheet that the CN was aware of these readings during the treatment and there is no documentation in the CN’s post treatment notes of this discrepancy. On 02/07/2024 - P1’s PL was less than 60 bpm in six (6) out of nine (9) readings throughout the 4 hour treatment cycle. There is no flow sheet note nor post treatment CN note addressing this deviation from policy. On 02/12/2024 - P1’s PL was less than 60 bpm for the entire 4 hour treatment. No documentation was found in the flow sheet intradialytic notes nor was there mention of this discrepancy mentioned in the CN’s post treatment assessment. P3: On 01/31/2024, P3’s post treatment weight of 84.9 kilograms (kg) compared to the EDW goal of 83.5 kg, is a 1.4 kg difference. There was no mention of this discrepancy in the CN’s post treatment assessment note. P5: On 02/10/2024, P5’s post treatment was 57.1 kg compared to the EDW of 55.5 kg, a 1.6 kg variance. There was no mention of this discrepancy in the CN’s post treatment assessment note. P9: On 02/09/2024 - the patient’s post treatment weight of 52.8 kg compared to the EDW of 50.5 kg is a 2.3 kg difference. No notation was found in the CN’s post treatment assessment. A review of the facility’s policy “Patient Assessment and Monitoring,” published 05/01/2023, reference number 45284, version 4, states, in part: ... “During Treatment ... 1...Pulse ... Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular. ... Post Treatment ... 1...Weight Obtain the patient’s post weight. Ensure the post weight is consistent with the goal set of the machine.” In a review of the facility’s policy “Nursing Supervision and Delegation,” published 11/06/2023, reference number 45265, version 6, states, in part: ... “Daily Treatment Prior to discharge, the RN (Registered Nurse) must review the treatment record to: Confirm patient is stable for discharge Record Review Identify any process that could have resulted in the patient experiencing a safety event or near miss The record must be reviewed for: Slow/fast/irregular heart rate [another term for pulse] ... Whether a patient is achieving dry weight [same as EDW] and identifying the reason for patient not achieving dry weight Heart rate <60 [less than 60] or >100 [greater than 100] addressed by the registered nurse with documentation present. ... Guidelines for PCT/LPN/LVN/RN: When to Refer a Patient to the Team Leader/Charge Nurse for Further Assessment ...Fluid Status Any weight gains greater than 4 kg pre-treatment. ...Any post treatment weight with a variance form the estimated dry weight (EDW) of 1.0 kg” A discussion of the above findings was held with Staff Member (SM) 1 on 02/14/2024, who agreed that notes should be made on the patient’s flow sheet and the CN should be notified of any variances. The CN should also be making reference to any EDW variances greater/or less than 1 kg in the post treatment note. These findings were discussed at the exit conference on 02/14/2024 at 1:09 p.m. with SMs 1, 11, 12, and 17.”

“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: 49355 Based on medical record reviews and document review, it was determined the facility staff failed to follow physician’s orders for the prescribed blood flow rate (BFR) and dialysate flow rate (DFR) for four (4) of eight (8) in-center hemodialysis patients included in the sample. Findings: On 02/13/2024 and 02/14/2024, the surveyors reviewed medical records and the last six (6) flow sheets for each of eight (8) in-center hemodialysis patients sampled. The review indicated that the staff failed to administer the prescribed orders for BFR and DFR and to document the reason why the orders were not adhered to and show documentation that the charge nurse (CN) was notified of the variance(s) in four (4) out of eight (8) sampled patients. Patient (P) 1: On 01/31/2024, the attending Nephrologist [kidney doctor] changed the patient’s BFR to 350 ml/min and the DFR was changed to 500 ml/min. On subsequent dialysis treatments on 02/05/2024, 02/07/2024, and 02/12/2024, the dialysis machine setting for BFR was 400 ml/min and the setting for DFR was 800 ml/min. There was no indication that the error was noted by the technician or the CN. There is no documentation in the flow sheet or in any of the assessment notes. P5: On 02/08/2024, the prescribed DFR was 600 ml/min. The machine setting for the DFR was 500 ml/min throughout the majority of the 3.5 hour treatment with no mention in any notes as to why the discrepancy occurred. P9: On 01/31/2024, the BFR was documented at 350 ml/min for the entire 3.5 hour treatment cycle, compared to the prescribed BFR of 400 ml/min. There was no documentation on the flow sheet that the CN was notified and there was no documentation in the post treatment assessment note. On 02/02/2024, the BFR was run at 300 ml/min and the DFR was run at 500 ml/min for the first one (1) hour of treatment versus the prescribed rates of 400 ml/min and 600 ml/min, respectively. There were no notes as to why this was done or if the CN had been notified or consulted. On 02/05/2024, the BFR rate was noted as 350 ml/min for the entire 3.5 hour treatment cycle, versus the prescribed rate of 400 ml/min. There was no documentation on the flow sheet or in the CN’s post treatment assessment regarding the disparity. P10: On 01/30/2024, the patient’s BFR was run at 350 ml/min for the entire 4 hour treatment cycle. The prescribed BFR was 400 ml/min. There was no documentation on the flow sheet or in the CN’s post treatment assessment addressing the disparity. A review of the facility’s policy “Patient Assessment and Monitoring,” published 05/01/2023, reference number 45284, version 4, states, in part: ... “During Treatment ... 3 Machine Parameters and Extracorporeal Circuit Check machine setting and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being achieved. ... 4 Document any findings and interventions in the medical record.” In the facility’s policy “Nursing Supervision and Delegation,” published 11/06/2023, reference number 45265, version 6, states, in part: ... “Record Review ... The record must be reviewed for: ...Correct dialysate prescription was delivered.” The above noted findings were discussed at the exit interview on 02/14/2024 at 1:09 p.m. with Staff Members 1, 11, 12 and 17.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues identified during the previous recertification survey. The findings include: Tag V-0113 Current Recertification Survey Based on four (4) infection control observations, interview and documentation review, it was determined that facility staff failed to follow the facility’s policy on hand hygiene and glove use. Recertification Survey Ending January 28, 2021 Based on three (3) infection control observations, it was determined the facility failed to perform proper hand hygiene while providing direct patient care. Tag V-0543 Current Recertification Survey Based on medical record reviews and document review, it was determined the facility staff failed to document pulse (PL) readings and estimated dry weight (EDW) that were not within facility guidelines in four (4) out of eight (8) in-center hemodialysis patient records reviewed. Recertification Survey Ending January 28, 2021 Based on interviews and document reviews, it was determined that the facility staff failed to: perform initial Registered Nurse (RN) evaluation within one hour of treatment initiation on six (6) out of nine (9) patients sampled; perform a daily treatment record review prior to patient discharge as per facility policy on nine (9) of nine (9) dialysis patients sampled; document the reason and notification to the registered nurse of the change in blood flow rate (BFR) for five (5) of nine (9) patients sampled; administer the prescribed order for the dialysate flow rate (DFR) for one (1) of nine (9) patients sampled, and document notification to the registered nurse or physician of target weight not being met for three (3) of nine (9) patients sampled.”