Rai-Chesapeake Ave-Newport News

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 46466 Based on observations and facility document review, the facility failed to maintain a safe environment for patients by not discarding two (2) expired medications. The findings include: On 6/24/24 at 11:25 a.m., the surveyor found one (1) bottle of Promethazine Hydrochloride that expired on 3/2024 and one (1) vial of Of Tubersol with a documented opened date of 5/16/24. The Tubersol package insert reads in part, “A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date”. A review of the facility’s policy “Medication Preparation and Administration”, published 2/6/23, stated in part “...Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded...Any open multi dose vials must be discarded 28 days after opening or per manufacturer’s expiration date...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 46466 Based on observation and facility document review, it was determined that the facility failed to ensure that test strips were labeled per facility guidelines. The findings include: On 6/24/24 at 12:05 p.m., the surveyor observed one (1) bottle of residual chlorine test strips, one (1) bottle of blood leak test strips and one (1) bottle of PH test strips on the treatment floor. All observed bottles were not labeled with the date the bottles were opened nor with the initials of the staff member who opened them. Staff Member #1 provided a copy of a facility document titled: “Test Strips and Solution Stability List” with no published date. The document read in part: “Note: ALL test trips and solutions MUST be dated and initialed when first opened...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 46466 Based on medical record review and document review, the facility staff failed to ensure an initial comprehensive assessment was completed within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session for one (1) of seven (7) patients included in the survey sample. The findings included: On 6/25/24, the review of seven (7) patient medical records found that Patient #1 started to dialyze on 4/8/24 at the frequency of three treatments per week. Patient #1’s Plan of Care (POC) was documented and signed on 5/24/24, which was outside the later of 30 calendar days or 13 treatments. A review of the facility’s policy, “Comprehensive Interdisciplinary Assessment and Plan of Care”, published 7/3/23, stated, in part, “...CIA and POC for Patients New to Dialysis. An initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”

“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: 46466 Based on medical record 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 (dialysate flow rate) for five (5) of seven (7) dialysis patients included in the sample. The findings included: On 6/25/24 the surveyor reviewed six most recent treatment flowsheets for seven (7) patients included in the survey sample, Patient #1-7. Patient #1: The surveyor reviewed six (6) dialysis treatment records from 6/12/24 through 6/24/24. The treatment sheets evidenced an order for a BFR of 400. On 6/12/24, the BFR was documented as 350. Patient #1’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed and/or who was notified of the change. Patient #2: The surveyor reviewed six (6) dialysis treatment records from 6/12/24 through 6/24/24. The treatment records evidenced an order for a DFR of 600. The treatment sheets evidenced the following: On 6/19/24, the DFR was documented as 800. On 6/21/24, the DFR was documented as 800. Patient #2’s clinical record failed to contain evidence of documentation explaining why the DFR was not being administered as prescribed and/or who was notified of the change. Patient #3: The surveyor reviewed six (6) dialysis treatment records from 6/12/24 through 6/24/24. The treatment records evidenced an order for a BFR of 450. The treatment sheets evidenced the following: On 6/19/24, the BFR was documented as 400. On 6/24/24, the BFR was documented as 400. Patient #3’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed and/or who was notified of the change. Patient #4: The surveyor reviewed six (6) dialysis treatment records from 6/12/24 through 6/24/24. The treatment records evidenced an order for a BFR of 450. The treatment sheets evidenced the following: On 6/24/24, the BFR was documented as 400. Patient #4’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed and/or who was notified of the change. Patient #5: The surveyor reviewed six (6) dialysis treatment records from 6/11/24 through 6/22/24. The treatment records evidenced an order for a BFR of 350. The treatment sheets evidenced the following: On 6/18/24, the BFR was documented as 300. Patient #5’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed and/or who was notified of the change. A review of the facility’s policy “Patient Assessment and Monitoring”, published 5/1/23, stated in part: “...3. Machine Parameters and Extracorpeal Circuit - 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. - Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...4. Document any findings and interventions in the medical record...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 46466 Based on observation and facility policy review, the facility staff failed to use aseptic technique when accessing an arteriovenous (AV) fistula/graft of two (2) patients during initiation of dialysis treatment. The findings included: On 6/24/24 at 11:50 a.m., the surveyor observed a staff member preparing to access patient’s AV site in station #13. The staff member cleansed the patient’s AV site with antiseptic, then palpated the access site prior to inserting the needle. The staff member did not reapply antiseptic to the AV site after palpating. On 6/24/24 at 12:45 p.m., the surveyor observed a staff member preparing to access patient’s AV site in station #14. The staff member cleansed the patient’s AV site with antiseptic, then palpated the access site prior to inserting the needle. The staff member did not reapply antiseptic to the AV site after palpating. A review of the facility’s policy “Access Assessment and Cannulation”, published 5/6/24, stated in part: “...Skin Disinfection...2. Perform skin antisepsis on one site at a time, allow to dry and them {sic} cannulate. Do not touch cannulation sites after skin disinfection...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”

“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: 46466 Based on interview, medical record and facility document review, it was determined that facility staff failed to ensure that one (1) of seven (7) Plan of Care (POC) included in the survey sample was signed by the patient. The findings included: Medical record review on 6/25/24, evidenced that one (1) of seven (7) medical records did not contain a signed POC by the patient. Patient #2’s medical record revealed a POC dated 2/23/24. The POC did not include Patient #2’s signature or the patient’s refusal to sign. On 6/25/24, Staff Member #1 confirmed that a signed copy of Patient #2’s POC could not be found. A review of the facility’s policy “Comprehensive Interdisciplinary Assessment and Plan of Care”, published 7/3/23, stated in part: “...Comprehensive Assessment Participation and Plan of Care Review...- The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for the refusal must be documented in the patient’s medical record...”. The findings were discussed with Staff Members #1, #2, #7, #9, and #11 at the exit conference on 6/25/24 at 2:40 p.m.”