Usrc Woodbridge

“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: 46466 Based on observations and facility document review, the staff failed to properly cover bleach containers according to facility policy. Findings: On 9/9/24 at 1:15 PM, two (2) bleach containers located at the “clean” and “dirty” areas were left uncovered. The containers remained uncovered the entire time that surveyors were making observations on the treatment floor. A review of the facility’s policy “Disinfection and Cleaning of Dialysis Machine Equipment”, revised 7/2023, indicated in part: “...2. Container will remain covered at all times...”. The findings were discussed with Staff Members #1, #7 and #8 at the exit conference on 9/10/24 at 2:45 PM.”

“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 (dialysis flow rate) for four (4) of seven (7) dialysis patients included in the sample. The findings included: Patient #1 : The surveyor reviewed five (5) dialysis treatment records from 8/26/24 to 9/6/24 . The treatment sheets for Patient #1 evidenced an order for BFR of 300. Two (2) of five (5) treatment records evidenced the following: On 8/28/24, the BFR was documented as 270. On 9/4/24, 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. Patient #3: The surveyor reviewed six (6) dialysis treatment records from 8/22/24 to 9/5/24. The treatment sheets for Patient #3 evidenced an order for BFR of 450 and a DFR of 500. Two (2) of six (6) treatment records evidenced the following: On 8/22/24, the BFR was documented as 400. On 9/5/24, the DFR was documented as 700. Patient #3’s clinical record failed to contain evidence of documentation explaining why the BFR and DFR were not being administered as prescribed. Patient #4: The surveyor reviewed five (5) dialysis treatment records from 8/30/24 to 9/9/24. The treatment sheets for Patient #4 evidenced an order for DFR of 500. One (1) of five (5) treatment records evidenced the following: On 8/30/24, the DFR was documented as 600. Patient #4’s clinical record failed to contain evidence of documentation explaining why the DFR was not being administered as prescribed. Patient #5: The surveyor reviewed six (6) dialysis treatment records from 8/28/24 to 9/9/24. The treatment sheets for Patient #5 evidenced an order for BFR of 350. One (1) of six (6) treatment records evidenced the following: On 9/2/24, 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. A review of the facility’s policy “Intradialytic Monitoring of Patient”, revised 7/2024, indicated in part: “...DELIVERY SYSTEM MONITORING...3. Blood flow rate: any variance from prescribed order requires documentation of reason. Dialysate flow rate: any variance from prescribed order requires documentation of reason...”. The findings were discussed with Staff Members #1, #7 and #8 at the exit conference on 9/10/24 at 2:45 PM.”

“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 observations and facility document review, facility staff failed to care for a patient’s arteriovenous (AV) graft/fistula according to the facility’s policy. Facility staff utilized two (2) clamps simultaneously on one (1) patient to achieve hemostasis post cannulation. The findings included: On 9/9/24 at 2:00 PM, the surveyor observed a staff member place two (2) clamps over Patient #5’s arteriovascular (AV) fistula/graft site on their arm. On 9/10/24, a review of Patient #5’s medical record was conducted. There was no evidence of a physician order to place two (2) clamps on Patient #5 found in the record. A review of the facility’s policy “Clamp Usage”, revised 2/2023, stated in part: “...4. If clamps are used on a mature fistula or graft, use one clamp at a time to prevent excessive pressure/thrombosis...”. The findings were discussed with Staff Members #1, #7 and #8 at the exit conference on 9/10/24 at 2:45 PM.”