Fresenius Kidney Care - Falls Run

“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 six (6) infection control observations, interview and documentation review, it was determined that staff failed to follow the facility’s policy on hand hygiene and glove use. Findings: On 04/08/2024 at 9:34 a.m., this surveyor observed Staff Member #4 not change gloves and perform hand hygiene while discontinuing dialysis on Patient # 9 who had an AV (Arteriovenous) fistula at station #3. At 9:57 a.m., this surveyor observed Staff Member #7 not change gloves and perform hand hygiene while discontinuing dialysis on Patient #6 who had an AV fistula at station #5. At 10:23 a.m., this surveyor observed Staff Member #6 not change gloves and perform hand hygiene while discontinuing dialysis on Patient #14 with an AV fistula at station #14. At 11:21 a.m., Staff Member #4, wearing gloves from another patient’s station, approached Patient #8 at station #15 to adjust the cannulas in the patient’s fistula. The staff member did not change gloves and perform hand hygiene before touching Patient #8’s site. At 11:27 a.m., Staff Member #6 did not change gloves and perform hand hygiene after using the keyboard at the patient’s dialysis machine and initiating dialysis via a CVC (Central Venous Catheter) on Patient #4 at station #16. At 3:05 p.m., Staff Member #7 did not perform hand hygiene before donning a new pair of gloves to discontinue dialysis via a CVC on Patient #15 at station #5. An interview with Staff Member #2 at 4:50 p.m. on 04/08/2024 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... ... When... ... Before and after direct contact with patients... ... Immediately after removing gloves ... After contact with inanimate objects near the patient... ... After contact with other objects within the patient station or treatment space.” 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.” A review of the facility’s policy titled “Post Treatment Fistula Needle Removal,” published 07/06/2021, version 2, states, in part: “... Procedure... ... 6. Discard needle in sharps container. ... 9. Remove the second needle following steps...above” The above concern was discussed at the exit conference on 04/09/2024 at 12:45 p.m. with Staff Members #2, 12 and 13.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on observations, interview, and document review, it was determined facility staff failed to maintain aseptic technique when providing care to a central venous catheter (CVC) exit site for two (2) out of two (2) observations. Findings: On 04/08/2024 at 11:18 a.m., Staff Member #6 started cleaning the CVC (Central Venous Catheter) exit site of Patient #4 at station #16. The patient was wearing a t-shirt with a crew neck, partially covering the CVC site. Staff Member #6 did not secure the neck of the shirt away from the CVC site and began cleansing the site with a swab, pulling the collar of the shirt away. Once the staff member finished swabbing the site and released the collar of the patient’s shirt, the neckline of the shirt returned to it’s original position, partially covering the cleansed CVC exit site. At 11:38 a.m., this surveyor observed Staff Member #6 providing care to the CVC exit site on Patient #7 at dialysis station #14. The staff member was cleaning the area of the site below the neckline of the patient’s shirt, sticking the swab down inside the neckline of the shirt. The garment would then immediately touch the freshly cleaned site. The above concern was discussed with Staff Member #2 at 4:50 p.m. on 04/08/2024. The staff member agreed that these observed procedures would contaminate the cleaned CVC exit sites. A review of the Fresenius procedure titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” states, in part: ... “Procedure ...3....Verify patient’s clothing is secured away from the exit site/work area.” A review of the policy provided by the facility, entitled, “Changing the Catheter Dressing Procedure,” states, in part: ... “Applying the Dressing... ... Step 1 Using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing with gloved hands or to any surface.” The above was noted with Staff Members #1, 12 and 14 at the exit conference on 04/09/2024 at 12:45 p.m. .”

“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 observations, interview and document review, it was determined the facility staff failed to ensure they maintained a safe environment by failing to dispose of contaminated sharps at the point of use in three (3) out of three (3) observations when disconnecting patients with a fistula or graft. Findings: On 04/08/2024 at 9:34 a.m., this surveyor observed Staff Member #4 discontinue dialysis on Patient #9 with an AV (Arteriovenous) fistula at station #3. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container. At 9:57 a.m., this surveyor observed Staff Member #7 discontinue dialysis on Patient #6 who had an AV fistula at station The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container. At 10:23 a.m., Staff Member #6 was observed discontinuing dialysis on Patient #14 with an AV fistula at station #14. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container. During an interview with Staff Member #2 on 04/08/2024 at 04:50 p.m., this surveyor confirmed the facility’s expectation that all contaminated sharps will be placed immediately into a sharps container once removed from a patient. A review of the facility’s policy titled “Post Treatment Fistula Needle Removal,” published 07/06/2021, version 2, states, in part: “... Procedure... ... 6. Discard needle in sharps container. ... 9. Remove the second needle following steps...above” The above concern was discussed with Staff Members #2, 12 and 13 at the exit conference on 04/09/2024 at 12:45 p.m.”

“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, interview and document review, it was determined the facility staff failed to document post treatment deviations in estimated dry weight (EDW) that exceeded +/- 1kg in one (1) out of four (4) in-center hemodialysis patient records reviewed. The findings include: The six (6) most recent flow sheets for four (4) in-center hemodialysis patients were reviewed on 04/08/2024 by this surveyor. Patient #1: On 03/29/2024, the post treatment weight was noted at 99.10 kilograms (kg) as compared to the estimated dry weight (EDW) of 98.00 kg, a difference of 1.1 kg. No notation was made in the post treatment note by the Charge Nurse (CN) of this discrepancy. On 04/01/2024, the post treatment weight was noted at 99.70 kg as compared to the EDW of 98.00 kg, a difference of 1.7 kg. No notation was made in the post treatment note by the CN of this discrepancy. On 04/03/2024, the post treatment weight was noted at 100.40 kg as compared to the EDW of 98.00 kg, a difference of 2.40 kg. No notation was made in the post treatment note by the CN. On 04/08/2024, the post treatment weight was noted at 100.30 kg as compared to the EDW of 98.50 kg, a difference of 1.80 kg. No notation was made in the post treatment note by the CN. During an discussion with Staff Member #2 on 04/09/2024 at 10:45 a.m., the Staff Member agreed that the CN should make a note in reference to any variances greater than 1 kg between the EDW and the post treatment weight in the patient’s post treatment note. 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 Record Review Prior to discharge, the RN (Registered Nurse) must review the treatment record to: ... The record must be reviewed for: ... Whether patient is achieving dry weight [same as EDW] and identifying reason for patient not achieving dry weight... ... Documentation ... Guidelines for PCT/LPN/LVN/RN: When to Refer a Patient to the Team Leader/Charge Nurse for Further Assessment ... Fluid Status ... Any post treatment weight with a variance from the estimated dry weight [EDW] of 1.0 kg” These findings were discussed at the exit conference on 04/09/2024 at 12:45 p.m. with Staff Members #2, 12 and 13.”

“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, interview and document review, it was determined the facility staff failed to follow physician’s orders for the prescribed dialysate flow rate (DFR) for one (1) of four (4) in-center hemodialysis patients included in the sample. Findings: On 04/08/2024, this surveyor reviewed medical records and the last six (6) flow sheets for each of four (4) in-center hemodialysis patients sampled. The review indicated that the staff failed to administer the prescribed orders for 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 in one (1) out of four (4) patient records reviewed. Patient #4: On 04/03/2024, during the patient’s entire four (4) hour treatment, the DFR was run at 800 ml/min versus the prescribed rate of 500 ml/min. There was no note in the flowsheet, explaining why the DFR was increased to that level, nor was there a note stating that the CN had been notified. During an interview with Staff Member #2 on 04/09/2024 at 10:45 a.m., the staff member agreed that the DFR should be run at the prescribed rate and that any variations to that rate should be noted on the flowsheet and the CN notified. 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 Record Review... ... The record must be reviewed for: ... Correct dialysate prescription was delivered.” The above noted findings were discussed at the exit interview on 04/09/2024 at 12:45 p.m. with Staff Members #2, 12 and 13.”

“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: 49355 Based on one (1) observation, interview, and document review, it was determined the facility staff failed to properly care for an arteriovenous (AV) graft/fistula according to the facility’s policy. The findings include: At 10:38 a.m. on 04/08/2024, the surveyor observed Staff Member #2 accessing an AV fistula on Patient #5 at station #13. The staff member cleaned the area and then palpated the site. Staff Member #2 then accessed the site with the cannulation needle, without cleaning the area again. In an interview with Staff Member #2 on 04/08/2024 at 4:50 p.m., the staff member confirmed that the fistula site should have been recleaned after palpating. A review of the facility’s policy, “Access Assessment and Cannulation,” published 07/05/2022, reference number 45178, version 3, states, in part: ... “Skin Disinfection ... Step 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 above concerns were discussed with Staff Members #2, 12 and 13 at the exit conference on 04/09/2024 at 12:45 p.m.”