Fmc Aberdeen

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 45034 . Based on document review, observation, and interview, the facility failed to ensure emergency medications are immediately available at all times. Failure to ensure emergency medications are immediately available puts patients at risk for harm due to receiving ineffective medications during an emergency. Findings included: 1. Document review of the facility policy titled, “Guidelines for Emergency Preparedness,” dated 07/03/23 shows that emergency medications must be functional and immediately available at all times. 2. On 04/09/24 at 09:50 AM, Surveyor #4 toured inspected the emergency cart and observed 4 vials of epinephrine (a medication used during a medical emergency) with an expiration date of 03/24/24. 3. On 04/09/24 at 10:00 AM, Surveyor #4 interviewed the Clinical Manager (Staff #401) regarding the expired emergency medications. Staff #401 acknowledged the findings and confirmed these medications should have been replaced upon expiration. .”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 45034 . Based on document review and interview, the facility failed to document the primary and alternative means of communicating with staff and/or Federal, State, and local emergency management agencies during an emergency. Failure to develop primary and alternative methods of communication puts patients, staff, and the community at risk for harm due to ineffective communication and activation of emergency events in the community. Findings included: 1. Document review of the facility’s emergency plan titled “Fresenius Kidney Care - Grays Harbor Emergency Plan,” last reviewed 01/17/24, failed to show the facility’s identified primary and alternate means of communication with staff and/or Federal, State, and local emergency management agencies during an emergency. 2. On 04/10/24 at 1:10 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the missing communication plan elements. Staff #401 and #402 confirmed the findings and acknowledged the communication plan failed to show the primary and alternative means of communicating with staff and/or Federal, State, and local emergency management agencies during an emergency. .”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 45034 . Based on document review and interview, the facility failed to develop a communication plan that included all required methods for sharing information including a means of providing information about the general condition and location of patients under the facility’s care. Failure to establish a communication plan that includes all required elements including a means of providing information about the general condition and location of patients under the facility’s care puts patients at risk for unmet care needs, delay in treatment, and inability to provide coordinated health care services with external organizations. Findings included: 1. Document review of the facility’s emergency plan titled, “Fresenius Kidney Care - Grays Harbor Emergency Plan,” last reviewed 01/17/24, showed no evidence of a communication plan that included a process for providing information about the general condition and location of patients under the facility’s care. 2. On 04/10/24 at 1:10 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the missing communication plan elements. Staff #401 and #402 confirmed the findings and acknowledged the facility failed to have a communication plan that included a means of providing information about the general condition and location of patients. .”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 45034 . Based on document review and interview, the facility failed to develop and implement a communication plan that includes a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction over an emergency or disaster. Failure to develop and maintain an emergency preparedness communication plan that includes a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction over an emergency or disaster risks patient harm related to the facility’s inability to access critical resources in an emergency. Findings included: 1. Document review of the facility’s emergency plan titled, “Fresenius Kidney Care - Grays Harbor Emergency Plan,” last reviewed 01/17/24, showed no evidence of a process for providing information about the facility’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction over an emergency or disaster. 2. On 04/10/24 at 1:10 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the missing communication plan elements. Staff #401 and #402 confirmed the findings and acknowledged the facility failed to have a communication plan that included a process for providing information about the facility’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction over an emergency or disaster. .”

“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: 45034 . Based on document review, observation, and interview, the facility failed to ensure all staff followed facility policies and procedures for glove use and hand hygiene. Failure to change gloves and perform hand hygiene places patients at risk for exposure to and transmission of infectious agents. Findings included: 1. Document review of the facility policy titled, “Post Treatment Fistula Needle Removal,” dated 07/06/21, showed that patients holding dialysis access sites are to remove gloves and perform hand hygiene after hemostasis is achieved. Staff are to instruct patient holding sites to perform hand hygiene. - Document review of the facility policy titled, “Hand Hygiene,” dated 11/03/23, showed that all facility staff must perform hand hygiene with either soap and water or an alcohol-based hand rub for the following: -Before and after direct contact with patients; -Before performing any invasive procedure such as vascular access cannulation or administration of medications; -After contact with inanimate objects near the patient; -When moving from a contaminated body site to a clean body site; -After contact with other objects within the patient station or treatment space. 2. On 04/09/24 at 10:18 AM, Surveyor #4 observed a Patient Care Technician (PCT) (Staff #412) discontinue dialysis treatment for Patient #426. The observation showed that Patient #426 held their access sites with a gloved hand after being disconnected from dialysis treatment to achieve hemostasis, exposing Patient #426 to blood and bodily fluids. Staff #412 failed to ensure Patient #426 performed hand hygiene after hemostasis was achieved and when Patient #426 removed their glove. - On 04/09/24 at 11:10 AM, Surveyor #4 observed a PCT (Staff #409) initiate dialysis treatment for Patient #429. The observation showed Staff #409 use their gloved hands to connect oxygen tubing to the oxygen machine and place the oxygen tubing on the patient; touching the patients face mask, cheeks, ears, and hair line. Staff #409 then placed a tourniquet on the patient’s arm and began assessing the patient’s vascular access. Staff #409 failed to change gloves or perform hand hygiene prior to performing vascular access cannulation. - On 04/09/24 at 11:40 AM, Surveyor #4 observed a PCT (Staff #408) discontinue dialysis treatment for Patient #428. The observation showed Staff #408 donned gloves, touch the patient to obtain a blood pressure, touch the dialysis machine keyboard, and the dialysis lines prior to disconnecting the dialysis lines from the patient’s central venous catheter (CVC) without performing hand hygiene or changing gloves. - On 04/09/24 at 2:15 PM, Surveyor #4 observed a nurse (Staff #404) perform a venous puncture for blood draw and administer an injection to Patient #430. During the observation Staff #404 donned gloves then proceeded to leave the room to obtain a pen, return to the room, handle supplies, perform the venous puncture to obtain blood samples, access a clean cabinet for gauze, and place the gauze on the patient’s venous puncture site without changing gloves or performing hand hygiene as required. Staff #404 changed gloves then placed their gloved hands into their pockets, obtained supplies from clean cabinet, and administered the injection without changing gloves or performing hand hygiene as required. 3. On 04/09/24 at 4:30 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the hand hygiene practice observations. Staff #401 and #402 acknowledged the findings and confirmed that staff failed to follow infection control policies. .”

“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: 45034 . Based on document review, observation, and interview, the facility failed to ensure staff followed policies for safe preparation, handling, and storage of medications by failing to appropriately label multidose vials and syringes containing medications. Failure to ensure staff follow policies for safe preparation, handling, and storage of medications places patients at risk of harm from exposure to infectious agents. Findings included: 1. Document review of the facility policy titled, “Medication Preparation and Administration,” dated 02/06/23, showed that multidose vials must have the date and time the vial was opened on the medication label along with the initials of the staff member who opened the vial. The staff member must never walk away from an opened multidose vial without writing the date and time the vial was opened. 2. On 04/09/24 at 9:40 AM, Surveyor #4 toured the patient care supply areas and observed the following: - One opened vial of lidocaine (a medication used to numb the skin) without the date or time opened noted on the vial. - One opened vial of Heparin (a medication used to prevent clotting) without the date or time opened noted on the vial. 3. On 04/09/24 at 10:00 AM, Surveyor #4 interviewed the Clinical Manager (Staff #401) regarding the unlabeled multidose vials. Staff #401 confirmed the findings and acknowledged that staff failed to follow safe medication management policies. .”

“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: 45034 . Based on document review, observation, and interview, the facility failed to ensure staff members followed infection prevention technique policies and standards during Central Venous Catheter (CVC) related procedures by failing to use aseptic technique during catheter care. Failure to follow policies and standards when working with a patient’s CVC risks infection of the access site, with the resultant risk of serious patient harm. Findings included: 1. Document review of the facility’s policy titled, “Changing the Catheter Dressing Procedure,” dated 11/04/19, showed that aseptic technique is to be maintained when applying the catheter dressing over the exit site. 2. On 04/09/24 at 10:55 AM, Surveyor #4 observed a Patient Care Technician (PCT) (Staff #407) initiate dialysis treatment and perform central venous catheter (CVC) exit site care on Patient #421. During the observation, Staff #407 removed the old dressing from the CVC and used their gloved hand to hold back the patient’s shirt while cleaning the CVC exit site. After cleaning, they released the shirt and let it fall onto the clean area while it was drying. Staff #407 failed to re-clean the area prior to applying the new dressing. 3. On 04/09/24 at 4:30 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the observed CVC care. Staff #401 and #402 acknowledged the observation and confirmed that staff failed to follow aseptic technique during CVC care. .”

“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: 45034 . Based on document review and interview, the facility failed to provide the necessary care and services to manage patients’ dose of dialysis by failing to manage patient blood pressure (BP) and heart rate (HR) per facility protocol in 4 of 8 patient medical records reviewed (Patients #420, #421, #423, and #425) (1) and failing to ensure nursing assessments occurred per facility policy in 6 of 8 patient medical records reviewed (Patients #420, #421,#422, #423, #424,and #425) (2). Failure to provide the necessary care and services to manage patients’ dose of dialysis places patients at risk for ineffective treatments and at risk for undetected complications. Findings Included: Item #1 - BP and HR 1. Document review of the facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, showed the following: - Patient systolic blood pressure (SBP) (a pressure measurement when the heart contracts) greater than 180 millimeters of mercury (mm/Hg) or less than 100 mm/Hg is an abnormal finding. - Patient diastolic blood pressure (DBP) (a pressure measurement of the heart at rest) greater than 100 mm/Hg is an abnormal finding. - Patient HR assessed below 60 beats per minute (BPM) or above 100 BPM is an abnormal finding. - Abnormal findings collected by a Patient Care Technician (PCT), or a Licensed Practical Nurse (LPN) must be reported to a Registered Nurse (RN), who must assess the affected patient. 2. Document review of patient medical records showed staff failed to manage patient BP and HR as required in the following: - On 03/28/24 a PCT (Staff #418) failed to document nurse notification of a HR less than 60 on Patient #423 in 2 of 10 HR measurements. - On 03/28/24 PCTs (Staff #413 and #414) failed to document nurse notification of a HR less than 60 on Patient #420 in 5 of 9 HR measurements. - On 03/30/24 a PCT (Staff #416) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #421 in 1 of 13 BP measurements. - On 03/30/24 a PCT (Staff #407) failed to document nurse notification of a HR less than 60 on Patient #420 in 6 of 10 HR measurements. - On 03/30/24 PCTs (Staff #411, #412, and #415) failed to document nurse notification of a HR less than 60 on Patient #425 in 7 of 10 HR measurements. - On 04/02/24 a PCT (Staff #415) failed to document nurse notification of a HR less than 60 on Patient #420 in 6 of 10 HR measurements. - On 04/02/24 PCTs (Staff #416 and #419) failed to document nurse notification of a HR less than 60 on Patient #425 in 10 of 10 HR measurements. - On 04/02/24 PCTs (Staff #407 and #408) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #421 in 2 of 10 BP measurements. - On 04/04/24 a PCT (Staff #418) failed to document nurse notification of a HR less than 60 on Patient #423 in 5 of 10 HR measurements. - On 04/06/24 a PCT (Staff #415) failed to document nurse notification of a HR less than 50 on Patient #421 in 2 of 9 HR measurements. Patient #421 had a physician order to allow dialysis if HR was greater than 50. - On 04/09/24 PCTs (Staff #409 and #414) failed to document nurse notification of a HR less than 60 on Patient #425 in 6 of 9 HR measurements. - On 04/09/24 PCTs (Staff#407, #408, and #411) failed to document nurse notification of a HR less than 50 on Patient #421 in 7 of 11 HR measurements. Patient #421 had a physician order to allow dialysis if HR was greater than 50. - On 04/09/24 PCTs (Staff #412 and #418) failed to document nurse notification of a HR less than 60 on Patient #425 in 5 of 9 HR measurements. 3. On 04/11/24 at 11:35 AM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the unmanaged patients’ BP and HR. Staff #401 and #402 confirmed the findings and acknowledged patient medical record review failed to show RN notification of abnormal findings in 4 of 8 patient medical records reviewed. Item #2 - Nursing Assessment 1. Document review of the facility policies titled, “Patient Assessment and Monitoring,” dated 05/01/23 and “Hypertension,” dated 09/07/21, showed the following: - Patient SBP greater than 180 mmHg, DBP greater than 100 mmHg, and Patient HR above 100 BPM are abnormal findings. - Abnormal findings collected by a Patient Care Technician (PCT), or a Licensed Practical Nurse (LPN) must be reported to a Registered Nurse (RN), who must assess the affected patient. - Staff will recognize, report, and immediately address SBP greater than 180 mm/Hg and DBP greater than 100 mm/Hg. - The registered nurse will assess/re-asses any findings addressed pre or during treatment as needed. The registered nurse will document findings and interventions in the medical record. 2. Document review of patient medical records showed the nursing staff failed to assess patients as required in the following medical records reviewed: - On 03/27/24 at 1:32 PM, 2:01 PM, and 2:38 PM, PCTs (Staff #413 and #414) documented notification to a nurse (Staff #406) regarding Patient #422’s SBP less than 100. Staff #406 failed to document a subsequent assessment of Patient #422. - On 03/28/24 at 2:33 PM, a PCT (Staff #414) documented notification to a nurse (Staff #403) of Patient #420’s HR of less than 60. Staff #403 failed to document a subsequent assessment of Patient #420’s abnormal HR. - On 03/30/24 at 6:57 AM, a PCT (Staff #411) documented initiation of dialysis on Patient #425 with a HR of less than 60. The nurse, (Staff #405) failed to document a nursing assessment prior to initiation of dialysis. - On 03/30/24 at 11:53 AM, a PCT (Staff #407) documented initiation of dialysis on Patient #420 with a HR of less than 60. The nurse, (Staff #405) failed to document a nursing assessment prior to initiation of dialysis. -On 04/01/24 PCTs (Staff #407, #413, and #414) documented notification to a nurse (Staff #417) regarding Patient #424’s SBP greater than 180 and DBP greater than 100 mmHg. Staff #417 failed to document a subsequent assessment of Patient #424’s abnormal SBP and DBP readings. - On 04/01/24 at 2:45 PM, an LPN (Staff #406) documented treatment termination on Patient #424 with a SBP greater than 180mm/Hg and DBP greater than 100mm/Hg. The nurse, (Staff #417) failed to document a nursing assessment that addressed the abnormal BP prior to discharge. - On 04/02/24 at 6:47 AM, a PCT (Staff #416) documented initiation of dialysis on Patient #425 with a HR of less than 60. The nurse, (Staff #405) failed to document a nursing assessment prior to initiation of dialysis. - On 04/02/24 at 10:38 AM, a PCT (Staff #407) documented initiation of dialysis on Patient #421 with a SBP greater than 180mm/Hg. The nurse, (Staff #406) failed to document a nursing assessment prior to initiation of dialysis. - On 04/02/24 at 4:27 PM, a PCT (Staff#414) documented treatment termination on Patient #422 with a SBP greater than 180mm/Hg. The nurse, (Staff #417) failed to document a nursing assessment that addressed the high SBP prior to discharge. - On 04/02/24 at 4:11 PM, a PCT (Staff#415) documented treatment termination on Patient #420 with an abnormal HR of 50 post treatment. The nurse, (Staff #405) failed to document a nursing assessment that addressed the low HR prior to discharge. - On 04/09/24 at 11:37 AM, a PCT (Staff #418) documented initiation of dialysis on Patient #423 with a HR of less than 60. The nurse, (Staff #417) failed to document a nursing assessment prior to initiation of dialysis. 3. On 04/11/24 at 11:35 AM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding the late and missing nursing assessments. Staff #401 and #402 confirmed the findings and acknowledged nursing staff failed to document patient assessments or interventions in 6 of 8 patient medical records reviewed. .”

“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: 45034 . Based on document review, observations, and interview, the dialysis facility failed to ensure staff members properly evaluated and cared for a patient’s vascular access pre and post dialysis. Failure to effectively care for a patient’s vascular access risks harm to patients from potential infection and malfunctioning of the access leading to missed dialysis treatments and potential need for vascular access replacement. Findings included: 1. Document review of the facility policy titled, “Access Assessment and Cannulation”, dated 07/05/22, showed that a patient’s access site is to be washed with soap and water prior to skin antisepsis. Staff are to perform skin antisepsis on one site at a time. Staff are not to touch cannulation sites after skin disinfection. - Document review of the facility policy titled, “Post Treatment Fistula Needle Removal,” dated 07/06/21, showed that once hemostasis is achieved, staff are to remove the gauze and place a band-aid, adhesive dressing, or gauze dressing secured with clean tape. 2. On 09/04/24 at 10:18 AM, Surveyor #4 observed a Patient Care Technician (PCT) (Staff #412) discontinue dialysis treatment for Patient #426. The observation showed that after hemostasis was achieved, blood was visibly noticeable on the gauze. Staff #426 failed to change the soiled gauze on the needle sites prior to discharge. - On 04/09/24 at 11:10 AM, Surveyor #4 observed a PCT (Staff #409) initiate dialysis treatment for Patient #429. The observation showed that Patient #429’s access site was not washed with soap prior to skin antisepsis by the patient or staff as required. After skin antisepsis and inserting the first needle, Staff #409 palpated the access site due to having difficulty with needle placement. Additional PCT’s (Staff #411 and #412) assisted with needle placement which involved palpating and holding the previously cleaned area. Staff failed to perform skin antisepsis prior to inserting the second needle. 3. On 04/09/24 at 4:30 PM, Surveyor #4 interviewed the Clinic Manager (Staff # 401) and Area Team Lead (Staff #402) regarding vascular access management policies and practices. Staff #401 and #402 acknowledged the findings and confirmed that staff are educated on and expected to adhere to the described practices around vascular access. .”

“QAPI-INDICATOR-VASCULAR ACCESS CFR(s): 494.110(a)(2)(v) The program must include, but not be limited to, the following: (v) Vascular access. This Standard is not met as evidenced by: 45034 . Based on document review and interview, the facility failed to document assessments of collected information and develop action plans to improve the patient central-venous catheter (CVC) rate that remained below identified goals. Failure to assess for root cause and apply corrective action to identified issues that were not meeting established goals places patients at risk of harm related to inappropriate use of catheters. Findings included: 1. Document review of the facility policy titled, “Quality Assessment and Performance Improvement (QAPI),” dated 05/02/22, showed that the facility will measure, analyze, and track quality indicators. The QAPI committee will monitor data, prioritize areas for improvement; determine potential root causes, develop, implement, evaluate, and revise action plans that result in sustainable improvement in patient care. 2. Document review of the facility’s QAPI online dashboard, associated meeting minutes dated September 2023 thru February 2024, and the most current annual CMS-generated dialysis facility report showed the following: -The percentage of patients with a CVC greater than 90 days was above the national threshold of 10.7% for the past 12 months with no significant improvements. Facility rates ranged from 19.4% to 28.6%. -The meeting minutes and electronic dashboard showed patient data was only collected. The minutes and dashboard showed no evidence of a root cause analysis or action plan identified for performance improvement. 3. On 04/11/24 at 1:55 PM, Surveyor #4 interviewed the Clinic Manager (Staff #401), the Area Team Lead (Staff #402), the Home Clinic Manager (Staff #431), the Registered Dietician (Staff #432), and the Social Worker (Staff #433) regarding the percentage of patients with a CVC greater than 90 days. Staff #401, #402, #431, #432, and #433 confirmed that the facility failed to analyze for cause and develop action plans aimed at improving rates. .”

“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: 45034 . Based on document review and interview, the facility failed to take action to improve performance related to the transplant waitlist and monitor performance to ensure that any improvements are sustained over time for. Failure to develop action plans to improve facility performance related to the transplant waitlist and to develop a process to ensure improvements are sustained over time places patients at risk for harm related to unidentified or unaddressed improvement needs. Findings included: 1. Document review of the facility policy titled, “Quality Assessment and Performance Improvement (QAPI),” dated 05/02/22, showed that the facility will measure, analyze, and track quality indicators. The QAPI committee will monitor data, prioritize areas for improvement; determine potential root causes, develop, implement, evaluate, and revise action plans that result in sustainable improvement in patient care. 2. Document review of the facility’s QAPI online dashboard, associated meeting minutes dated September 2023 thru February 2024, and the most current annual CMS-generated dialysis facility report showed the following: -The percentage of eligible patients waitlisted for transplant was below the national threshold of 20.1% for the past 12 months and is currently at 2.63%. -The meeting minutes and electronic dashboard showed tracking of patient education and an overall rate only. The minutes and dashboard showed no evidence of a root cause analysis or action plan identified for performance improvement. 3. On 04/11/24 at 1:55 PM, Surveyor #4 interviewed the Clinic Manager (Staff #401), the Area Team Lead (Staff #402), the Home Clinic Manager (Staff #431), the Registered Dietician (Staff #432), and the Social Worker (Staff #433) regarding transplant waitlist tracking and monitoring. Staff #401, #402, #431, #432, and #433 confirmed that the facility failed to develop action plans aimed at improving rates of patients placed on the transplant waitlist. .”