Panorama Dialysis

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to validate risk levels for community-based emergencies within a facility-based and community-based all-hazards risk assessment, preventing the facility from identifying high-risk facility hazards and allocating resources for incident-specific mitigation strategies. Failure to validate risk levels for emergencies within an all-hazards risk assessment places patients, staff, and visitors at risk of injury or death during an emergency related to inadequate preparation and inadequate mitigation resources or strategies. Findings included: 1. Document review of the facility policy titled, “General Disaster Preparedness,” dated 07/23, showed that the facility must perform a facility- and community-based hazard vulnerability assessment annually, identifying high-risk facility hazards and selectively allocating resources for incident-specific mitigation strategies. 2. Document review of the facility document titled, “Electrical Failure,” dated 07/12, showed that the facility assessed electrical failure (interruption of electricity supply to the facility) as a medium risk for the facility, with a moderate probability of occurrence and a low level of disruption to facility activity. 3. Document review of facility emergency system activation documents titled, “Dialysis Facility Incident After Action Review/Improvement Plan” showed the following: - On 01/14/21 at 7:15 AM, the facility sustained an electrical failure. The electrical failure led to a disruption of facility activity resulting in one patient (Patient #342) being unable to receive dialysis treatment. - On 04/06/23 at 11:10 AM, the facility sustained an electrical failure. The electrical failure led to a disruption of facility activity resulting in in four patients (Patients #343, #344, #345, and #346) being unable to complete their dialysis treatment. 4. On 04/10/24 at 10:50 AM, Surveyor #3 observed the facility treatment area. The observation showed that the facility sustained an electrical failure for approximately two hours. The electrical failure led to a disruption of facility activity resulting in in three patients being unable to complete their dialysis treatments (Patients #325, #331, and #333), and two patients being unable to receive dialysis treatment (Patients #330 and #334). 5. On 04/11/24 at 12:00 PM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) regarding the facility’s risk assessment and facility history of electrical failures. Staff #301 confirmed that the facility sustained three electrical failures within the past three years, resulting in disruption to facility activity, including missed patient dialysis treatment and treatment time. Staff #301 acknowledged that the facility failed to validate the risk level of electrical failure as having a high probability of occurrence and high level of disruption to facility activity based on the frequency of facility-experienced electrical failures, impeding the facility’s ability to identify electrical failure as a high-risk facility hazard and to allocate resources for incident-specific mitigation strategies. .”

“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: 45888 . 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, “Hand Hygiene,” dated 11/23, showed the following: - Staff must perform hand hygiene with either soap and water or an alcohol-based hand rub before and after contact with patients, and before performing any invasive procedure. - Patients who perform procedures which risk exposure to blood, such as holding access sites after treatment to achieve hemostasis, must perform hand hygiene after completion of the procedure. 2. On 04/09/24 at 11:26 AM, Surveyor #3 observed a Patient Care Technician (PCT) (Staff #314) discontinue dialysis treatment for Patient #337. The observation showed that the PCT (Staff #314) failed to perform hand hygiene after checking Patient #337’s temperature, and before donning gloves and removing dialysis needles from Patient #337’s arteriovenous fistula. 3. On 04/09/24 at 3:10 PM, Surveyor #3 observed a Registered Nurse (RN) (Staff #310) discharge Patient #318 from the facility after dialysis treatment. The observation showed that Patient #318 held their access sites after treatment to achieve hemostasis. The RN (Staff #310) failed to ensure Patient #318 performed hand hygiene after achieving hemostasis and before leaving the facility. 4. On 04/10/24 at 3:20 PM, Surveyor #3 interviewed the RN (Staff #310) regarding patient hand hygiene. Staff #310 confirmed that facility policy required staff to ensure patients performed hand hygiene after patients performed procedures risking patient exposure to blood. 5. On 04/09/24 at 4:20 PM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) and Area Team Lead (Staff #302) regarding the observed staff hand hygiene. Staff #301 and #302 confirmed that facility policy required staff to perform hand hygiene after contact with patients and before performing a procedure. .”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to implement infection control policies and activities consistent with Centers for Disease Control and Prevention (CDC) guidelines by failing to fully conduct a baseline Tuberculosis (TB) screening in 2 of 5 personnel files reviewed (Staff #305 and Staff #306). Failure to implement infection control policies consistent with CDC guidelines places patients and staff at risk for exposure to infectious diseases such as TB. Reference: Centers for Disease Control and Prevention (CDC). “TB Screening and Testing of Health Care Personnel” (2022) - “All U.S. health care personnel should be screened for TB upon hire ...TB screening is a process that includes a TB blood test or TB skin test, TB symptom evaluation and a baseline individual TB risk assessment.” Findings included: 1. Document review of the facility policy titled, “Employee Tuberculosis Testing,” dated 02/24, showed that all staff must complete a baseline TB test, symptom screening, and risk assessment upon hire. 2. Document review of employee personnel files showed the following: - The facility Social Worker (Staff #305) completed a TB risk assessment on 04/10/24, greater than 25 years after their hire date on 09/28/98. - The facility Registered Dietician (Staff #306) completed a TB risk assessment on 04/10/24, greater than 4 years after their hire date on 02/10/20. 3. On 04/11/24 at 10:55 AM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) regarding the missing TB documentation. Staff #301 confirmed that employee personnel file review failed to show TB screening as required by the CDC in 2 of 5 personnel files reviewed. 4. This is a repeat citation. DOH previously cited the facility for this finding during a 04/30/23 End Stage Renal Disease Facility Recertification Survey. .”

“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: 45888 . Based on document review, observation, and interview, the facility failed to ensure staff members followed infection prevention technique policies during central venous catheter (CVC)-related procedures by failing to use aseptic technique during CVC care. Failure to follow policies for aseptic technique when working with a patient’s CVC places patients at risk for infection of the access site, with the resultant risk of serious patient harm or death. Findings included: 1. Document review of the facility’s policy titled, “Changing the Catheter Dressing Procedure,” dated 02/24, showed that aseptic technique must be maintained when applying catheter dressings to CVC exit sites. 2. On 04/09/24 at 12:20 PM, Surveyor #3 observed a Patient Care Technician (PCT) (Staff #313) change Patient #319’s CVC dressing. The observation showed that Staff #313 removed Patient #319’s old CVC dressing and cleansed the CVC, CVC exit site, and surrounding skin. While waiting for the cleanser to dry, Patient #319’s shirt touched the cleaned area, contaminating the site. Staff #313 failed to re-clean the area prior to applying a new dressing. 3. On 04/09/24 at 4:20 PM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) and Area Team Lead (Staff #302) regarding the observed CVC care. Staff #301 and #302 acknowledged the observation and confirmed that staff failed to follow aseptic technique and facility policy 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: 45888 . 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) per facility protocol in 1 of 3 patient medical records reviewed (Patient #318). 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: 1. Document review of the facility policies titled, “Nursing Supervision and Delegation,” dated 11/23, and “Patient Assessment and Monitoring,” dated 05/23, 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. - Staff will recognize, report, and immediately address SBP greater than 180 mm/Hg or less than 100 mm/Hg and DBP greater than 100 mm/Hg. - Abnormal findings collected by a Patient Care Technician (PCT) must be reported to a Registered Nurse (RN), who must assess the affected patient. 2. Document review of patient medical records showed the following: - On 04/02/24, a PCT (Staff #317) failed to document RN notification of SBP greater than 180 mm/Hg in 2 of 14 BP measurements for Patient #318. - On 04/06/24, a PCT (Staff #313) failed to document RN notification of a SBP greater than 180 mm/Hg in 1 of 11 BP measurements for Patient #318. - On 04/09/24, a PCT (Staff #313) failed to document RN notification of a SBP less than 100 mm/Hg in 1 of 12 BP measurements for Patient #318. - On 04/09/24, an RN (Staff #310) failed to document an assessment of Patient #318 after a PCT (Staff #314) notified the RN of a DBP greater than 100 mm/Hg in 1 of 12 BP measurements for Patient #318. 3. On 04/10/24 at 4:23 PM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) and Area Team Lead (Staff #302) regarding the unmanaged patient BPs. Staff #301 and #302 confirmed that patient medical record review showed that PCTs failed to report abnormal findings to RNs, and that RNs failed to assess patients after being alerted of abnormal findings. .”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to fully measure, analyze, and track medical injuries and medical errors by failing to document medical injury and error investigation, injury or error resolution, or implementation of an action plan to mitigate contributing factors to prevent medical injury or error recurrence. Failure to fully measure, analyze, and track medical injuries and medical errors places patients at risk for harm related to unidentified and uncorrected medical risks. Findings included: 1. Document review of the facility policy titled, “Quality Assessment and Performance Improvement Program,” dated 05/22, showed that members of the facility’s interdisciplinary team must measure, analyze, investigate root causes, create action plans, and implement preventative measures for medical injuries and medical errors within a Quality Assessment and Performance Improvement (QAPI) program. 2. Document review of facility medical injury and medical error adverse event reports from 05/23 to 04/24, facility QAPI meeting minutes from 10/23 to 04/24, and the facility electronic QAPI documentation dashboard failed to show investigation, resolution, or implementation of an action plan to mitigate contributing factors to prevent recurrence of reported adverse medical events. 3. On 04/11/24 at 2:00 PM, Surveyor #3 interviewed the facility Clinic Manager (Staff #301) regarding the facility’s medical injury and medical error QAPI monitoring. Staff #301 confirmed that review of the facility’s adverse event reports, QAPI meeting minutes, and QAPI electronic dashboard failed to show that the facility investigated, sought resolution for, or implemented preventative action plans for medical injuries or medical errors. .”