Puget Sound Kidney Centers-Lakewood

“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: 46647 . Based on observation, document review, and interview, the facility failed to develop and implement infection prevention policies and procedures on proper gloving and performing hand hygiene when touching patient’s equipment. Failure to develop and implement proper infection prevention policies and procedures when touching patient’s equipment places patients and staff at risk for exposure to and transmission of infectious agents. Findings included: 1. Document review of the undated facility policy titled, “Personal Protective Equipment in the Dialysis Setting,” showed that hand hygiene should be performed before donning personal protective equipment. The policy showed no evidence of instructions to wear gloves when touching patient’s equipment as required. - Document review of the undated facility policy titled, “Hand Hygiene,” showed that hand hygiene is “required” after every glove removal. 2. On 11/17/25 at 10:00 AM, Surveyor #7 observed a Patient Care Technician (Staff #710) respond to a machine alarm at Station #2. Staff #710 grabbed a glove and used it to silence the machine alarm. Staff #710 did not perform hand hygiene before and after touching the dialysis machine. 3. On 11/17/25 at 10:45 AM, Surveyor #7 observed a Patient Care Technician (Staff #710) respond to a machine alarm on Station #3. Staff #710 grabbed a glove and used it to silence the machine alarm. Staff #710 did not perform hand hygiene before and after touching the dialysis machine. 4. On 11/17/25 at 1:30 PM, Surveyor #7 interviewed the facility’s Care Coordinator (Staff #702) about the proper use of gloves and hand hygiene when touching dialysis equipment. Staff #702 acknowledged the findings and stated that staff should wear gloves and perform hand hygiene before and after gloving. .”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 46647 . Based on observation, document review, and interview, the facility failed to ensure privacy and confidentiality in personal medical records by failing to secure mobile computer stations containing personal information. Failure to ensure privacy and confidentiality of medical records risks disclosure of private patient information to other patients and visitors who have no right to the information. Findings included: 1. Document review of the facility’s policy titled, “Notice of Privacy Practices”, dated 10/17, showed that the facility is obligated to ensure that each patient’s PHI is kept private. - Document review of the facility’s policy titled, “Patient Rights” dated 06/19 showed that the facility is committed to maintaining and respecting patient’s privacy. - Document review of the undated facility policy titled, “Confidentiality of Information,” showed that members of the workforce will follow all rules and regulations as stated in the policies and procedures that includes technology and systems usage, portable devices policies, and HIPPA Privacy. 2. On 11/17/25 at 9:35 AM, Surveyor #7 observed that the two mobile computer station screens were open and unattended with patient specific information on display. 3. On 11/17/25 at 10:45 AM, Surveyor #7 interviewed the Dialysis Clinic Manager (Staff #701) about open and unattended computer stations with patient’s medical record on display. Staff #701 acknowledged the findings and stated that all computer stations should be secured when unattended. .”

“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: 46647 . 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) in 2 of 5 patient medical records reviewed (Patients #721 and #722) (1) and failing to ensure post dialysis fluid volume status is assessed per facility policy in 3 of 5 patient medical records reviewed (Patients #721, #723, and #724) (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 1. Document review of the undated facility policy titled, “Assessment and Monitoring of the Patient during In-center Hemodialysis,” showed the following: - Intradialytic monitoring is the ongoing assessment of patients during treatment and patients will be monitored at least every 30 minutes to determine appropriateness of dialysis goals and treatment interventions. - All findings, interventions, and patient responses are documented in the patient’s electronic medical record (EMR). - All abnormal findings are reported to the primary nurse and documented. - The nurse will document all follow-up details and any interventions performed. - Document review of the facility document titled, “2025 In-Center Hemodialysis Standing Orders,” dated 11/2024, showed the following: - Hypovolemia/Hypotension (Systolic BP (SBP) <100 or Diastolic BP (DBP) <60). - Hypertension (SBP >200 or DBP>120). - Bradycardia (Pulse <50) or Tachycardia (Pulse >120) 2. Document review of patient hemodialysis treatment records from 11/05/25 to 11/17/25 showed staff failed to document patient BP management and intervention in the following: a. On 11/05/25 the post-dialysis BP on Patient #721 was 96/56. There was no evidence of documentation reporting the abnormal post dialysis BP by the Patient Care Technician (Staff #710) to the licensed nurse. There was also no evidence of documentation of post dialysis patient assessments regarding the abnormal BP by the licensed nurse (Staff #714). b. From 11/05/25 to 11/17/25, Patient #722’s treatment records showed abnormal intra dialysis BP in 28 of 71 readings. There was no evidence of documentation reporting of the abnormal intra dialysis BPs by the PCTs (Staff #709, #710, and #715) to the licensed nurse (Staff #714). 3. On 11/18/25 at 2:45 PM, Surveyor #7 interviewed the facility Dialysis Manager (Staff #701) about the missing documentation of reporting and assessment of abnormal BP readings. Staff #701 acknowledged the findings. Item #2 - Not achieving dry weight 1. Document review of the undated facility policy titled, “Assessment and Monitoring of the Patient during In-center Hemodialysis,” showed that the nurse will gather post-treatment data that includes fluid volume status prior to the patient’s discharge. - Document review of the undated facility policy titled, “Assessment and Monitoring of the Patient during In-center Hemodialysis,” showed the following: - All findings, interventions, and patient responses are documented in the patient’s EMR. - All abnormal findings are reported to the primary nurse and documented. - The nurse will document all follow-up details and any interventions performed. 2. Document review of treatment records showed no evidence the nurse addressed fluid volume status of patients not achieving dry weight (DW), the ideal weight of a patient without excess fluid retention, post dialysis for the following: a. Patient #721’s medical records showed a DW of 124 Kilograms (Kg). - On 11/05/25, post weight was 122.4 Kg which was 1.6 Kg below DW. - On 11/07/25, post weight was 122.6 Kg which was 1.4 Kg below DW. - On 11/10/25, post weight was 125.5 Kg which was 1.5 Kg above DW. - On 11/12/15, post weight was 125.4 Kg which was 1.4 Kg above DW. - On 11/17/25, post weight was 122.2 Kg which was 1.2 Kg below DW. b. Patient #723’s medical records showed a DW of 144 Kg. - On 11/03/25, post weight was 147.5 Kg which was 3.5 Kg above DW. - On 11/07/25, post weight was 146.9 Kg which was 2.9 Kg above DW. - On 11/10/25, post weight was 145.1 Kg which was 1.1 Kg above DW. c. Patient #724’s medical records showed a DW of 101.5 Kg. - On 11/03/25, post weight was 96.9 Kg which was 4.6 Kg below DW. - On 11/05/25, post weight was 95.9 Kg which was 5.6 Kg below DW. - On 11/07/25, post weight was 95.1 Kg which was 6.4 Kg below DW. 3. On 11/18/25 at 2:45 PM, Surveyor #7 interviewed the facility Dialysis Manager (Staff #701) about the missing post-treatment fluid volume status assessment by the nurse prior to patient’s discharge. Staff #701 acknowledged the findings. .”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 46647 . 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 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 undated facility policy titled, “Discontinuing Hemodialysis Using the Dialog+ Machine - Internal Access,” showed that when the cannulation sites achieved hemostasis, staff are to remove gauze and apply Band-aids to each site, cover with gauze and stabilize with paper tape. - Document review of the undated facility policy titled, “Internal Access Assessment, Evaluation, and Intervention,” showed that a sterile Band-Aid should be applied over the needle site then covered with sterile 3x4 gauze after hemostasis has been achieved. 2. On 11/17/25 at 9:45 AM, Surveyor #7 observed a Patient Care Technician (PCT) (Staff #709) discontinue dialysis treatment for Patient #726. The observation showed that after hemostasis was achieved, Staff #709 failed to change the gauze on the needle sites prior to discharge. 3. On 11/17/25 at 10:20 AM, Surveyor #7 interviewed the PCT (Staff #709) regarding vascular access management policies and practices. Staff #709 acknowledged the findings and confirmed that the gauze should be changed after hemostasis has been achieved. .”

“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: 46647 . Based on document review and interview, the facility failed to ensure all members of the interdisciplinary team (IDT) signed each patient’s plan of care (POC) according to regulation requirements and facility policy in 4 of 5 patient medical records reviewed (Patients #721, #723, #724, and #725). Failure to ensure all members of the IDT sign each patient’s POC places patients at risk for having incomplete or unapproved plans of care. Findings included: 1. Document review of the undated facility policy titled, “Comprehensive Interdisciplinary Patient Assessment (CIPA) and Plan of Care,” showed that the CIPA/POC must be dated and signed electronically by all members of the IDT including the patient. If the patient chose not to participate, the RN must discuss the finalized POC with the patient and obtain the patient’s signature electronically or by paper and scanned back to the electronic medical records. 2. Document review of medical records showed no evidence of the patient’s or their designee’s signature for the following CIPA/POC: a. Patient #721, CIPA/POC dated 06/04/25. b. Patient #723, CIPA/POC dated 08/23/25. c. Patient #724, CIPA/POC dated 01/02/25. d. Patient #725, CIPA/POC dated 10/06/25. 3. On 11/18/25 at 2:45 PM, Surveyor #7 interviewed the facility Dialysis Manager (Staff #701) regarding the missing patient’s or designee’s signature in the CIPA/POC. Staff #701 confirmed the findings. .”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 46647 . Based on interview and document review, the facility failed to maintain complete and accurate medical records for 1 of 5 patients (Patient #122). Failure to ensure accurate documentation places patients at risk for harm related to documentation errors, inadequate assessments, and inappropriate care. 1. Document review of a patient’s medical records showed the following: - On 10/17/25 at 10:34 AM, the Social Worker (Staff #116) documented a psychosocial assessment that Patient #122 was ambulatory and activity level was normal. - On 10/29/25, the Registered Nurse (Staff #108) documented that Patient #122 was hospitalized on 10/14/25 for 10 days with Osteomyelitis (a bone infection) to the foot. On 10/24/25 the patient was discharged with a foot drain and was using a wheelchair. - On 11/03/25, the Nephrologist (Staff #117) documented on the “Physician Notes,” that the patient was not hospitalized in the past 104 days. 2. On 11/18/25 at 10:20 AM, Surveyor #1 interviewed the facility’s Social Worker (Staff #105) regarding the inaccurate ambulatory assessment. Staff #105 stated that due to short staffing, in-person patient assessments are not being performed, and they utilize the medical records to complete the patient assessment. 3. On 11/18/21 at 2:45 PM, Surveyor #7 interviewed the Facility Clinical Manager (Staff #701) regarding patient medical records. Staff #701 confirmed the findings, stating the Social Worker’s and the Provider’s documentation records were inaccurate.”