Davita Oconomowoc Dialysis

“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: 29972 Based on observation, record review, and interview staff failed to ensure there was an appropriate number of emergency supplies/medication in the evacuation kit for all patients in 1 of 1 emergency evacuation kit observed (in-center dialysis) in a total of 1 evacuation kit observed. Findings: Review of the Facility Emergency Management Plan last reviewed October 2023 revealed, “The contents of the evacuation kit(s) will include, at a minimum, enough supplies to provide care for a full shift of patients...likely to be present in the facility at any given time.” Per observations on 02/13/2023 at 9:30 am, there are 14 stations used to provide dialysis treatment to patients. Observations of the emergency evacuation kit on 02/13/2023 beginning at 12:54 PM, revealed that there were 10 bags of normal saline. Per interview with Facility Administrator (FA) B on 02/14/2024 at 11:30 AM, FA B stated that the evacuation kit should include enough bags of normal saline to cover a shift of patients.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 29972 Based on observations and interview, staff failed to maintain a sanitary environment free from potential infection control risk in 2 of 3 areas observed (treatment area, Water room), in a total sample of 3 areas observed. Findings Include: On 02/13/2024 beginning at 9:40 AM observed the following: Treatment area: -Observed dust, debris, and brownish residue inside of cabinet under the “dirty” sink. Per observations there was an old visibly soiled (yellowing) white pad at the bottom of the cabinet. -Observed dust and debris inside of a supply drawer at the nurses station. On 02/13/2024 beginning at 1:23 PM observed the following: Water Room: -Observed a large amount of brown sludge/residue surrounding the floor drain in front of the water heaters. Per interview with Facility Administrator (FA) B on 02/14/2024 beginning at 1:45 PM, while discussing observations, FA B stated that she/he was not aware of the last time the cabinet and drawer were cleaned. When asked who is responsible for cleaning the cabinets and drawers, FA B stated that there is no schedule and/or staff assignment to regularly clean the inside of the cabinets and drawers; per FA B housekeeping does not clean inside the cabinets and drawers. Per interview with FA B while observing the water room findings on 02/15/2024 beginning at 2:30 PM, FA B stated that the dialysis staff are responsible for cleaning the water room floor; FA B was not sure what the sludge around the floor drain was and why it was not cleaned.”

“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: 29972 Based on observation, record review, and interview staff failed to perform hand hygiene before donning gloves and immediately after removing gloves while providing patient care in 2 of 14 observations of care (Patient (Pt# 10, 11); and failed to remove gloves and perform hand hygiene before touching “clean” items in 1 of 14 observations of care (Pt #12), in a total sample of 14 observations of patient care. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection control for Dialysis Facilities” last reviewed April 2023 revealed the following: 1. “All teammates...will perform hand hygiene...b. prior to gloving and immediately after removal of gloves...g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” On 02/13/2024 beginning at 10:16 AM, observed Registered Nurse (RN) I administer intravenous (IV) medication to Pt #10. RN I did not perform hand hygiene before donning gloves, then proceeded to administer IV Venofer (iron) to Pt #10; RN I did not perform hand hygiene after removing gloves. On 02/14/2024 beginning at 9:10 AM, observed RN D administer IV medication to Pt #11. RN D donned gloves then typed on keyboard with gloved hands. RN D then removed gloves, donned a new pair of gloves, and administered IV Venofer to Pt #11; RN D did not perform hand hygiene between glove changes. On 02/14/2024 beginning at 10:00 AM, observed Patient Care Technician (PCT) F discontinuing Pt #12’s dialysis treatment using an arteriovenous fistula (AVF). PCT F removed Pt #12’s needle then applied gauze and a clamp to the vascular access site; PCT F then proceeded to touch PCT F’s face mask without first removing the “dirty” gloves and performing hand hygiene. During interviews with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 11:30 AM, while discussing observations, FA B stated that staff should be performing hand hygiene before donning gloves and immediately after removing gloves. FA B stated that staff should be removing gloves and donning hand hygiene before touching personal protective equipment (PPE) (face mask). FA B confirmed that staff should not type on keyboard with gloved hands.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 29972 Based on observations, record review and interview staff failed to ensure that clean supplies are protected from potential cross contamination in 7 of 14 dialysis stations observed (Station (St) 1, 2, 6, 7, 9, 12, and 13), in a total sample of 14 dialysis stations observed. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed, “Unused supplies...taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients.” On 02/13/2024 beginning at 2:00 PM, observed “clean” supplies (dialyzer, bag of normal saline, needles, tourniquet etc.) on the countertop at dialysis St #1, 2, 6, 7, 9, 12, and 13. Per observations, the “clean” supplies (for the next patient) was being stored at the dialysis stations while patients were receiving dialysis treatment. Per interview with Registered Nurse (RN) C at the time of the observation, RN C confirmed that the “clean” supplies for the next patients are gathered a head of time and stored on the countertop at each station while patients are still on dialysis. RN C stated that staff place the supplies on the counter at the station a head of time due to space constraints.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 29972 Based on observation, record review, and interview staff failed to clean and disinfect all the equipment at the dialysis station between patients to prevent cross contamination in 2 of 3 observations of dialysis station cleaning (Station (St) #3, 7), in a total sample of 3 observations of station cleaning; and failed to ensure the bleach solution is labeled to ensure the appropriate concentration and effectiveness in 1 of 2 observations of bleach solution (1:100) in a total sample of 2 observations. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed the following: -“At the end of each treatment, the dialysis station will be cleaned and disinfected.” - “a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel, top, front and sides of dialysis machine; touchscreens; countertops).” Review of policy and procedure #1-05-08B titled, “Preparation of one to one hundred (1:100) Bleach Solution” last revised October 2023 revealed to “label with one to one hundred (1:100) bleach solution...label container with expiration date, time, and initials. The solution is good for 24 hours only.” On 02/13/2024 at 9:29 AM, observed a container filed with bleach solution not labeled with concentration, expiration date, time, and initials. Per interview with Patient Care Technician (PCT) E, at the time of observation, PCT E stated that the bleach solution should be labeled with the concentration, expiration date, time made, and initials. On 02/13/2024 at 1041 AM, observed Patient Care Technician (PCT) G cleaning and disinfecting St 3 after Pt #13’s dialysis treatment. During Pt #13’s treatment observed Pt #13’s belongings on the counter top at the station. PCT G did not clean the following: -Basket attached to the dialysis machine -Blue emergency disconnect bag hanging from TV -Inside of the Prime waste container -Crevices between the arm rest and tray table (fold down the tray table) -Counter tops at the dialysis station On 02/14/2024 at 10:09 AM, observed PCT F cleaning and disinfecting St 7 after Pt #7’s dialysis treatment. PCT F did not clean the following: -Basket attached to the dialysis machine -Extra blood pressure cuff in the basket attached to the dialysis machine -IV (intravenous) pole and hooks -Acid and Bicarbonate lines attached to the dialysis machine During interviews with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 11:30 AM, while discussing observations, FA B confirmed that the above areas of the station should be cleaned between patients as per policy.”

“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: 29972 Based on record review, observation and interview, staff failed to ensure Central Venous Catheters (CVCs) are accessed in a manner to prevent potential cross contamination in 1 of 4 patients observed with a CVC (Patient (Pt) #7) in a total sample of 4 patients observed with a CVC. Findings include: Review of policy and procedures #1-04-02B titled, “Central Venous Catheter....” last reviewed October 2023 revealed the following: -“Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason.” Review of the CVC procedure “Upon completion of dialysis” revealed to, “...Aseptically disconnect arterial blood line from arterial CVC limb. Attach a 10 milliter (ml) syringe filled with normal saline to arterial catheter limb and push normal saline into arterial port...” Per review, the procedure in the policy did not include to perform a 15 second hub scrub after disconnecting the blood lines and before attaching normal saline syringe, to ensure potential contaminates are not pushed into the blood stream. Review of CDC (Centers for Disease Control) “Hemodialysis Central Venous Catheter Scrub the Hub Protocol” last reviewed September 26, 2016 revealed, “Catheter hubs should be disinfected again after disconnecting from bloodlines and before replacing a new cap at the end of a treatment. This should be done in a manner similar to that used when disinfecting the hub prior to accessing. On 02/13/2024 beginning at 9:45 AM, observed Patient Care Technician (PCT) F discontinuing Pt #7’s dialysis treatment using a CVC. PCT F did not scrub/disinfect the CVC hubs after disconnecting the blood lines and prior to accessing the CVC with a 10 ml syringe and pushing normal saline into the CVC ports. During interview with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 11:30 AM, while discussing observations, FA B stated the staff are trained as per the procedure in the CVC policy. Per FA B, staff are taught to disconnect the blood lines from the CVC, administer normal saline and the CVC locking solution, and then scrub the hub with alcohol wipe prior to applying the caps. FA B stated that she/he was following the policy and did not know the CVC hub scrub should be done immediately after disconnecting the blood lines and before accessing the CVC ports as per CDC guidelines.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 29972 Based on observation and interview staff failed to ensure water chlorine testing was done according to the requirements of the water treatment system in 1 of 1 observations of staff performing chlorine test (Patient Care Technician (PCT) E), in a total sample of 1 staff observation of water testing. Findings Include: Per interview with the Biomedical technician (Bio) H on 02/14/2024 at 12:30 PM, Bio H stated that staff should run the water for 30 seconds prior to collecting the water used to perform the chlorine test. Per Bio H, based on the length of the pipes carrying the water from the carbon tanks to the sample port, staff should run the water for 30 seconds to ensure they get a “fresh” sample from the chlorine tanks and not the water sitting in the lines. Bio H confirmed this procedures was not documented in the policy, but Bio H stated that staff were trained on this process. On 2/13/2024 beginning at 1:18 PM, observed PCT E performing the chlorine water testing. PCT E obtained a water sample from a port located downstream from the primary carbon tank (across the water room near Deionization hook up). PCT E filled up a 30 cc sample cup with water and dumped twice. PCT E did not let the water run 30 seconds prior to collecting the water sample.”

“DI-CONTIN MONITOR/LOGGED 2X/DAY CFR(s): 494.40(a) 5.2.8 Deionization: continuous monitor resistivity/logged 2 X day Refer to RD62:2001, 4.3.6 Deionization: Deionization systems, when used to prepare water for hemodialysis applications, shall be monitored continuously to produce water of one megohm/cm or greater specific resistivity (or conductivity of one microsiemen/cm or less) at 25°C. 6.2.8 Deionization Deionizers shall be monitored continuously using resistivity monitors that compensate for temperature and are equipped with audible and visual alarms. Resistivity monitors shall have a minimum sensitivity of 1.0 megohm-cm. Patients shall not be dialyzed on deionized water with resistivity less than 1.0 megohm-cm measured at the output of the deionizer Resistivity monitor readings should be recorded on a log sheet twice each treatment day. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to complete the DI (Deionization) monitoring Log when using DI tanks as per policy in 1 of 1 month of DI logs reviewed (April 2023), in a total sample of 1 month of DI logs reviewed. Findings Include: Review of the policy and procedure #02-04-02 titled, “Daily Water Treatment System Monitoring” last revised April 2018 revealed, “When DI is used in a facility, in the event the RO (Reverse Osmosis) is inoperable or as a polish: The DI Monitoring Log will be implemented...The resistivity monitor readings should be recorded on the DI monitoring Log every 4 hours of each treatment day...” Review of the DI monitoring log from 04/01/2023 through 04/24/2023 revealed that the following days on the daily monitoring logs did not have times documented indicating when the DI was checked: 04/06/2023, 04/07, 04/08, 04/10, 04/12, 04/17, 04/18, 04/19, 04/20, 04/21, 04/22, and 04/24. Per interview with Biomedical Technician (Bio) H on 02/14/2024 at 12:50 PM, Bio H confirmed the findings and stated that staff should be documenting the time of each check to ensure the DI is monitored as per policy.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 29972 Based on observation and interview staff failed to post the State agency and Network 11 patient rights contact info in the dialysis facility easily seen by patients in 1 of 1 observations (in-center dialysis), in a total sample of 1 observation. Findings Include: Per observations of the dialysis treatment area and waiting room beginning on 02/13/2024 at 8:40 AM, there was no evidence of the State agency and Network 11’s contact info (mailing address and complaint telephone number) being posted in a place easily seen by patients. During interview with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 11:30 AM, while discussing observations, FA B confirmed that the information was not posted in the facility at the time of the observation.”

“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: 29972 Based on record review and interview, staff failed to ensure that nursing assessments and evaluations address fluid management needs in 3 of 5 records reviewed (Patients (Pt) #1, 3, 5); and failed to ensure that staff perform nursing assessments when blood pressures (BP) are out of parameters as per policy in 2 of 5 medical records reviewed (Pt #1, 3), in a total sample of 5 medical records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last reviewed October 2023 revealed the following: - “If abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis.” - “The nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one hour of dialysis treatment initiation.” - “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary.” - “All findings, interventions and patient response will be documented in the patient’s medical record.” - Abnormal findings include, “Removal goal not to exceed maximum ordered by physician;” “If patient is above or below 1 kilogram from the target weight (TW);” “Systolic (blood pressure) greater than 180...or less than 90...Diastolic (blood pressure) greater than or equal to 100...” “Difference of 20...increase or decrease from patient’s last intradialytic treatment BP (blood pressure) reading.” Fluid Assessment and Evaluations: Review of Pt #1’s Treatment Sheets revealed the following: -02/10/2024: Pt #1’s TW pre treatment was 57.0 kg and Post Weight was 59.1 kg; 2.1 kg above TW. There was no documentation of nursing interventions addressing Pt #1’s post weight being >1 kg over the TW as per policy. Review of Pt #3’s Treatment Sheet revealed the following: -02/05/2024: Pt #3’s dialysis treatment started at 9:30 AM and the nurse did not document a Pre-treatment (tx) assessment until 11:36 AM; 2 hours and 6 minutes later (Should be within 1 hour per policy). -02/09/2024: Pt #3’s TW pre treatment was 85.0 kg and Post Weight was 86.2 kg; 1.2 kg above TW. There was no documentation of nursing interventions addressing Pt #3’s post weight being >1 kg over the TW as per policy. Review of Pt #5’s Treatment Sheet revealed the following: -02/09/2024: Pt #5’s dialysis treatment started at 11:12 AM and the nurse did not document a Pre-tx assessment until 12:16 PM; 1 hour and 4 minutes later (Should be within 1 hour per policy). Blood Pressure Assessments and monitoring: Review of Pt #1’s Treatment Sheet revealed the following: -02/06/2024: Pt #1’s BP parameter orders revealed “Pre-tx may start with SBP (systolic BP/top number) below 180... DBP (Dialstolic BP/bottom number) below 100...” At 9:15 AM Pt #1’s Pre-tx standing BP was 212/125 and sitting BP was 198/145 (out of parameters). At 9:22 AM, Pt #1’s dialysis tx was started with a BP of 204/120; there was no nursing assessment prior to starting treatment (as per policy) to address signs and symptoms of hypertension. At 9:48 AM Pt #1’s RN Pre-tx assessment stated, “bp within parameters,” this is inconsistent with Pt #1’s BP findings. Review of Pt #1’s In-Center medications revealed, “Clonidine (lowers bp) 0.10 milligram...every 4 hours as needed...if no blood pressure response, notify provider...” Review of Pt #1’s treatment sheet revealed that at 9:46 AM BP was 200/119, at 10:16 AM BP was 191/114, at 10:46 AM BP was 192/111; there were no interventions documented, including administering Clonidine and notifying the Provider. -02/08/2024: At 9:16 AM Pt #1’s Pre-tx sitting BP was 206/124 (out of parameters). At 9:29 AM, Pt #1’s dialysis tx was started with a BP of 203/119; there was no nursing assessment prior to starting treatment to address signs and symptoms of hypertension. -02/10/2024: At 11:02 AM Pt #1’s BP was 172/99, then at 11:31 AM BP dropped to 126/96 (44 points), there was nursing assessment of Pt #1’s BP dropping more than 20 points as per policy. Review of Pt #3’s Treatment Sheet revealed the following: -02/02/2024: Pt #3’s TW pre treatment was 85.0 kg and Post Weight was 88.3 kg; 3.3 kg above TW. There was no documentation of nursing interventions addressing Pt #3’s post weight being >1 kg over the TW as per policy. During interviews with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 2:22 PM, while discussing medical record findings, FA B stated that the nurse should be assessing patients prior to the start of dialysis treatment when there are abnormal findings. FA B stated that the nurse should assess patients within a hour of the start of treatment when there are no abnormal findings. Per FA B, staff should be notifying the Provider when the patient is more than 1.0 kg above dry weight at the end of treatment.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to address the nutritional needs of patients in the comprehensive plan of care in 1 of 1 patient medical records sampled for low albumin (Patient (Pt) #4), in a total sample of 5 medical records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last reviewed July 2023 revealed the following: - “The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes...” - “The plan of care will address, but not be limited to, the following:...Nutritional status which addresses the necessary care and counseling services provided by the interdisciplinary team to achieve and sustain an effective nutritional status. A patient’s albumin level...should be measured at least monthly. Review of CMS (Centers of Medicare & Medicaid) MAT (Measures Assessment Tool) guidelines revealed the professionally-accepted nutritional standard for Albumin is >4.0. Per review of Pt #4’s monthly labs, on 11/16/2023 Pt #4’s Albumin was--3.0, on 12/21/2023--3.4, and on 01/25/2024--3.1. Review of Pt #4’s Comprehensive Plan of Care dated 12/27/2023 revealed that there was no documented evidence of the IDT developing an individualized plan of care to address Pt #4 not meeting the nutritional goal for Albumin. Per interview with Facility Administrator (FA) B on 02/15/2024 at 2:22 PM, FA stated that the facility goal for Albumins is to be at least >3.5. FA B confirmed that Pt #4’s Comprehensive Plan of Care did not include interventions to address Pt #4 not meeting goal for Albumin.”

“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: 29972 Based on record review, observation, and interview staff failed to assess the Arteriovenous Venous Fistula/Graft (AVF/G) after applying a clamp as per policy in 1 of 2 observations of treatment discontinuation using an AVF/G (Pt #9), in a total sample of 4 patients observed with an AVF/G. Findings Include: Review of policy and procedure #1-04-08A titled, “Utilizing Vascular Access Clamp Procedure” last reviewed April 2023 revealed the following: -“After placement of clamp, check for thrill (feel vibration indicating movement of blood) and bruit (sound of blood moving through access) above and below clamp. If thrill cannot be palpated or bruit heard, release clamp slightly and recheck until thrill can be palpated or bruit heard.” -“Clamp may remain in place for 5-10 minutes before checking to see if bleeding has stopped...if bleeding has not stopped, reapply clamp checking for thrill and bruit above and below the clamp.” On 02/13/2024 beginning at 10:04 AM, observed Patient Care Technician (PCT) E discontinuing Pt #9’s treatment using an AVF/G. PCT E applied a clamp to Pt #9’s AVF/G and did not check for bruit and thrill as per policy. At 11:02 AM observed PCT G (different PCT) check Pt #9 to see if bleeding stopped; PCT G then reapplied the clamp and did not check for bruit and thrill as per policy. During interview with Facility Administrator (FA) B and FA A on 02/14/2024 beginning at 11:30 AM, while discussing observations, FA B stated that staff should be checking for bruit and thrill after applying a clamp to the AVF/G as per policy.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to ensure the initial comprehensive plan of care is completed within 30 days of the first dialysis treatment in 2 of 2 medical records reviewed for new admissions less than 90 days (Patient (Pt) #1, 2), in a total sample of 5 medical records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last reviewed July 2023 revealed, “An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days beginning the first outpatient dialysis treatment...” Review of Pt #1’s medical record revealed Pt #1’s first dialysis treatment was on 12/05/2023; the initial Comprehensive Plan of Care was completed on 01/23/2024 (more than 30 days later). Review of Pt #2’s medical record revealed Pt #2’s first dialysis treatment was on 12/07/2023; the initial Comprehensive Plan of Care was completed on 01/23/2024 (more than 30 days later). During interview with Facility Administrator (FA) B and FA A on 02/15/2024 beginning at 2:22 PM, while discussing medical record findings, FA B confirmed the findings, and stated the initial Plan of Care should be done within 30 days from first treatment.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to ensure that the Comprehensive Interdisciplinary Plan of Care is completed within 15 days of the completion of the Comprehensive Interdisciplinary Patient Assessments in 2 of 5 medical records reviewed (Patient (Pt) #1, 2), in a total sample of 5 medical records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last reviewed July 2023 revealed, “...The IDT will meet within 15 days of completion of the re-assessment, finalize the Plan of Care and initiate the Plan.” Review of Pt #1’s medical record revealed the Comprehensive IDT Plan of Care was completed on 01/23/2024. Review of the IDT Comprehensive Assessments revealed the Social Worker completed Pt #1’s assessment on 12/27/2023 (27 days before the Plan of Care meeting) and the Dietician completed Pt #1’s assessment on 12/30/2023 (24 days before the Plan of Care meeting). Review of Pt #2’s medical record revealed the Comprehensive IDT Plan of Care was completed on 01/23/2024. Review of the IDT Comprehensive Assessments revealed the Social Worker completed Pt #1’s assessment on 1/02/2023 (21 days before the Plan of Care meeting). During interview with Facility Administrator (FA) B and FA A on 02/15/2024 beginning at 2:22 PM, while discussing medical record findings, FA B confirmed the findings, and stated the IDT team has 2 weeks (15 days) to complete the Plan of Care meeting after completing the IDT Comprehensive Patient Assessments.”