Fmc Dialysis - Chequamegon Bay

“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: 43037 Based on observation, interview and record review the facility staff failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 3 of 3 patients (Patient #s 2, 6 & 11) observed holding access sites in a total sample of 14 observations of patient care. Findings include: A review of facility policy “Hand Hygiene” Version 8 published 11/6/2023 revealed, “...Patients should perform hand hygiene if able, prior to and after each dialysis treatment...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment to achieve hemostasis. To ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed...” During an observation on 11/5/2024 at 11:21 AM Patient #6 held access sites with a gloved hand, removed the glove when bleeding stopped and left the facility without performing hand hygiene. During an observation on 11/5/2024 at 11:28 AM Patient #2 held access sites with a gloved hand, removed the glove when bleeding stopped and left the facility without performing hand hygiene. During an observation on 11/6/2024 at 10:35 AM Patient #11 held access sites with a gloved hand, removed the glove when bleeding stopped and left the facility without performing hand hygiene. During an interview on 11/6/2024 at 2:09 PM, the observation findings were discussed with Clinical Manager A who stated that patients should complete hand hygiene after holding access sites.”

“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: 43037 Based on observation, record review and interview the facility staff failed to disinfect all surfaces in the dialysis station between patients to prevent possible cross contamination for 2 of 3 patients (Patient #s 8 & 15) in a total of 14 observations of patient care. Findings include: A review of facility policy “Cleaning and Disinfecting the Dialysis Station” Version 14 Published 9/5/2023 revealed, “...3. Use a cloth wetted with 1:100 bleach solution or EPA (Environmental Protection Agency)-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables machine, television, IV (intravenous) pole, B/P (blood pressure) cuff, hand sanitizer dispenser and holder, chaise wall behind chair). Place the chair in Trendelenberg (head down and feet up) position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. 4. Clean all surfaces...” During an observation on 11/5/2024 at 11:01 AM, PCT F was observed cleaning and disinfecting station #7 in preparation for the next dialysis patient (Patient #8). PCT F did not clean the back of the dialysis machine, the back of the chair or the entire left outside of the chair side panel. During an observation on 11/5/2024 at 11:50 AM, PCT F was observed cleaning and disinfecting station #10 in preparation for the next dialysis patient (Patient #15). PCT F did not clean the back of the dialysis machine, the blood pressure cuff basket, the back of the chair or the entire left outside of the chair side panel. During an interview on 11/5/2024 at 4:00 PM, observation findings were discussed with Clinical Manger A. When asked if PCT F should have cleaned and disinfected all surfaces of the machine and the chair, Clinical Manager A stated, “Yes.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 43037 Based on observation, record review and interview, the facility staff failed to ensure patient vascular accesses and faces remained visible during dialysis treatment for 2 of 2 patients (Patient #s 12 & 13) observed in a total sample of 12 patients observed. Findings include: A review of facility policy “Patient Assessment and Monitoring” Version 4 published 5/1/2023 revealed, “...All patients must be under visual observation by clinical staff during treatment...Ensure each patient’s face is visible and uncovered...Ensure access remains uncovered throughout the treatment...” During an observation on 11/6/2024 at 8:05 AM Patient #12’s body was completely covered over Patient #12’s head with a blanket, covering Patient #12’s access CVC (Central Venous Catheter) access site and face. During an observation on 11/6/2024 at 8:05 AM Patient #13’s body was completely covered up to Patient #13’s chin with a blanket, covering Patient #13’s AVF (arteriovenous fistula) access site. During an interview on 11/6/2024 at 2:09 PM, observation findings were discussed with Clinical Manager A who stated that staff should uncover access sites and faces during treatment even if they need to do it several times per treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 43037 Based on record review and interview, the facility staff failed to ensure the administration of the pre-treatment Heparin (anticoagulant medication) bolus was at least 3 to 5 minutes prior to the initiation of dialysis per facility policy in 1 of 2 in-center hemodialysis patients (Patient #4) with current active orders for Heparin boluses in a total sample of 5 medical records reviewed. Findings include: A review of facility policy “Heparinization” Version 4 published 8/3/2020 revealed, “...Heparin must be given at least 3-5 minutes prior to dialysis...” A review of Patient #4’s medical record revealed a physician order for Heparin bolus of 3,200 units IVP (intravenous push) every treatment. Treatment sheet dated 6/3/2024 revealed dialysis treatment started at 10:46 AM and heparin bolus given at 10:48 AM (2 minutes after initiation of treatment). During an interview on 11/6/2024 at 2:09 PM, record review findings were discussed with Clinical Manager A who stated that heparin was to be given 3 to 5 minutes prior to initiation of treatment.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must 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 must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 43037 Based on record review and interview the facility staff failed to ensure patients had updated goals in their plans of care in 4 of 5 (Patient #s 2, 3, 4 & 5) medical records in a total sample of 5 medical records reviewed. Findings include: A review of facility policy “Comprehensive Interdisciplinary Assessment and Plan of Care” Version 6 published 7/3/2023 revealed, “...The Plan of Care must include measurable and expected outcomes and an estimated timetable to achieve these outcomes...” A review of Patient #2’s medical record revealed the Plan of Care open Areas of Focus with expired due dates: Area of Focus: Goal Due date: Hospitalization within last 90 days 12/1/2023 Fall Risk 11/29/2023 Vaccination/Immunization Status 12/2/2023 Pain Assessment 12/29/2023 Modality Education 12/1/2023 BP and Fluid Management 1/12/2024 Anemia Management 1/5/2024 Body Weight 6/30/2024 A review of Patient #3’s medical record revealed the Plan of Care open Areas of Focus with expired due dates: Area of Focus: Goal Due date: Dialysis Access (HD) 3/14/2024 Dialysis Adequacy (IHD) 3/14/2024 BP and Fluid Management 3/14/2024 Anemia Management 3/14/2024 Hospitalization within last 90 days 2/9/2024 Pain Assessment 2/9/2024 Fall Risk 2/9/2024 Vaccination/Immunization Status 2/9/2024 Modality Education 2/9/2024 Diabetes Management 9/30/2024 Coping Adjusting to Dialysis Issues 2/29/2024 Ability to Independently Function 2/29/2024 Mineral Metabolism/Bone Disease 9/30/2024 Body Weight 9/30/2024 Albumin Management 9/30/2024 A review of Patient #4’s medical record revealed the Plan of Care open Areas of Focus with expired due dates: Area of Focus: Goal Due date: Dialysis Access(HD) 3/18/2024 Anemia Management 3/18/2024 Dialysis Adequacy (IHD) 3/18/2024 Hospitalization within last 90 days 3/18/2024 Pain Assessment 3/18/2024 Fall Risk 3/18/2024 Vaccination/Immunization Status 3/18/2024 Modality Education 3/18/2024 BP and Fluid Management 3/18/2024 Diabetes Management 9/30/2024 Ability to Independently Function 5/31/2024 Treatment Adherence 5/31/2024 Emotional/Mental Health 5/31/2024 Advance Directives/End of Life Issue 5/31/2024 Coping/Adjusting to Dialysis Issues 5/31/2024 Transplantation Status 5/31/2024 Body Weight 9/30/2024 Mineral Metabolism/Bone Disease 9/30/2024 Albumin Management 9/30/2024 A review of Patient #5’s medical record revealed the Plan of Care open Areas of Focus with expired due dates: Area of Focus: Goal Due date: Dialysis Access (PD) 9/30/2024 Modality Education 9/30/2024 Hospitalization within last 90 days 9/30/2024 Fall Risk 9/30/2024 Dialysis Adequacy (IHD) 3/14/2024 Anemia Management 9/30/2024 During an interview on 11/6/2024 at 2:09 PM with Clinical Manager A, Manager A stated that goal dates should be updated.”