Fmc Dialysis - Waupaca

“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: 29963 Based on record review, observation and interview, the facility staff failed to perform hand hygiene when moving from “dirty” to “clean” tasks while providing cares for 1 of 8 patients (Patient #1); staff failed to perform hand hygiene when preparing medication for 1 of 1 patient (Patient #9), and facility staff failed to wear gloves when touching the dialysis machine for 3 of 7 patients (Patients #6, 7, 9) observed out of a total of 15 observations of patient care. Findings include: A review of the facility’s policy #47664 titled, “Hand Hygiene,” Version 8 published 11/06/2023 revealed, “ ...Responsibility: All staff, patients, patient caregivers, including physicians and non physician practitioners, social workers, dietitians and any other indirect patient care staff must follow the same requirement for hand hygiene... Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water. When ... Before and after direct contact with patients... Before performing an invasive procedures such as vascular access cannulation or administration of parenteral medications... Immediately after removing gloves...” A review of the facility’s policy #47488 titled, “Medication Preparation and Administration,” Version 7 published 11/1/2021 revealed, “ ...The following steps must be taken to ensure infection control. Perform hand hygiene prior to accessing supplies, handling vials, and IV solutions and preparing or administering medications.” A review of the facility’s policy #45650 titled, “Initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer” published 05/06/2024 revealed, “... Gloves should be worn at all times while touching the machine or any documenting components of the machine...” During an observation on 02/25/2025 at 10:40 AM, Patient Care Technician E was discontinuing dialysis on Patient #1’s Central Venous Catheter (CVC). Patient Care Technician E unhooked the blood lines from the CVC, took off gloves, walked over to the supply cart and grabbed gauze and placed the gauze on the table attached to the dialysis chair. Patient Care Technician E then put on new gloves without completing hand hygiene. During an observation on 02/25/2025 at 11:35 AM, Registered Nurse C was drawing up Intravenous (IV) Venofer for Patient #9 into a sterile syringe. No hand hygiene was performed prior to putting on gloves to draw up the IV Venofer. During an observation on 02/25/2025 at 11:18 AM, Patient Care Technician D touched Patient #7’s dialysis machine without wearing gloves. During an observation on 02/25/2025 at 11:22 AM, Registered Nurse C touched Patient #9’s dialysis machine without wearing gloves. During an observation on 02/25/2025 at 1:38 PM, Patient Care Technician E touched Patient #6’s dialysis machine without wearing gloves. During an interview on 02/26/2025 at 10:45 AM, the observation findings were discussed with Director of Operations A and Clinic Manager B. Director of Operations A stated staff should be completing hand hygiene when removing gloves, before administering medications and facility staff should not be touching the dialysis machines without gloves. 47413”

“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: 29963 Based on record review, observation and interview, the facility staff failed to ensure that patients vacated the dialysis station prior to disinfection of the dialysis station in 1 of 2 patients (Patient #5) observed in a total of 15 observations of patient care. Findings include: A review of the facility policy titled, “Cleaning and Disinfection of the Dialysis Station,” Version 14, published 09/05/2023 revealed, “ ...Vacating the Machine ...To prevent cross-contamination between patients, it is important that the previous patient completely vacate the station before staff begin cleaning and disinfection of the station and set up for the next patient. For patients dialyzing in a treatment area where multiple patients dialyze, the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next treatment.” During an observation on 02/25/2025 at 9:35 AM, Patient Care Technician E was cleaning and disinfecting the dialysis machine while Patient #5 was sitting in the dialysis chair holding access site after needles were removed. During an interview on 02/25/2025 at 10:45 AM, the observation findings were discussed with Director of Operations A who stated patients should vacate the dialysis chair before the staff begin to clean the dialysis machine.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47413 Based on record review, observation and interview, facility staff failed to ensure aseptic technique was followed prior to Intravenous (IV) medication administration for 1 of 1 patients (Patient #9) in a total of 15 observations of care. Findings Include: A review of the facility’s policy #47488 titled, “Medication Preparation and Administration” published 02/06/2023 revealed, “... Use of Saline needle injection port for Administering Medication: ... 2. Wipe the injection port with an alcohol wipe...” During an observation on 02/25/2025 at 11:38 AM, Registered Nurse C administered IV Venofer into Patient #9’s injection port and did not clean the injection port with an alcohol wipe. On 02/26/2025 at 10:55 AM, the observation findings were discussed with Director of Operations A who stated that the injection port should be cleaned with an alcohol wipe prior to medication administration.”

“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: 47413 Based on record review, observation and interview, the facility staff failed to perform central venous catheter exit site care using aseptic technique for 1 of 2 patients (Patient #4) in a total sample of 2 observations of care of patients with a CVC. Findings Include: A review of the facility’s policy #47516 titled, “Central Venous Catheter (CVC) Dressing Change” last published 05/06/2024 revealed, “... Cleaning the Catheter Site: ... Note: Do not contaminate the antiseptic product...” During an observation on 02/25/2025 at 11:08 AM, Patient Care Technician D was observed performing CVC exit site care for Patient #4. Patient #4 was observed to be wearing a collared shirt. Patient Care Technician D was observed moving the collar of the shirt away from Patient #4’s exit site but did not secure the shirt away from the site. Upon completion of exit site cleansing, Patient #4’s shirt was observed to be touching the right side of the exit site. The shirt continued to touch the exposed site while Patient Care Technician D performed other tasks until 11:10 AM when Patient Care Technician D moved the shirt away with a gloved hand and placed a new dressing over the exit site without repeat cleansing. On 02/26/2025 at 10:46 AM the observation findings were discussed with Director of Operations A who stated that patient clothing cannot touch the exit site once it is cleaned.”

“PR-INFORMED OF EXTERNAL GRIEVANCE PROCESSES CFR(s): 494.70(a)(15) The patient has the right to- (15) Be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State survey agency; This Standard is not met as evidenced by: 29963 Based on observation, record review and interview, facility staff failed to provide State Agency contact information available for patients in 1 of 1 patient waiting areas in a total of 1 patient waiting area observed. Findings include: A review of the facility’s policy titled, “Patient Rights and Responsibilities” Version 2 published 04/04/2012 revealed, “... Dialysis facilities must prominently display a copy of the patient’s rights in a visible and accessible area in the facility and must include contact information for the State survey agency and ESRD (End Stage Renal Disease) Network.” During an observation of the facility’s waiting room on 02/25/2025 at 5:00 PM, there was no State Agency/DQA (Department of Quality Assurance) contact information posted for patients. During an interview on 02/26/2025 at 8:00 AM, Clinic Manager B confirmed that there was no State Agency/DQA contact information posted for patients.”

“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: 29963 Based on record review and interview, the facility staff failed to ensure the prescribed dose of Heparin was given to 2 of 3 in-center hemodialysis patients (Patients #1, 2) with Heparin infusion orders in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy #46759 titled, “Use of Heparin Pump for Continuous Heparin Infusion,” Version 2 published 11/01/2021 revealed, “ ...4. Verify the heparin pump is on and heparin is being infused. Document amount of heparin in the pump at the beginning of the treatment and the amount remaining or infused at each safety check until the heparin pump is turned off. This ensures that the pump is functioning properly and that the prescribed amount of heparin is being delivered to the patient ...” A review of Patient #1’s current in-center hemodialysis orders revealed an order for Heparin infusion of 500 units per hour for 195 minutes (3 hours and 15 minutes). The total infusion dosage ordered was 1700 units. The treatment sheet dated 02/20/2025 revealed Patient #1’s treatment ran for 202 minutes (3 hours and 22 minutes). In the section titled, “Anticoagulation ...Infusion Heparin,” 1400 units of Heparin infusion was documented as administered, 300 units less than ordered. The treatment sheet dated 02/22/2025 revealed Patient #1’s treatment ran for 209 minutes (3 hours and 29 minutes). In the section titled, “Anticoagulation ...Infusion Heparin,” 2000 units of Heparin infusion was documented as administered, 300 units greater than ordered. The treatment sheet date 02/25/2025 revealed Patient #1’s treatment ran for 206 minutes (3 hours and 26 minutes). In the section titled, “Anticoagulation ...Infusion Heparin,” 1600 units of Heparin infusion was documented as administered, 100 units less than ordered. A review of Patient #2’s current in-center hemodialysis orders revealed an order for Heparin infusion of 500 units per hour for 180 minutes (3 hours). The total infusion dosage ordered was 1500 units. The treatment sheet dated 02/22/2025 revealed Patient #2’s treatment ran for 173 minutes (2 hours and 53 minutes). In the section titled, “Anticoagulation ...Infusion Heparin,” 3700 units of Heparin infusion was documented as administered, 2200 units greater than ordered. During an interview on 02/25/2025 at 10:22 AM, the medical record review findings were discussed with and confirmed by Director of Operations A who stated the total heparin given should be what is ordered; if it is given wrong it should be caught.”

“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: 29963 47413 Based on record review and interview, the facility staff failed to ensure that nursing documentation addressed notifying the nephrologist about patients leaving below their Estimated Dry Weight (EDW) in 2 of 5 patients (Patients #1,4) in a total universe of 5 in-center medical records reviewed. Findings Include: A review of the facility’s policy #45625 titled, “Nursing Supervision and Delegation” Version 6 published 11/06/2023 revealed, “... Fluid Status ...Any post treatment weight with a variance from the estimated dry weight of 0.5 kg (kilograms). Any weight loss or no change in weight from a patient’s last treatment post weight...” A review of Patient #1’s current in-center hemodialysis orders revealed an EDW of 73.1 kilograms (kgs) and “do NOT bring patient below EDW”. The treatment sheet dated 02/20/2025 revealed Patient #1’s post dialysis weight was documented as 71.3 kgs, 1.8 kgs under the EDW. There was no documented contact of the physician to report the patient leaving below the target weight. The treatment sheet dated 02/22/2025 revealed Patient #1’s post dialysis weight was documented as 72 kgs, 1.1 kgs under the EDW. There was no documented contact of the physician to report the patient leaving below the target weight. The treatment sheet dated 02/25/2025 revealed Patient #1’s post dialysis weight was documented as 71.3 kgs, 1.8 kgs under the EDW. There was no documented contact of the physician to report the patient leaving below the target weight. A review of Patient #4’s current in-center hemodialysis orders revealed an EDW of 150.6 kgs and “do NOT bring patient below EDW.” The treatment sheet dated 02/20/2025 revealed Patient #4’s post dialysis weight was documented as 148.4 kgs, 2.10 kgs under the EDW. There was no documented contact of the physician to report the patient leaving below the target weight. On 02/26/2025 at 9:59 AM, the medical record review findings were discussed with and confirmed by Director of Operations A who stated “This should have been passed onto the rounding provider.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to complete documentation of why physician orders were not followed for prescribed blood flow rates for 4 of 5 in-center medical records reviewed (Patients #1, 2, 3, 4) in a total universe of 5 medical records reviewed. Findings Include: A review of the facility’s policy #47334 titled, “Unable to Achieve Prescribed Blood Flow Rate” published 11/01/2021 revealed, “... Notify physician/extender if unable to achieve prescribed blood flow rate...” A review of Patient #1’s medical record revealed a physician order for the blood flow rate (BFR) of 400 mL/min (milliliters per minute). The treatment sheets dated 02/10/2025, 02/18/2025 and 02/20/2025 revealed the BFR was set at 350 mL/min for the entire treatments. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheet dated 02/25/2025 revealed the BFR was set at 300 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. A review of Patient #2’s medical record revealed a physician order for the BFR of 400 mL/min. The treatment sheet dated 02/11/2025 revealed the BFR was set at 325 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheets dated 02/13/2025, 02/15/2025, 02/20/2025, 02/22/2025 revealed the BFR was set at 350 mL/min for the entire treatments. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheet dated 02/18/2025 revealed the BFR was set at 300 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. A review of Patient #3’s medical record revealed a physician order for the BFR of 400 mL/min. The treatment sheet dated 02/15/2025 revealed the BFR was set at 350 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheets dated 02/18/2025 and 02/25/2025 revealed the BFR was set at 300 mL/min for the entire treatments. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheet dated 02/22/2025 revealed the BFR was set at 275 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. A review of Patient #4’s medical record revealed a physician order for the BFR of 400 mL/min. The treatment sheet dated 02/18/2025 revealed the BFR was set at 300 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. The treatment sheet dated 02/20/2025 revealed the BFR was set at 350 mL/min for the entire treatment. There was no documentation in the medical record for the reason why the BFR was lower than the ordered rate or that the physician/extender was notified. During an interview on 02/26/2025 at 10:22 AM, the medical record findings were discussed with and confirmed by Director of Operations A who stated facility staff were expected to document a reason for not meeting prescribed blood flow rates and the physician needs to be notified.”

“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: 29963 Based on record review, observation and interview, the facility staff failed to change the gauze dressing used to hold access sites once bleeding had stopped for 1 of 2 patients (Patient #5) observed for discontinuation of dialysis with an AV Fistula/Graft and facility staff failed to perform skin antisepsis prior to cannulation per policy for 2 of 2 patients (Patients #6, 7) observed for initiation of dialysis with an AV Fistula/Graft in a total of 15 observations of patient care. Findings include: A review of the facility’s policy #47619 titled, “Post Treatment Fistula Needle Removal” Version 3 published 07/01/2024 revealed, “...8. Once hemostasis is achieved: Remove the gauze... Place Band-Aid, adhesive dressing or gauze dressing secured with clean tape ...” A review of the facility’s policy #45178 titled, “Access Assessment and Cannulation” published 05/06/2024 revealed, “... Skin Disinfection: ... Perform skin antisepsis on one site at a time, allow to dry and them [sic] cannulate. Do not touch cannulation sites after skin disinfection...” During an observation on 02/25/2025 at 9:50 AM, Patient Care Technician E was observed discontinuing dialysis on Patient #5’s fistula/graft. Patient Care Technician E and Registered Nurse C taped over the existing gauze dressing. The original gauze dressing was not removed to assess the site and the dressing was not changed prior to Patient #5’s discharge. During an observation on 02/25/2025 at 10:06 AM, Patient Care Technician E was observed cleansing Patient #6’s cannulation sites on his fistula/graft. Patient Care Technician E touched the cannulation sites after they were cleansed and dry and cannulated Patient #6’s fistula/graft without re-cleaning the cannulation sites. During an observation on 02/25/2025 at 10:34 AM, Patient Care Technician D was observed cleansing Patient #7’s cannulation sites on his fistula/graft. Patient Care Technician D touched the cannulation sites after they were cleansed and dry and cannulated Patient #7’s fistula/graft without re-cleaning the cannulation sites. During an interview on 02/26/2025 at 10:45 AM, the observation findings were discussed with Director Of Operations A who stated the staff should be replacing the dressing prior to the patient leaving and the cannulation sites should not be touched once they are disinfected. 47413”