Fresenius Medical Care Midwest 27th Street Branch

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 27438 Based on observations, interviews, and policy review, the facility failed to ensure staff remove personal protective equipment (PPE-used to prevent potential exposure) when leaving the dialysis treatment floor for two of three survey days. Failure to ensure removal of disposable gowns when leaving the treatment floor provided a mode of cross contamination with the potential spread of infection which could negatively impact patients or visitors waiting in the lobby area in this facility. Findings include: 1. Observations of the hemodialysis treatment area on 12/02/24 at 9:30 AM, revealed Patient Care Technician (PCT)3 exited the dialysis treatment door, which leads to the patient waiting area while wearing his/her PPE gown. Observation of the closed interior lobby treatment door revealed two signs stating, “Absolutely no PPE beyond this point,” and “Stop!! No PPE beyond this point.” 2. Observations of the hemodialysis treatment area lobby door on 12/03/24 between 9:20 AM and 9:38 AM, revealed the following four staff members PCT1, Registered Nurse (RN)1, RN2, and PCT2, fail to remove PPE gowns prior to exiting treatment door and entering the lobby area. During an interview on 12/03/24 at 3:00 PM, the Charge Nurse verified PPE gowns had to be removed prior to leaving the treatment area for any reason. During an interview on 12/04/24 at 10:30 AM, Facility Administrator verified staff training included removal of PPE gowns when leaving the dialysis treatment. Review of the facility’s policy titled, “Personal Protective Equipment,” revision date 11/06/23, indicated, “PPE is used to protect employees who are occupationally exposed to blood or other potentially infectious materials ...All personal protective equipment shall be removed prior to leaving the treatment area.””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 27438 Based on observation, interviews, and review of the Occupational Safety and Health Administration (OSHA), the facility failed to maintain the clearance and working space around the electrical panel/equipment. This failure could create delay during electrical emergency. This failure had the potential to negatively affect all 86 in-center hemodialysis patients. Findings include: Observation on 12/03/24 at 10:00 AM of the storage area revealed an electrical panel described as “A1 High Voltage Box” with a floor taped caution area in front of the panel. Within the marked area was a tri-folded metal/cloth privacy screen leaning against the electrical panel door, a four wheeled cart with a missing tabletop, and a stepping stool. Located on the electrical panel was a laminated sign that read, “There must be three feet of clearance in front of all electrical panels at all times” and “Danger High Voltage.” During an interview on 12/03/24 at 10:45 AM, the Biomedical Technician 2 verified equipment should not be within the taped caution area at any time. During an interview on 12/03/24 at 2:30 PM, the Facility Administrator verified no equipment should be stored within the caution area of the electrical panel. Review of the Occupational Safety and Health Administration (OSHA), standard 1910.303 requirement titled, “Accessibility,” indicated, “OSHA requires sufficient access and working spaces around all electrical equipment, or panels ...””

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 27438 Based on interview, facility document review, and review of the facility’s policy, the facility failed to ensure all members of the Interdisciplinary Team (IDT) met and held collaborative (real time discussion) Comprehensive Care Plan team meetings. The failure of all members of the IDT to not attend the regular IDT discussion meetings could result in missed opportunities for improved patient outcomes. The deficient practice has the potential to affect all 86 in-center hemodialysis patients. Findings include: During an interview on 12/02/24 at 10:15 AM, the Facility Administrator was asked if the treating physicians attend meetings and it was revealed the IDT routinely meet without the treating physician in person or remotely. The Facility Administrator verified, “If the IDT have a question for a Dr they can leave a message for the Dr to call.” During an interview on 12/03/24 at 10:45 AM, the Charge Nurse (IDT member) verified that he/she was the lead at the IDT meetings, was required to “get the patient list together, set the date of the IDT meeting, and the SW, RD, and a physician who may be available by phone.” The Charge Nurse was asked to specify an IDT meeting date the Medical Director, who cares for 79 of the 86 incenter patients, attended the actual IDT meeting by phone or in person, the Charge Nurse Stated, “I can’t recall when the Medical Director attended the actual meeting in person or by phone.” The Charge Nurse revealed the Medical Director would meet patients during their dialysis treatment at a later date to go over the Assessment. During an interview on 12/03/24 at 2:15 PM, the RD verified the IDT meet in the shared office without a physician, “It’s hard for us to all sit down to meet together, the Dr (Medical Director) is so busy.” The RD verified he/she will routinely accompany the Medical Director on the treatment floor to discuss any updated IDT assessments with the patients. The Social Worker declined to verbally verify that Medical Director did or did not attend the IDP meetings monthly in person or by phone. During an interview on 12/03/24 at 2:45 PM, the SW verified he/she attended the IDT meetings routinely. When questioned if the Medical Director or other physicians attended in person or by phone, the SW stated, “It would be nice if they did.” The SW verified no physicians routinely join the IDT, meeting in person or by phone, with the Charge Nurse, SW, and the RD. During a phone interview on 12/04/24 at 1:40 PM, the Medical Director verified he/she does the assessment on each patient due for the IDT meeting during each month, however, is not able to attend the IDT meetings in person or by phone, however, is available by phone if needed during the meeting. Review of the facility’s Medical Staff Bylaws titled, “Guidance Regarding the Conditions for Coverage,” revision date August 25, 2011, indicated, “. . .6.1 Interdisciplinary Team. The comprehensive interdisciplinary patient assessment (as opposed to the initial assessment) and plan of care are documents which must be developed and implemented by an interdisciplinary team consisting of, at a minimum, the patient or patient’s designee (if patient desires), a registered nurse, Attending Physician, social Worker, and registered dietitian. The Attending Physician shall serve as the leader of the interdisciplinary team ...7.1 Comprehensive Interdisciplinary Patient Assessment. The Attending Physician shall participate on, and serve as the leader of, the interdisciplinary team(s) for each of the Attending Physician’s patients ...” Review of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” revision date 07/03/23, indicated, “The Comprehensive Assessment and Plan of Care (adult patient) must be completed electronically in the patient’s medical record. The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting...””

“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: 27438 Based on record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for six of seven in-center patients (Patient (P)1, P2, P3, P5, P6, and P7). Failure to follow the medical providers dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for all 86 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1’s “Treatment Sheet” forms, found in the electronic medical record (EMR), revealed three of six printed “Treatment Sheet” forms from 11/22/24 through 11/29/24, indicated the following: On 11/25/24, the staff failed to follow the dialysis prescription Blood Flow Rate (BFR) of 400 milliliters per minute (ml/min) when during the four-hour treatment the BFR remained at 450 ml/min. The staff failed to follow the dialysis prescription Dialysis Flow Rate (DFR) of 600 ml/min when during the four-hour treatment the DFR remained at 700 ml/min. On 11/27/24, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour treatment the BFR remained at 475 ml/min. The staff failed to follow the dialysis prescription DFR of 600 ml/min when during the four-hour treatment the DFR remained between 700 and 800 ml/min. On 11/27/24, the staff failed to follow the dialysis prescription DFR of 600 ml/min when during the four-hour treatment the DFR remained between at 800 ml/min. There was no documented rationale for the change to the prescribed BFR. 2. Review of P2’s “Treatment Sheet” forms, found in the EMR, revealed one of six printed “Treatment Sheet” forms from 11/25/24 through 12/02/24, indicated the following: On 11/29/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour treatment the DFR remained at 800 ml/min. There was no documented rationale for the change to the prescribed BFR or DFR. 3. Review of P3’s “Treatment Sheet” forms, found in the EMR, revealed two of six printed “Treatment Sheet” forms from 11/22/24 through 12/02/24, indicated the following: On 11/22/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour and 15-minute treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour treatment the DFR remained at 700 ml/min. On 11/27/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour and 15-minute treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 600 ml/min. On 12/02/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour and 15-minute treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 600 ml/min. There was no documented rationale for the change to the prescribed BFR or DFR. 5. Review of P5’s “Treatment Sheet” forms, found in the EMR, revealed three of six printed “Treatment Sheet” forms from 11/19/24 through 11/26/24, indicated the following: On 11/19/24, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour and 15-minute treatment the BFR remained at 450 ml/min. The staff failed to follow the dialysis prescription DFR of 600 ml/min when during the four-hour treatment the DFR remained at 800 ml/min. On 11/23/24, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour and 15-minute treatment the BFR remained at 450 ml/min. The staff failed to follow the dialysis prescription DFR of 600 ml/min when during the four-hour and 15-minute treatment the DFR remained at 800 ml/min. On 11/26/24, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour and 15-minute treatment the BFR remained at 450 ml/min. The staff failed to follow the dialysis prescription DFR of 605 ml/min when during the four-hour and 15-minute treatment the DFR remained at 700 ml/min. There was no documented rationale for the change to the prescribed BFR or DFR. 6. Review of P6’s “Treatment Sheet” forms, found in the EMR, revealed four of six printed “Treatment Sheet” forms from 11/20/24 through 11/29/24, indicated the following: On 11/20/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour treatment the DFR remained at 600 ml/min. On 11/22/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 600 ml/min. On 11/25/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 600 ml/min. On 11/27/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 800 ml/min. On 11/29/24, the staff failed to follow the dialysis prescription BFR of 450 ml/min when during the four-hour and 15-minute treatment the BFR remained at 400 ml/min. The staff failed to follow the dialysis prescription DFR of 675 ml/min when during the four-hour and 15-minute treatment the DFR remained at 800 ml/min. There was no documented rationale for the change to the prescribed BFR or DFR. 6. Review of P7’s “Treatment Sheet” forms, found in the EMR, revealed one of six printed “Treatment Sheet” forms from 11/19/24 through 11/30/24, indicated the following: On 11/30/24, the staff failed to follow the dialysis prescription DFR of 675 ml/min when during the three-hour and 30-minute treatment the DFR remained at 800 ml/min. During an interview on 12/03/24 at 2:30 PM, the Charge Nurse reviewed and verified the discrepancy between the prescription and machine generated “Treatment Sheet” forms for P1, P2, P3, P5, P6, and P7 forms and revealed that he/she expects staff to monitor and document the DFR and BFR findings every 30 minutes and all treatment prescriptions for patients to be followed or have documentation on why the prescription was not followed. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” revised 05/01/2023, indicated, “During Treatment...Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations ...Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.””