Fond Du Lac Dialysis Ctr

“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: 47413 Based on record review, observation and interview, the facility staff failed to wear gloves when touching the dialysis machine for 3 of 13 patients (Patients #10, 11, 12) in a total of 16 observations of patient care. Findings Include: A review of the facility’s policy titled, “Dialysis Unit Infection Specific Precautions” last reviewed 03/15/2024 revealed, “... Gloves are required whenever caring for patients or touching patients’ equipment...” During an observation on 08/26/2025 at 9:16 AM, Hemodialysis Technician F touched Patient #12’s dialysis machine without gloves. During an observation on 08/26/2025 at 10:13 AM, Registered Nurse B touched Patient #10’s dialysis machine without gloves. During an observation on 08/26/2025 at 10:40 AM, Registered Nurse C touched Patient #11’s dialysis machine without gloves. During an interview on 08/27/2025 at 11:21 AM, Dialysis Director A stated the policy is that staff need to wear gloves when touching the machine.”

“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 47413 Based on record review, observation and interview, the facility staff failed to complete disinfection of all equipment in the dialysis station for 2 of 2 dialysis stations (Stations #9, 17) observed being cleaned in a total of 16 observations of patient care. Findings Include: A review of the facility’s policy titled, “Cleaning and Disinfection Procedures for the Dialysis Machines and Equipment” last reviewed 02/05/2024 revealed, “... Disinfect machine... Disinfect chair/bed, TV, blood pressure cuff...” During an observation on 08/26/2025 at 9:40 AM, Patient Care Technician H was observed cleaning Station #9 and did not wipe down the hooks on the IV pole or the TV. During an observation on 08/26/2025 at 9:45 AM, Hemodialysis Technician D was observed cleaning Station #17 and did not wipe down the hooks on the IV pole. During an interview on 08/27/2025 at 11:20 AM, Dialysis Director A stated that the entire machine and surfaces should be disinfected.”

“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, facility staff failed to wear a mask during discontinuation of dialysis with a central venous catheter in 1 of 2 patients (Patient #11) in a total sample of 2 observations of care of patients with a CVC. Findings Include: A review of the facility’s policy titled, “Central Venous Access Device (CVAD), Chronic Hemodialysis Access” last reviewed 08/21/2025 revealed, “... Termination of Hemodialysis Treatment... Apply mask to patient and associates...” During an observation on 08/26/2025 at 10:40 AM Registered Nurse C was observed discontinuing dialysis on Patient #11 who had a CVC. Registered Nurse C was not wearing a mask. On 08/27/2025 at 11:13 AM, the observation findings were discussed with Dialysis Director A who stated that masks need to be worn with CVC care.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 29963 Based on observation and interview, staff failed to maintain a sanitary environment free from potential infection risk in 5 of 19 dialysis treatment stations (#7, 17, 1, 18, and the isolation room) in a total of 19 stations observed. Findings Include: Observation on 08/27/2024 at 4:27 PM revealed the following findings: Dialysis chair at station #7 and #17 had tears in the vinyl material exposing a porous surface making it difficult to disinfect. The walls at station #1, station #18, and the isolation room had scuffs in the drywall exposing a porous surface making it difficult to disinfect. During an interview on 08/27/2024 at 4:30 PM, Regulatory Specialist R stated the walls get bumped with equipment. Regulatory Specialist R stated it does make those areas hard to clean.”

“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: 29963 Based on record review and interview the staff failed to ensure all members of the interdisciplinary team complete a comprehensive assessment of the patients’ needs prior to the care plan meeting in 2 of 7 patient records reviewed (Patient #1, 5) in a total sample of 7 medical records reviewed. Findings Include: A review of policy titled, “Assessment and Care Planning of the Dialysis Patient” dated 05/05/2021 revealed, “Patients new to dialysis will have comprehensive assessments by the interdisciplinary team (IDT) along with the development of an individualized care plan. This requirement applies to all new dialysis patients, without regard to the modality of treatment. Patients returning to dialysis from a failed transplant or changing modalities are also considered new patients. 1) A comprehensive initial patient assessment will be completed within the first 30 days of first 13 treatments. 2) Comprehensive re-assessment will be done within 90 days of the completion of the initial assessment ...” A review of Patient #5’s medical record revealed Patient #5 returned to in-center hemodialysis on 05/27/2025 after developing an infection during peritoneal dialysis. A comprehensive initial patient assessment was completed on 06/10/2025. The comprehensive re-assessment dated 08/18/2025 was not completed by the nurse. A review of the comprehensive re-assessment revealed, “Care team members have met as a team to review the assessment and create/update the plans of care- dated 08/25/2025. A review of Patient #1’s medical record revealed Patient #1 starting in-center hemodialysis on 07/11/2025. A comprehensive initial patient assessment was dated 08/13/2025 the assessment was not completed by the nurse, physician, or the social worker. A review of the comprehensive interdisciplinary initial assessment revealed, “Patient is Unstable”. During an interview on 08/27/2025 at 8:30 AM, the medical record review findings were discussed with and confirmed by Lead Registered Nurse M who stated the comprehensive interdisciplinary assessment were not completed. During an interview on 08/27/2025 at 8:40 AM, Dialysis Director A stated it is the responsibility of the primary nurse and the social worker to complete the assessment.”

“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 47413 Based on record review and interview, the facility staff failed to ensure the administration of the pre-treatment Heparin bolus was at least 3 to 5 minutes prior to the initiation of dialysis, per facility policy, in 3 of 4 in-center hemodialysis patients (Patients #1, 3, 4) with current active orders for Heparin boluses and failed to ensure the prescribed dose of Heparin was given to 1 of 4 in-center hemodialysis patients (Patients #1) with Heparin infusion orders in a total universe of 7 medical records reviewed. Findings Include: A review of facility policy titled, “Initiation and Termination of Hemodialysis” last reviewed 04/08/2025 revealed, “... 12) Administer prescribed heparin bolus and wait 3-5 minutes prior to starting dialysis... 18) Set heparin pump to prescribed rate... “ Example of Heparin Bolus Not Administered Per Policy: A review of Patient #1’s current in-center hemodialysis order revealed an order for 500 units of Heparin bolus. A review of treatment sheet dated 08/23/2025 revealed Patient #1’s dialysis was started at 11:32 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 11:30 AM, 2 minutes before the initiation of dialysis. A review of Patient #3’s current in-center hemodialysis orders revealed an order for 2000 units of Heparin bolus. A review of treatment sheet dated 08/16/2025 revealed Patient #3’s dialysis was started at 6:49 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 6:49 AM, the same time as initiation of dialysis. A review of Patient #4’s current in-center hemodialysis orders revealed an order for 2000 units of Heparin bolus. A review of treatment sheet dated 08/13/2025 revealed Patient #4’s dialysis was started at 10:42 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 10:42 AM, the same time as initiation of dialysis. During an interview on 08/27/2025 at 8:30 AM, the medical record review findings were discussed with Dialysis Director A who stated, “The Heparin bolus should be given 3-5 minutes prior.” Example of Heparin Infusion Not Administered as Ordered: A review of Patient #1’s current in-center hemodialysis orders revealed an order for Heparin infusion of 500 units per hour for 210 minutes (3 hours and 30 minutes). The total infusion dosage ordered was 1.75 units. The treatment sheet dated 08/12/2025 revealed Patient #1’s treatment ran for 214 minutes (3 hours and 34 minutes). In the “Heparin” column on the Intradialytics flow sheet, 0.9 units of Heparin infusion was documented as administered, .85 units less than ordered. The treatment sheet dated 08/23/2025 revealed Patient #1’s treatment ran for 209 minutes (3 hours and 33 minutes). In the “Heparin” column on the Intradialytics flow sheet, 1.2 units of Heparin infusion was documented as administered, .55 units less than ordered. During an interview on 08/27/2025 at 9:11 AM, the medical record review findings were discussed with and confirmed by Lead Registered Nurse M who stated it looks like the pump was not set correctly, more heparin should have been given.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to ensure data is being collected, analyzed, and trended to identify potential problems with blood pressure monitoring for 2 of 2 dialysis programs (In-center and Home Dialysis) in the monthly quality meetings for a total of 2 dialysis services offered at this dialysis facility. Findings include: A review of the facility’s policy titled, “Quality Assessment and Performance Improvement,” effective date, 02/09/2024 revealed, “3) The Renal Service Team will provide oversight to the continuous monitoring, analyzing, and performance improvement of clinical and other processes that improve and identify outcomes... 5) The dialysis facility will monitor its performance; take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. b) Data is reviewed by the Medical Director.” A review of the facility’s Quality Assessment and Performance Improvement Program with Dialysis Director A, including data from May 2025 through July 2025 revealed the In-Center and Home Dialysis quality program dashboard does not include documentation related to data for blood pressure management for In-center or home dialysis patients. During an interview on 08/26/2024 at 3:25 PM, Dialysis Director A stated, the facility’s quality program does not have data regarding blood pressure management.”