Beaver Dam Dialysis

“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 prior to preparing medications for 1 of 2 patients (Patient #15) in a total of 18 observations of patient care. Findings include: A review of the facility’s policy titled, “Hand Hygiene,” last revised 07/24/2024 revealed, “A. SSM Health follows the Centers for Disease Control and Prevention (CDC) and the World Health Organization’s (WHO) ‘5 Moments for Hand Hygiene’ ... 2. Before a clean/aseptic procedure (Moment 2) ... G. Glove Use ... 2. Perform hand hygiene before putting on gloves and upon removal of gloves.” During an observation on 01/22/2025 at 8:10 AM, Registered Nurse N was preparing medications for Patient #15. Registered Nurse N did not do hand hygiene prior to preparing the medications. During an interview on 01/22/2025 at 11:18 AM, the observation findings were discussed with Nurse Manager A who stated the expectation is that staff perform hand hygiene all the time.”

“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: 47413 Based on observation, record review and interview, the facility staff failed to complete disinfection of all equipment in the dialysis station for 1 of 2 dialysis stations (Station #10) observed being cleaned in a total of 18 observations. Findings Include: A review of the facility’s policy titled, “Cleaning and Disinfection Procedures for the Dialysis Machines and Equipment” last revised 06/04/2021 revealed, “... Disinfect machine with fresh cleaning cloth saturated with bleach solution... and apply to all surfaces of the dialysis machine ensuring that surfaces are visibly wet... Disinfect all surfaces of the emptied priming bucket...” During an observation on 01/21/2025 at 9:55 AM, Registered Nurse C was observed cleaning Station #10 and did not wipe down the IV pole, hooks, or priming bucket. On 01/22/2025 at 12:04 PM, the observation findings were discussed with Nurse Manager A who stated all surfaces of the dialysis machine need to be cleaned.”

“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 3 patients (Patient #9) and facility staff failed to ensure patients wore a mask during central venous catheter exit site care in 1 of 3 patients (Patient #10) in a total sample of 3 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 revised 01/20/2020 revealed, “... 12) Staff and patients will always wear masks during... catheter dressing changes... Dressing Changes: 7) Cleanse the section of the catheter that lies adjacent to the skin... starting at the exit site and working outwards... 11) Apply the sterile gauze to the exit site...” During an observation on 01/21/2025 at 9:20 AM Hemodialysis Technician G was observed performing CVC exit site care for Patient #9. Patient #9 was not wearing a mask during exit site care. During an observation on 01/21/2025 at 9:40 AM, Registered Nurse E was observed performing CVC exit site care for Patient #10. Patient #10 was observed to be wearing a sweatshirt. Registered Nurse E was observed moving the collar of the sweatshirt away from Patient #10’s exit site but did not secure the shirt away from the site. Upon completion of exit site cleansing, Patient #10’s shirt was observed to be touching the right side of the exit site. The shirt continued to touch the exposed site while Registered Nurse E performed other tasks until 9:41 AM when Registered Nurse E moved the shirt away with gloved hand and placed a new dressing over the exit site without repeat cleansing. On 01/22/2025 at 10:04 AM, the observation findings were discussed with Nurse Manager A who stated that patients need to mask during CVC exit site care and that patient clothing cannot touch the exit site once it is cleaned.”

“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: 47413 Based on observation, record review, and interview the facility staff failed to ensure that 1 of 3 staff members (Hemodialysis Technician G) executed chlorine testing according to facility policy and manufacturer directions for use in a total universe of 3 observations of chlorine testing. Findings include: A review of the facility’s policy titled, “Water System” last revised 02/08/2022 revealed, “... D) Chlorine/Chloramine Testing... a) Open Sample port to a slow running stream to flush out. Flush for one minute. b) Collect at least 20 ml of sample test water in a 100 ml container(cup)... c) Dip the test strip into the test water, and move the strip back-and-forth moderately... for 30 seconds...” A review of the chlorine test bottle titled, “Serim Guardian HiSense Ultra 0.1 Test for Total Chlorine (chloramines/free chlorine) in feed or rinse water” revealed the following manufacturer directions for use: “... Semi-Quantitative Procedure: 1. Fill a clean container with sample. Discard contents and refill... 2. Immerse indicator pad in solution and move strip back and forth vigorously for 30 seconds...” During an observation of routine chlorine testing on 01/21/2025 at 12:05 PM, Hemodialysis Technician G was responsible for testing the hemodialysis water for total chlorine. Hemodialysis Technician G opened the sample port and flushed the water for only 30 seconds. Hemodialysis Technician G put the chlorine strip directly under the stream of water, held it there for 15 seconds, and compared the result to the test bottle. Hemodialysis Technician G did not fill a 100 ml container and did not dip the test strip into the test water and did not move the strip back-and-forth in the test water. During an interview on 01/21/2025 at 3:30 PM, the observation findings were discussed with Nurse Manager A who stated that staff need to follow the quantitative test method for chlorine checks, which requires a container to be filled with test water and that staff need to move the strip back and forth in the test water.”

“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: 47413 Based on observation, record review and interview, facility staff failed to have 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 and Grievance Procedure” last revised 04/27/2021 revealed, “... All patients are informed of their rights... The Patient Rights/Responsibilities are posted in conspicuous locations in the dialysis units... 5) If an ESRD patient feels that a grievance has not been adequately addressed at the facility level, or chooses not to use the facility grievance process, the patient may file a grievance with... the Division of Quality Assurance (DQA)...” During an observation of the facility’s waiting room on 01/21/2025 at 8:05 AM, there was no State Agency/DQA contact information posted for patients. During an interview on 01/22/2025 at 12:24 PM, Nurse Manager A confirmed that there was no State Agency/DQA contact information posted for patients.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 29963 Based on record review and interview the facility staff failed to ensure monthly documentation was completed by the Registered Dietician, per policy, in 4 of 5 (Patients #1, 3, 4, 5) in-center medical records reviewed in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy titled, “Nutrition Care- Dialysis” last revised 08/26/2020 revealed, “... Documentation of the nutritional assessment will be done in the EHR. B) Individual Assessment- Ongoing- 1) Monthly Review of: a) All lab values; b) Medical records; c) Dry weight and interdialytic weight gains...” A review of Patient #1’s current in-center hemodialysis medical record revealed the Registered Dietitian did not complete the monthly note for October 2024 or November 2024. A review of Patient #3’s current in-center hemodialysis medical record revealed the Registered Dietician did not complete the monthly note for December 2024. A review of Patient #4’s current in-center hemodialysis medical record revealed the Registered Dietician did not complete the monthly note for November 2024. A review of Patient #5’s current in-center Hemodialysis medical record revealed the Registered Dietician did not complete the monthly note for November 2024. During an interview on 01/22/2025 at 11:36 AM, the medical record review findings were discussed with and confirmed by Nurse Manager A who stated the dietitian is expected to document a monthly note. 47413”

“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 evaluate access by locating/palpating cannulation sites prior to cannulation, per policy, for 2 of 2 patients (Patients #7, 12) observed for initiation of dialysis with an AV Fistula/Graft and failed to check for a thrill after the application of clamps, per policy, for 1 of 1 patient (Patient #8) observed for discontinuation of dialysis with an AV Fistula/Graft in a total of 18 observations of patient care. Findings include: A review of the facility’s policy titled, “Cannulation and Care of Fistula or Graft” last revised 06/02/2022 revealed, “... 2). Palpate the access to determine the presence of thrill...” A review of the facility’s policy titled, “Clamp Use for Venostasis “ last revised 09/19/2023 revealed, “...3). Ensure clamp is tight enough to prevent bleeding from site, but not too tight to cut off flow of fistula. Assess above and below clamp to palpate for presence of thrill ...” During an observation on 01/21/2025 at 9:10 AM, Registered Nurse C was observed initiating dialysis on Patient #12’s Fistula/Graft. Registered Nurse C was not observed palpating the access site prior to cannulation. During an observation on 01/21/2025 at 9:15 AM, Registered Nurse E was observed initiating dialysis on Patient #7’s Fistula/Graft. Registered Nurse E was not observed palpating the access site prior to cannulation. During an observation on 01/21/2025 at 9:38 AM, following discontinuation of dialysis with an AV Fistula, Registered Nurse D applied clamps to Patient #8’s fistula access sites and did not check for thrill as per policy. During an interview on 01/22/2025 at 10:17 AM, the observation findings were discussed with Nurse Manager A who stated the staff should be assessing for thrill prior to starting dialysis and assessing for thrill above and below clamps after being placed. 47413”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility staff failed to document the follow-up completed for 6 of 6 adverse events (involving Patients #14, 16, 17, 18, 19, 20) recorded in a total universe of 6 events reviewed. Findings Include: A review of the facility’s policy titled, “Quality Assessment and Performance Improvement” last revised 08/26/2020 revealed, “... The dialysis facility will measure, analyze, and track quality indicators... h) Medical injuries and medical errors identification...” A review of the facility’s adverse events log for the past 6 months revealed missing or incomplete follow-up for 6 patient events: A review of the adverse event involving Patient #19 revealed that Patient #19’s lines or access clotted and dialysis was ended early on 07/29/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. A review of the adverse event involving Patient #20 revealed that Patient #20 required an additional venous needle for cannulation on 08/27/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. A review of the adverse event involving Patient #18 revealed that Patient #18 had prolonged bleeding post-dialysis on 09/09/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. A review of the adverse event involving Patient #16 revealed that Patient #16 had a difficult venous access on 10/08/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. A review of the adverse event involving Patient #17 revealed that Patient #17 was not given a dose of Parsabiv on 11/07/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. A review of the adverse event involving Patient #14 revealed that Patient #14 was given the wrong dialyzer for treatment on 12/16/2024. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. During an interview on 01/22/2025 at 12:04 PM, the findings were discussed with Nurse Manager A who stated there needs to be more follow-up for adverse events than just “reviewed”, and that there is no specific policy as to what is required for follow-up.”