Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on September 15, 2023, Fayette County Dialysis was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on September 15, 2023, Fayette County Dialysis was found to have the following deficiency and to be in standard compliance with the requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS
Name - Component - 00
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.
Observations:
Based on reviews of facility policy, observations, and staff (EMP) interview, the facility failed to ensure staff followed facility policy for Access of AV Fistula of Graft Initiation of Dialysis for one (1) of three (3) observations of Access of AV Fistula of Graft Initiation of Dialysis (OBS# 1 & 2 ). The facility also failed to ensure staff follow facility policy for post dialysis access care for AV fistula or graft for four (4) of six (6) observations of Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft. (OBS# 2-4, & 6.)
Findings included:
Review of facility policy on 9/14/2023 at approximately 3:00pm revealed:
"...AV FISTULA OR GRAFT CANNULATION WITH NIPRO OR MEDISYSTEMS SAFETY FISTULA NEELES...`13. Do not palpate insertion site once area has been prepped...16. Remove gloves, perform hand hygiene and put on new gloves prior to cannulation..."
"...POST DIALYSIS VASCULAR ACCESS CARE...PROCEDURE...Locate and palpate the needle sites prior to skin preparation...12. Hold site(s) for at least 5-10 minutes before checking to see if bleeding has stopped. 13. Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect site for any trauma and for hemostasis. 14. Apply band-aid type or sterile dressing over cannulation site...If dressing is used, apply tape lightly. Do not wrap tape completely around extremity..."
Observations revealed:
Access of AV Fistula of Graft Initiation of Dialysis OBS #2 conducted at station 14 on 9/15/2023 at approximately 8:40am, EMP 4 failed to perform hand hygiene between glove change prior to cannulation. EMP4 also palpated cannulation site post prep with antiseptic.
Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft OBS #2, conducted at station 3 on 9/13/2023 at approximately 10:40am, EMP 4 failed to discard gauze that patient used to hold sites, inspect site for any trauma and for hemostasis, and apply band-aid type or sterile dressing over cannulation site, per policy. EMP 4 asked patient if they should change the gauze, patient replied, "whatever you are supposed to do" EMP 4 applied additional tape over tape and gauze held by patient without removing to assess site.
Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft OBS #3, conducted at station 1 on 9/13/2023 at approximately 10:50am, EMP 2 removed lower needle site dressing after patient returned to treatment floor due to bleed post treatment. EMP 2 failed to discard gauze that patient used to hold sites, inspect site for any trauma and for hemostasis, and apply band-aid type or sterile dressing over cannulation site, per policy. EMP 2 applied additional tape over tape and gauze held by patient without removing to assess site. No removal of tape or inspection of upper needle site.
Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft OBS #4, conducted at station 4 on 9/15/2023 at approximately 11:00am, EMP 2 inspect site for any trauma and for hemostasis, and apply band-aid type or sterile dressing over cannulation site, per policy. EMP 2 stated "...I don't think you are bleeding, like I said, you weren't really on it..."
Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft OBS #6, conducted at station 13 on 9/15/2023 at approximately 9:45am, EMP 4 failed to discard gauze that patient used to hold sites, inspect site for any trauma and for hemostasis, and apply band-aid type or sterile dressing over cannulation site, per policy. EMP 4 applied additional tape over tape and gauze held by patient without removing to assess site.
Interview with the Facility Administrator on 9/15/2023 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:06954 Fayette County PA CMS Core 091523
POC Due Date: 09/29/23
POC Completion Date: 11/14/23
V 550
The Facility Administrator or designee held mandatory in-services for clinical teammates starting on 09/15/23. Surveyor observations were reviewed. Education included but was not limited to a review of A. Procedure 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" and B. Procedure 1-04-01B "Post Dialysis Vascular Access Care: Fistula Graft using Safety Fistula Needles" with emphasis on but not limited to:
A. AVF/AVG Cannulation: 1) Step 13: Do not palpate insertion site once area has been prepped. 2) Step 16: Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation.
B. Post dialysis vascular access care: 1) Step 12: Hold site(s) for at least 5-10 minutes before checking to see if bleeding has stopped. 2) Step 13: Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect site for any trauma and for hemostasis. 3) Step 14: Apply band-aid type or sterile dressing over cannulation site... If a sterile dressing is used, apply tape lightly. Do not wrap tape completely around extremity.
The Facility Administrator or designee will perform observational cannulation and treatment discontinuation audits to verify teammates are compliant with procedure steps: [two (2) observations for each teammate over span of daily and weekly audits]: daily for two (2) weeks and weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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