There are  2 surveys for this facility. Please select a date to view the survey results.

V113

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/08/24. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-02B "Central Venous Catheter (CVC) with Cleargaurd HD Antimicrobrial End Caps Procedure" with emphasis on but not limited to: 1) Step 1: Perform hand hygiene per procedure. Put on PPE... 2) Step 4: Remove old dressing and discard. 3) Step 7: Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 4) Step 8: Holding catheter with the nondominant hand and using aseptic technique, clean exit site ... wait 60 seconds for air dry time... 5) Step 10: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 6) Steps 12: Place sterile 2x2 gauze over the catheter exit site ... Seal edges of gauze with tape. 7) Step 14: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 8) Step 16: Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds... 9) Step 17: Attach sterile 10 ml syringes to the arterial and venous limbs. Verification of attendance for the in-service was evidenced by teammate's signature on an attendace sheet.
The Facility Administrator or designee will conduct CVC procedure audits to verify teammates perform proper hand hygiene during CVC exit site care and treatment initiation: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the 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 and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed, until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V715

A Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held 04/08/24 to review the results of the survey ending on 04/04/24. The Governing Body reviewed the document Medical Director Qualifications and Responsibilities Policy COMP-DD-017 section 4.2.1. (C) Oversight of policies and procedures relative to patient admissions, patient care, infection control and safety are adhered to by all individuals who treat patients in the center, including attending physicians and non-physician providers. The Medical Director acknowledges that he/she is responsible to ensure the facility teammates are trained, follow policy and procedure, and deficiencies identified need to be corrected timely with the support of the facility team. Plans of correction have been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 4/08/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: A. [Pre-treatment data collection]: 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes: Measurement of blood pressure, sitting and standing and intradialytic BP in the sitting/reclined or supine position... 2) Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse ... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 3) The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis.
B. [Intradialytic monitoring]: 1) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately... The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 2) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 3) All findings, interventions and patient response will be documented in the patient's medical record.
C. [Post treatment]: 1) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 2) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 3) Licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility.
D. [Abnormal findings]: Blood pressure - Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg. Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Blood Pressure Post Treatment if the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Pre/Intra/Post Patient Reports/ Complaints and/or teammate observation of: Pain, chest pain... Weakness or numbness... Cramping... Changes in level of consciousness, ability to communicate...
The Facility Administrator or designee will conduct flow sheet audits to verify proper documentation of data collection, with timely notification of abnormal findings to nurse and appropriate response / intervention as needed, by nurse: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.