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Based on document review and interview, it was determined that the Hospital failed to provide nursing supervision of patient care, to ensure STAT (immediate) physician's orders were being carried out within appropriate timeframes. This deficient practice has the potential to affect any patient admitted to the Hospital requiring immediate dialysis services. As a result, the Condition of Participation, 42 CFR 482.23 Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to ensure hemodialysis treatments were provided in accordance to STAT orders. See deficiency at A-395 (A).

A. Based on document review and interview, it was determined that for 3 of 3 (Pt #9, Pt #10, Pt #11), clinical records reviewed for patients requiring acute hemodialysis services, the Hospital failed to ensure that a registered nurse supervised and evaluated nursing care, by failing to initiate STAT (immediate) dialysis treatments within an appropriate timeframe, in accordance to the physician's order.

Findings include:

1. The Hospital's policy titled, "Guidelines for STAT Dialysis" (dated 7/16/2021), was reviewed on 1/11/2023, and required, "The purpose of this protocol/policy is to outline appropriate timing for emergency dialysis services in the acute hospital...Procedure...An active hemodialysis order must be present...Make contact for on-call hemodialysis staff...If there is a delay in response or inability to reach the on-call: a. Nephrologist or Nursing supervisor will reach out to Dialysis Supervisor on call. b. Dialysis Supervisor will work with nephrologist to evaluate if transfer is appropriate or waiting time is appropriate..."

2. Three clinical records (Pt #9, Pt #10, Pt #11) for patients requiring STAT hemodialysis treatments, in the acute setting , were reviewed on 1/11/2023. The clinical records included the following:

- Pt #9 was admitted on 12/9/22, with a diagnosis of shortness of breath. Pt #9's physician orders included STAT hemodialysis treatment orders.
On 12/11/2022 at 10:32 AM, a STAT hemodialysis treatment order was placed. The hemodialysis flowsheet was reviewed and included a treatment start time on 12/11/22 at 4:05 PM (5 hours and 33 minutes after STAT treatment ordered).
On 12/12/2022 at 12:42 AM, a STAT hemodialysis treatment order was placed. The hemodialysis flowsheet included a treatment start time on 12/12/2022 at 5:55 AM (5 hours and 13 minutes after STAT treatment ordered).

- Pt #10 was admitted on 12/22/2022, with a diagnosis of AKI (acute kidney injury). Pt #10's physician orders included a STAT hemodialysis treatment order on 12/24/2022 at 10:06 AM. The hemodialysis flowsheet included a treatment start time on 12/24/2022 at 2:50 PM (4 hours and 44 minutes after STAT treatment ordered).

- Pt #11 was admitted on 12/25/2022, with a diagnosis of hypertensive emergency, fluid overload. Pt #11's physician's orders included a STAT hemodialysis treatment order on 12/25/2022 at 9:01 AM. The hemodialysis flowsheet included a documented treatment start time on 12/25/2022 at 4:22 PM (7 hours and 21 minutes after STAT treatment ordered).

Pt #9. Pt #10, and Pt #11, hemodialysis flowsheets or hemodialysis notes lacked documentation indicating a reason for delay in initiating STAT hemodialysis treatments. The clinical records lacked documentation of the nephrologist being notified of delay in treatment.

3. On 1/11/2023 at 11:10 AM, an interview was conducted with the Acute Care Dialysis Manager (E #3). E #3 stated that STAT hemodialysis orders are generally carried out within an hour. E #3 stated that if the order is placed during on-call hours, then either himself or the supervisor is notified. E #3 stated that the nephrologist usually calls, directly with a STAT order. E #3 stated that if the STAT order could not be initiated within a hour, they will give the nephrologist a general time frame when the staff will be available to initiate the treatment, E #3 stated that there are times when there may be a cause of delay in treatment, including the patient not having a dialysis access. E #3 stated that if there is a delay, this information should be communicated with the nephrologist.

4. On 1/11/2023 at approximately 10:00 AM, an interview conducted with the Nephrologist (MD #1). MD #1 stated that the expectation of STAT orders are within an hour. MD #1 stated that an example of an indication for a STAT hemodialysis order, would be if a patient came in with a potassium level of 7.0. MD #1 stated that this patient would be priority in regards to hemodialysis treatments and would be ordered as STAT.


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B. Based on document review and interview, it was determined that for 1 of 4 patients (Pt. #2) clinical records reviewed for dialysis treatment orders, the Hospital failed to ensure that the registered nurse (RN) evaluated the nursing care for each patient by failing to ensure that the physician's dialysis treatment orders were followed.

Findings include:

1. On 1/10/2023, the Hospital's job description for inpatient hemodialysis registered nurses (dated 12/2022) was reviewed and required, "... Primary Duties and Responsibilities... 8. Documents... interventions... Accurately and promptly implements physician's orders..."

2. On 1/11/2023, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 1/2/2023 with a diagnosis of Non-STEMI (Non-ST Elevated Myocardial Infarction/Heart Attack). On 1/7/2023, the clinical record included a physician's order to dialyze Pt. #2 for three hours and thirty minutes. The physician's order also included to administer saline bolus (intravenous fluid) if Pt. #2's blood pressure drops below 90 mm/millimeter systolic. The dialysis treatment record on 1/7/2023 indicated that from 1:00 PM thorough 2:00 PM, Pt. #2's blood pressure was below 90 mm systolic. Pt. #2's clinical record did not indicate that the saline bolus was administered, or why the bolus was not administered.

3. On 1/11/2023 at approximately 1:30 PM, findings were discussed with E #3 (Acute Care Dialysis Manager). E #3 stated that the dialysis nurse should have supervised and followed the physician's orders. E #3 could not provide documentation why the physician's order was not followed.

Based on observation, document review and interview, it was determined that the Hospital failed to adhere to infection prevention and control recommendations in reducing hospital-acquired infections for patients receiving dialysis treatments. This is likely to cause serious harm, impairment, or even death to any patient receiving care from the acute inpatient dialysis unit. As a result, the Condition of Participation, 42 CFR 482.42, Infection Prevention Control and Antibiotic Stewardship, was not met.

Findings include:

1. The Hospital failed to follow the recommended weekly chemical disinfection, to ensure methods for preventing and controlling transmission of infections within the hospital are being followed. See deficiency A-749.

The immediate jeopardy (IJ) was identified on 1/10/2023 at 42 CFR 482.42, Infection Prevention Control and Antibiotic Stewardship, due to the Hospital's failure to ensure that the portable RO/reverse osmosis machine/machine that purifies the water for dialysis treatment was appropriately disinfected before each patient use. The IJ was identified on 1/10/2023 at 42 CFR 482.42, Infection Prevention Control and Antibiotic Stewardship, and was announced on 1/11/2023 at 4:15 PM, during a meeting with the President of the Hospital, Executive Director of Patient Safety, Regulatory Compliance Specialist, Executive Director of Clinical Service Line, Chief Nursing Officer, Vice President of Clinical Professional Services, Assistant Chief Nursing Officer, and Acute Dialysis Care Manager. The IJ was removed by the survey exit date of 1/12/2023.

Based on observation, document review, and interview, it was determined that for 1 of 1 portable RO/reverse osmosis machines (machine that purifies the water for dialysis treatments (Machine #3/WR0 300) that requires weekly disinfection, the Hospital failed to follow the recommended weekly chemical disinfection, to ensure methods for preventing and controlling transmission of infections within the hospital are being followed. This has the likelihood to cause cross-contamination or death to any patient using the machine.

Findings include:

1. On 1/10/2023 between approximately 9:00 AM through 10:30 AM, an observational tour of the Hospital's acute dialysis unit was conducted. During the tour, the portable RO (Machine #3), was available for use for any patient requiring dialysis treatments at the bedside.

2. On 1/10/2023, the Hospital's Operator's Manual titled, "Mar Cor Purification (MCP) WRO 300" (2016) was reviewed and required, " ... Regular Maintenance ... Chemical Disinfection ... As a guideline, MCP recommends a minimum frequency of weekly chemical disinfection to ensure consistent microbiological quality of the product water ... If the WRO 300 will not be used for an extended period, weekly chemical disinfection will help maintain the microbiological quality of the product water ... Approved Chemical Disinfectant (Minn Care/a disinfectant that stops organism growth) ..."

3. On 1/10/2023, the Hospital's disinfection logs for Machine #3 from October 1, 2022, through 1/10/2023 were reviewed. The log indicated that the Hospital performs monthly (not the required weekly) chemical disinfection for Machine #3. The logs indicated:

- In October 2022, Machine #3 was chemically disinfected on 10/5/2022. Machine #3 was used from 10/15/2022 through 10/24/2022, without ensuring that the weekly chemical disinfection was performed.

- In November 2022, Machine #3 was chemically disinfected on 11/17/2022. Machine #3 was used from 11/24/2022 through 11/29/2022, without ensuring that the weekly chemical disinfection was performed.

- In December 2022, Machine #3 was chemically disinfected on 12/13/2022. Machine #3 was used from 12/20/2022 through 12/23/2022, without ensuring that the weekly chemical disinfection was performed.

- In January 2023, Machine #3 was chemically disinfected on 1/2/2023. Machine #3 was not chemically disinfected on 1/9/2023 (one day past the required weekly chemical disinfection).

3. On 1/10/2023, the clinical record for Pt. #8 was reviewed. Pt. #8 was admitted on 12/19/2022 with a diagnosis of clotted hemodialysis graft/dialysis access. On 12/20/2022, E #7 (Hemodialysis Technician) used Machine #3 to dialyze Pt. #8, without ensuring that the required weekly chemical disinfection was performed.

4. On 1/10/2023 at approximately 11:05 AM, an interview was conducted with E #3 (Acute Dialysis Care Manager). Regarding chemical disinfection requirements for Machine #3, E #3 stated that the Hospital follows the manufacturer's guidelines (Mar Cor Purification (MCP) WRO 300, 2016). E #3 stated that he knows that the dialysis staff perform monthly chemical disinfection for Machine #3 (not weekly). E #3 stated, "One of the potential main killers of not properly disinfecting (Machine #3) is sepsis/generalized infection. Septic shock is not a joke. It is a killer!"

5. On 1/10/2023 at approximately 1:42 PM, an interview was conducted with E #7 (Hemodialysis Technician). E #7 stated that her practice is to perform monthly chemical disinfection for Machine #3. E #3 stated that she has been using Machine #3 even though it is only chemically disinfected once a month. E #3 stated, "In our orientation, they told us to (chemically disinfect Machine #3) every month."

6. On 1/11/2023 at approximately 9:30 AM, an interview and findings were discussed with E #8 (Infection Control Practitioner). E #8 stated that the dialysis unit should follow Machine #3's manufacturer's recommendation for disinfection. E #8 stated that she trusts the dialysis unit's supervisor to ensure that the chemical disinfection requirements are being followed. E #8 agreed that the Hospital staff were not following the chemical disinfection requirements. E #8 stated that if the chemical disinfection recommendations are not followed, there is a risk for hospital-acquired infections that can potentially kill patients.

7. On 1/11/2023 at approximately 10:00 AM, an interview was conducted with MD #1 (Nephrologist). MD #1 stated that the manufacturer's guidelines should be followed. MD #1 stated, "If not properly disinfected, (Machine #3) should not be used because it can cause harm."