Fmc Chase

“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: 28297 Based on observation, interview, and policy review the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood. (i) The filtered blood then flows back through the access into the body) for one of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 84 in-center patients. Findings include: Observation on 08/20/25 at 12:02 PM revealed Patient (P) 5 at Station 8 applied pressure to the left upper arm access site until bleeding had stopped. When the patient was finished the patient walked to the scale to retrieve his/her weight. Patient Care Technician (PCT) 1 assisted the patient to the scale to retrieve his/her weight and escorted the patient to the lobby. The patient did not wash or sanitize hands and PCT1 did not instruct or encourage the patient to wash or sanitize hands. During an interview on 08/20/25 at 12:20 PM PCT 1 acknowledged the patient did not wash or sanitize hands after holding access site and he/she did not instruct or encourage the patient to prevent cross contamination. During an interview on 08/22/25 at 12:40 PM the Charge Nurse stated patients should wash or sanitize hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. Review of the facility policy titled, “Hand Hygiene,” indicated, “ ...Gloves must be provided to patients when performing procedures which risk the exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed ...””

“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: 28297 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure contaminated bloodlines, and dialyzers were capped and transported in a manner to prevent contamination of other surfaces for two of three survey days. The failure to abide by proper infection control practices had the potential for surfaces within the dialysis unit to be contaminated and this could affect 84 in-center patients. Findings include: Observation on 08/20/25 at 12:06 PM revealed that Registered Nurse (RN) 1 carried dirty dialyzers and uncapped lines from Station 10 down the treatment floor to the red biohazard container stored across from Station 13. Observation on 08/20/25 at 12:10 PM Patient Care Technician (PCT) 1 carried dirty dialyzers and uncapped lines from Station 9 across the floor to the red biohazard container stored across from Station 13. Observation on 08/22/25 at 10:45 AM PCT 2 carried dirty dialyzers and uncapped lines from Station 6 across the floor to the red biohazard container stored across from Station 13. Interview on 08/22/25 at 10:45 AM PCT 2 confirmed that it was the practice to only have two biohazard containers stationed near the nurses’ station by Station 13 on each side and to care the biohazard supplies to the container. During an interview on 08/22/25 at 12:40 PM the Charge Nurse stated no one has ever said that staff could not transport biohazard supplies to the biohazard container but acknowledged that with the lines not capped they could drip and contaminate other surfaces during transportation of the biohazard dialyzers and uncapped lines. The facility did not have a specific policy on transporting biohazard dialyzers or uncapped lines.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 28297 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure an open vial of medication was dated and labeled as required for one of three survey days. In addition, a vial of Purified Protein Derivative (PPD) medication used to test patients for Tuberculosis (a contagious respiratory illness) was opened and dated 06/16/25 and available for use for one of three survey days. The failure to date and label the medication vial had the potential for staff to use a medication that expired and could affect 84 in-center patients. Findings include: Observation on 08/22/25 at 10:15 AM revealed a multi-dose vial of Heparin 30,000 units per 30 milliliters (ML), stored at the medication preparation area was opened. Further inspection of the vial revealed it was not dated and the initials of person who opened the vial had not been written on the vial. A vial of PPD solution was opened and dated 06/16/25. During an interview on 08/22/25 at 10:15 AM, Registered Nurse (RN) 1 acknowledged the medication vial was not labeled as required with the date and initials of the person who opened the vial. RN1 stated he/she thought it only had to be labeled at the end of the day. RN 1 stated he/she thought the vial of PPD solution was good for three months not 28 days per facility policy. During an interview on 08/22/25 at 10:25 AM the Charge Nurse confirmed the bottle of heparin was not labeled and the PPD solution was expired. The Charge Nurse acknowledge the PPD medication vial should not be used if opened longer than 28 days and the Heparin bottle should have dated and labeled when opened. Review of the facility’s policy titled, “Medication Preparation and Administration” revised 07/07/25, indicated, “ ...Any open multi-dose vials must be discarded 28 days after opening or per manufacturer’s expiration date ...When preparing medications, if the vial is not used immediately in its entirety, the nurse or PCT (if allowed by state regulation), must place the date and time the vial was opened on the medication labeled along with their initials ...””

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 28297 Based on observation, interview, and facility document review, the facility failed to ensure a copy of the patient’s rights, including the current State agency and End Stage Renal Disease (ESRD) network mailing addresses and telephone complaint numbers, were prominently display where it can be easily seen and read by patients for one of three survey days. The failure to display required items as required had the potential for patients not to have access to important numbers outside of the facility in case of a grievance and this could affect 84 in-center patients. Findings include: Observation on 08/20/25 at 8:15 AM upon entrance to the facility revealed the state contact information and ESRD contact information was written on a document that was 8 ½ inch by 11-inch piece of paper, that was place in a glass cabinet at the top of the cabinet. In front of the cabinet was a wheelchair preventing access to the information. In addition, the information was written in small print and not prominently displayed. There was also no patient rights/responsibility documentation located in the lobby area. During an interview on 08/20/25 at 9:10 AM the Covering Facility Administrator confirmed the State Agency and ESRD network information was not prominently displayed where patients would have ease of access and readable information. He/she also confirmed there were no patient rights or responsibilities located in the lobby area. The Covering Facility Administrator stated the facility did not have a specific policy on what was required to be available to patients lobby however the “Fresenius Medical Care Regulatory Affairs,” undated had a “List of Required Lobby Postings,” that included: ...Patient Rights and Responsibilities, Grievance Procedure: FKC, Network (if applicable), State (if applicable) ...””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 28297 Based on interviews, record review, and review of the facility’s policy, the facility failed to ensure patients were monitored every 30 minutes as required for three of eight sampled patients (Patient (P) 1, P2, and P4). In addition, the facility failed to adjust a patient dry weight in a timely manner for one of eight sampled patients (P3). The failure to monitor patients and adjust dry weights as required had the potential for adverse events such as low blood pressure, high blood or irregular heart rates that may not be captured in a timely manner that could affect 84 in-center patients. Findings include: 1.a.Review of the medical record for P1 revealed the facility admitted the patient on 03/26/25 with diagnosis of end stage renal disease (ESRD). Review of P1’s six dialysis treatment flowsheets from 08/06/25 through 08/18/25 revealed the following: On 08/06/25, the patients’ blood pressure was checked at 10:40 AM with a reading of 133/67 and was not checked again until 12:05 PM with a reading of 112/65, 40 minutes late. On 08/15/25, the patient’s blood pressure was checked at 10:54 AM with a reading of 91/66 and was not checked again until 11:50 AM with a reading of 112/60, 11 minutes late. On 08/18/25, the patients’ blood pressure was checked at 8:31 AM with a reading of 103/73 and not checked again until 9:30 AM with a reading of 92/60, 14 minutes late. b. Review of the medical record for P2 revealed the facility admitted the patient on 07/18/25 with diagnosis of ESRD. Review of P2’s six dialysis treatment flowsheets from 08/04/25 through 08/18/25 revealed the following: On 08/18/25 the patients blood pressure was checked 3:02 PM with a reading of 136/82 and was not checked again until 4:00 PM with a reading of 123/77, 13 minutes late. c. Review of the medical record for P4 revealed the facility admitted the patient on 04/23/25 with diagnosis of ESRD. Review of P4’s six dialysis treatment flowsheets from 08/06/25 through 08/18/25 revealed the following: On 08/18/25 the patients’ blood pressure was checked 8:46 AM with a reading of 168/89 and was not checked again until 10:47 AM with a reading of 104/63, one hour and 16 minutes late. The patient’s blood pressure was not checked again until 12:08 PM with a reading of 100/60, 36 minutes late. During an interview on 08/22/25 at 12:25 PM, Patient Care Technician (PCT) 3 confirmed he/she was the PCT who missed blood pressure checks on P4. PCT3 confirmed the missing blood pressure and that patients should be checked every 30 minutes or they were at risk of an adverse event. 2. Review of the medical record for P3 revealed the facility admitted the patient on 05/17/25 with Diagnosis including Acute Kidney Injury (AKI). Review of six dialysis treatment flowsheets from 08/07/25 through 08/20/25 revealed the following: On 08/12/25 the patient’s dry weight was ordered at 57.5 kilograms (kg). The patient’s post treatment weight was 66.8 kg, 9.3 kg over the ordered dry weight. There was no documentation the practitioner was notified of the post treatment weight. On 08/14/25 the patient’s ordered dry weight was 57.5 kg and the patient post treatment weight was 65.1 kg, 7.6 kg over the prescribed dry weight. There was no documentation the practitioner was notified of the post weight. On 08/16/24 the patient’s dry weight was 57.5 kg and the patient’s post dialysis weight was 64.3 kg, 6.8 kg over the prescribed dry weight. The nurse documented he/she notified the Nurse Practitioner in the post assessment however no new orders were written. On 08/20/25 the patients prescribed dry weight was 57.5 kg and the patient post treatment weight was 66.8 kg, 9.3 kg over the prescribed dry weight. There was no documentation the practitioner was notified of the post weight. Review of the “Nurse Practitioner Notes,” dated 08/14/25, revealed that he/she documented they would increase the patient dry weight to 61.0 kg however the order was never placed, and the patient dry weight was not changed. During an interview on 08/21/25 at 12:40 PM the Covering Facility Administrator stated she/he called the Nurse Practitioner who documented the change to the dry weight for P2. The Nurse Practitioner stated he/she tried to change the dry weight in the provider hub, but it wouldn’t let them because of the amount of Dry Weight change. The Nurse Practitioner stated he/she instructed the nurse to change P2 weight but that did not occur. During an interview on 08/22/25 at 12:00 PM Registered Nurse (RN) 2 stated if the patient post weight is less than or greater than one kg variance from the dry weight the nurse is required to notify the Nurse Practitioner and document on the treatment sheet. RN2 confirmed it was not documented on three of four treatments for P3. During an interview on 08/22/25 at 12:40 PM the Charge Nurse stated staff were required to document the patient vital signs and machine checks every 30 minutes to ensure the patient was stable. He/she confirmed the missing blood pressure/safety checks on P1, P2 and P4 flowsheets. The Charge Nurse also stated the nurses were required to call the Nurse Practitioner if there is a variance of greater or less than 1 kg from the patient dry weight. He/she confirmed there was no documentation on three of four flowsheets reviewed for P2. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” revised 05/01/23 indicated, “ ...Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulation ...” Review of the facility’s policy titled, “Nursing Supervision and Delegation,” revised 11/06/23 indicated “ ...Record review ...identify any process that could have resulted in the patient experiencing a safety event or near miss. The record must be reviewed for: Slow/fast/irregular heart rate, Low or high blood pressures, whether patient is achieving dry weight and identifying reason for patient not achieving dry weight. Heart rate <60 or >100 addressed by the registered nurse with documentation present Blood pressures < 100 systolic or greater than 180 systolic. The following criteria can be used as a guideline to identify when a staff shall refer a patient to the Team Leader/Charge Nurse for further assessment pre, during or post treatment. The Team Lead Charge Nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. Any weight gains greater than 4 kg pre-treatment. Any swelling in the facial area, and lower extremity edema. A post treatment weight with a variance from the estimated dry weight of 1 kg change in weight from a patient’s last treatment. Any weight loss or no change in weight ...””