Fmc Magnolia

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 50873 Based on observation and interview, the facility failed to provide enough room to safely provide emergency services. This had the potential to impact all patients that received treatments at the facility. Findings include: On 08/12/2025 at 12:51 PM, Patient Care Technician (PCT) #3 was observed using a mechanical lift to get a patient into treatment Station 11. The Clinic Manager went to assist the PCT and moved the clean cart in the center aisle out of the way to move the mechanical lift and get the patient into a chair. On 08/12/2025 at 1:00 PM, Emergency Medical Services (EMS) entered the clinic floor with a stretcher. PCT #7 and the Facility Administrator moved two trash cans, two clean carts, and a sharps bin from the center aisle to make room for EMS and a stretcher to get to the patient at treatment Station 9. A clean cart was observed to go into patient treatment Station 1 and was within approximately 1 foot of the foot of the patient’s chair in Station 1. A biohazard bin was moved to within approximately 2 feet of the chair at treatment Station 9. Another clean cart was moved to approximately 2 feet from the chair in patient treatment Station 16. On 08/12/2025 at 3:17 PM, PCT #6 confirmed that she bumped into a clean cart while using the mechanical lift and stated this was due to there not being enough room to use the mechanical lift. PCT #6 reported that the sharps bins were supposed to go in between the treatment stations but there was not enough space, so they got pulled into the center aisle. PCT #6 stated that in an emergency, staff would have to move all of the items in the center of the aisle between the treatment stations as there would not be enough room to get the stretcher to the patient treatment stations without moving the items in the center aisle and that could potentially delay care. On 08/12/2025 at 2:36 PM, PCT #7 stated that the staff always had to move items out of the center aisle for stretchers and mechanical lifts. PCT #7 stated that they did not believe this would delay care. PCT #7 confirmed that when a stretcher was used in the clinic, all the items in the center of the aisle were bunched up at the ends of the aisle. On 08/15/2025 at 1:00 PM, the Clinic Manger confirmed that there was not enough space on the treatment floor for emergency services without moving the supply carts and biohazard bins. On 08/15/2025 at 1:00 PM, the Facility Administrator confirmed that there was not enough space on the treatment floor for emergency services without moving the supply carts and biohazard bins. On 08/15/2025 at 2:00 PM, the Medical Director indicated understanding of the concern regarding a lack of space for emergency services on the clinic floor.”

“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: 50873 Based on record review, interview, and facility policy review, the facility failed to ensure patients fluid status was monitored per facility policy for 6 (Patients #1, #2, #4, #5, #6, and #7) of 7 sampled patients. Findings include: A facility policy titled, “Patient Assessment and Monitoring,” with a publication date of 05/01/2023, indicated that staff should “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 [minutes] or more often as needed but not to exceed 45 minutes or per state regulations.” The policy revealed, “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury - unit of measurement for blood pressure readings], Diastolic blood pressure greater than 100 mm/Hg, Blood pressure less than or equal to 100 mm/Hg systolic” and “Report to the nurse patients whose heart rates have dropped below 60 [beats per minute, bpm], risen above 100 or become irregular.” 1. Patient #1’s treatment sheet dated 08/01/2025 revealed Patient Care Technician (PCT) #3 documented that the patient’s blood pressure was 160/103 mm/Hg at 2:49 PM. The treatment sheet revealed there was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range blood pressure reading. Patient #1’s treatment sheet dated 08/04/2025 revealed PCT #3 documented that the patient’s blood pressure was 163/105 mm/Hg and 164/107 mm/Hg at 10:48 AM. The treatment sheet revealed there was no documented evidence that the PCT notified an RN of the out-of-range blood pressure readings. 2. Patient #2’s treatment sheet dated 08/02/2025 indicated there was no documented evidence that staff monitored the patient from 9:05 AM through 10:09 AM and 11:10 AM through 12:07 PM. Patient #2’s treatment sheet dated 08/07/2025 revealed Patient Care Technician (PCT) #2 documented that the patient’s blood pressure was 163/105 mm/Hg at 8:03 AM. The treatment sheet revealed there was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range blood pressure reading. 3. Patient #4’s treatment sheet dated 07/30/2025 revealed Patient Care Technician (PCT) #6 documented that the patient’s blood pressure was 93/63 mm/Hg at 4:00 PM. The treatment sheet revealed there was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range blood pressure reading. Patient #4’s treatment sheet dated 08/01/2025 indicated there was no documented evidence that staff monitored the patient’s blood pressure and heart rate from 3:30 PM through 4:24 PM. Patient #4’s treatment sheet dated 08/04/2025 indicated there was no documented evidence that staff monitored the patient’s blood pressure and heart rate from 1:35 PM through 2:35 PM. The treatment sheet revealed PCT #2 documented that the patient’s heart rate was 104 bpm at 12:05 PM, 113 bpm at 12:31 PM, and 103 bpm at 1:04 PM. The treatment sheet revealed there was no documented evidence that the PCT notified an RN of the out-of-range heart rates. Patient #4’s treatment sheet dated 08/08/2025 indicated there was no documented evidence that staff monitored the patient from 12:43 PM through 1:36 PM and no documented evidence of staff monitoring the Dialysis Flow Rate (DFR) and Blood Flow Rate (BFR) from 3:00 PM through 4:30 PM. The treatment sheet revealed PCT #6 documented that the patient’s blood pressure was 128/106 mm/Hg and heart rate was 103 bpm at 4:30 PM. The treatment sheet revealed that there was no documented evidence that the PCT notified an RN of the out-of-range blood pressure and heart rate readings. 4. Patient #5’s treatment sheet dated 07/29/2025 revealed Patient Care Technician (PCT) #7 documented that the patient’s blood pressure was 96/61 mm/Hg at 9:02 AM and 95/51 mm/Hg at 9:42 AM. The treatment sheet revealed there was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range blood pressure readings. Patient #5’s treatment sheet dated 08/05/2025 revealed PCT #6 documented that the patient’s blood pressure reading was 92/62 mm/Hg at 8:38 AM. The treatment sheet revealed PCT #7 documented that the patient’s blood pressure was 97/51 mm/Hg at 9:48 AM. The treatment sheet revealed there was no documented evidence that the PCTs notified an RN of the out-of-range blood pressure readings. 5. Patient #6’s treatment sheet dated 07/28/2025 revealed Patient Care Technician (PCT) #7 documented that the patient’s heart rate was 59 bpm at 6:38 AM and 52 bpm at 8:53 AM. The treatment sheet revealed PCT #2 documented that the patient’s heart rate was 57 bpm at 8:08 AM. The treatment sheet revealed there was no documented evidence that the PCTs notified a registered nurse (RN) of the out-of-range heart rate readings. Patient #6’s treatment sheet dated 07/30/2025 revealed PCT #4 documented that the patient’s heart rate was 54 bpm at 6:02 AM and 57 bpm at 6:33 AM. The treatment sheet revealed there was no documented evidence that the PCT notified an RN of the out-of-range heart rate readings. Patient #6’s treatment sheet dated 08/01/2025 indicated that there was no documented evidence that staff monitored the patient from 8:09 AM through 9:12 AM. Patient #6’s treatment sheet dated 08/04/2025 revealed PCT #6 documented that the patient’s heart rate was 59 bpm at 8:12 AM. The treatment sheet revealed PCT #3 documented that the patient’s heart rate was 59 bpm at 8:32 AM. The treatment sheet revealed that there was no documented evidence that the PCTs notified an RN of the out-of-range heart rate readings. Patient #6’s treatment sheet dated 08/06/2025 revealed PCT #6 documented that the patient’s blood pressure was 153/104 mm/Hg at 8:04 AM and 97/82 mm/Hg at 8:34 AM. The treatment sheet revealed PCT #4 documented that the patient’s heart rate was 49 bpm at 9:34 AM. The treatment sheet revealed that there was no documented evidence that the PCT notified an RN of the out-of-range blood pressure and heart rate readings. Patient #6’s treatment sheet dated 08/08/2025 revealed PCT #7 documented that the patient’s blood pressure was 181/104 mm/Hg at 6:35 AM. The treatment sheet revealed that there was no documented evidence that the PCT notified an RN of the out-of-range blood pressure reading. 6. Patient #7’s treatment sheet dated 07/29/2025 revealed Patient Care Technician (PCT) #2 documented that the patient’s blood pressure was 98/58 mm/Hg at 7:04 AM and heart rate was 57 bpm at 8:32 AM and 59 bpm at 9:08 AM. The treatment sheet revealed PCT #4 documented that the patient’s blood pressure was 93/57 mm/Hg at 6:32 AM and heart rate was 57 bpm at 8:00 AM and 57 bpm at 9:30 AM. The treatment sheet revealed that there was no documented evidence that the PCTs notified a registered nurse (RN) of the out-of-range blood pressure and heart rate readings. Patient #7’s treatment sheet dated 08/05/2025 revealed PCT #3 documented that the patient’s heart rate was 58 bpm at 9:34 AM, 58 bpm at 10:09 AM, and 59 bpm at 10:24 AM. The treatment sheet revealed that there was no documented evidence that the PCT notified an RN of the out-of-range heart rate readings. Patient #7’s treatment sheet dated 08/09/2025 indicated there was no documented evidence that the staff monitored the patient from 8:06 AM through 9:06 AM. On 08/15/2025 at 1:25 PM, PCT #2 stated that the PCTs checked vital signs every 30 minutes and reported high blood pressure readings of greater than 150 and below 100 systolic, diastolic blood pressures less than 60 or above 100, and heart rates above 100 or less than 50. PCT #2 stated that when this happened, she should notify the nurse and document the notification. PCT #2 stated that she did this regularly but occasionally forgot. On 08/15/2025 at 2:27 PM, RN #10 stated that the PCTs monitored the patients every 30 minutes but did not always report to the nurses, so the nurses conducted rounds every hour. On 08/12/2025 at 4:21 PM, the Facility Administrator (FA) confirmed that it was the facility expectation for PCTs to report to the RNs per facility policy and to document the notification. On 08/15/2025 at 2:00 PM, the Medical Director confirmed that it was the facility expectation for PCTs to report out of range vital signs to the RNs per facility policy.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50873 Based on record review, interview, and facility policy review, the facility failed to implement the dialysis prescription as ordered for 5 (Patients #1, #2, #3, #4, and #7) of 7 sampled patients. Findings include: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated that patient monitoring should include, “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” 1. Patient #1’s treatment sheet dated 08/04/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed the patient’s BFR was 300 from 10:55 AM through 12:33 PM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. An “Orders Summary Report” for Patient #1 showed an order for the patient to receive 3,000 units of heparin every treatment starting on 07/19/2025. Patient #1’s treatment sheets for 07/28/2025, 07/30/2025, 08/01/2025, 08/04/2025, 08/06/2025, and 08/08/2025 revealed no documented evidence that heparin was administered to the patient. On 08/13/2025 at 4:03 PM, the Clinic Manager (CM) confirmed the facility expectation for heparin to be administered as ordered. The CM described that all orders were based on the treatment schedule and that when a patient changed their regular treatment schedule all the treatment orders had to be manually changed by staff to reflect the new days of the week, and surmises that this was not done. The CM stated that if it was not done, a medication label would not be printed out on the day of treatment to trigger staff that the patient was prescribed the medication. 2. Patient #2’s treatment sheet dated 08/05/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed the patient’s BFR was 300 from 6:54 AM through 7:32 AM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. 3. Patient #3’s treatment sheet dated 08/05/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed that the patient’s BFR was 300 from 5:27 AM through 6:03 AM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. 4. Patient #4’s treatment sheet dated 07/30/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed that at 3:02 PM the treatment BFR was decreased to 300. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. Patient #4’s treatment sheet dated 08/04/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed that the patient’s BFR was 300 from 12:05 PM through 12:31 PM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. Patient #4’s treatment sheet dated 08/08/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed that the patient’s BFR was 300 from 1:36 PM through 3:00 PM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. 5. Patient #7’s treatment sheet dated 08/05/2025 indicated that the prescribed blood flow rate (BFR) was 350. The treatment sheet revealed that the patient’s BFR was 300 from 5:57 AM through 6:33 AM and 7:34 AM through 8:33 AM. The treatment sheet revealed that there was no documented evidence of a rationale for the deviation from the patient’s prescription. On 08/15/2025 at 1:25 PM, Patient Care Technician (PCT) #2 stated that if a PCT was having trouble with the BFR the nurse should be notified and that the notification to the nurse should be documented. PCT #2 stated that this was something they did regularly but occasionally forgot. On 08/15/2025 at 2:27 PM, Registered Nurse (RN) #10 stated that if the staff was unable to achieve the prescribed BFR they should document that, including a rationale, even if the reason was access flow testing. On 08/12/2025 at 4:21 PM, the Clinic Manager confirmed that the facility expectation for when the BFR was not run as ordered the staff should document a rationale as well as RN notification. On 08/12/2025 at 4:21 PM, the Facility Administrator stated that if the reason the BFR was not achieved as ordered due to access flow testing the staff should document that the BFR was 300 for access flow and then after access flow testing was completed, the staff should document that the testing was completed. On 08/15/2025 at 2:00 PM, the Medical Director confirmed the facility expectation that staff should document deviations from the ordered BFR, even during access flow testing.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to assess patients’ access sites prior to cannulation per facility policy for 2 of 2 observations of access cannulation. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, indicated that the pre-treatment access site assessment included “Look. Listen. Feel.” On 08/12/2025 at 11:49 AM, Patient Care Technician (PCT) #7 was observed at patient treatment Station 6 initiating dialysis treatment for a patient with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). PCT #7 cleaned the access site with paper towels and soap and water, applied alcohol to the access site, applied a tourniquet, and cannulated the access site. PCT #7 failed to auscultate the access site prior to cannulation. On 08/12/2025 at 11:49 AM, PCT #6 was observed at patient treatment Station 2 initiating dialysis treatment for a patient with an AVF or AVG. PCT #6 cleaned the access site with paper towels and soap and water, applied a tourniquet, applied alcohol to the access site, and cannulated the access site. PCT #6 failed to auscultate the access site prior to cannulation. On 08/12/2025 at 2:36 PM, PCT #7 stated that to assess an AVF or AVG the staff were to feel and listen to the access site. PCT #7 confirmed that he did not listen to the patient’s access site prior to cannulation at patient treatment Station 6 and that it was due to him rushing. On 08/12/2025 at 3:17 PM, PCT #6 stated that to assess an access site prior to cannulation, the staff should look, listen, and feel and use a stethoscope. PCT #6 confirmed that she did not auscultate the patient’s access site prior to cannulation at patient treatment Station 2. PCT #6 stated that it was her normal practice to auscultation prior to cannulation but she forgot to bring her personal stethoscope to work that day. PCT #6 confirmed that the facility provided stethoscopes for the staff, but she did not get one. On 08/15/2025 at 2:00 PM, the Medical Director confirmed that it was the facility’s expectation that staff auscultate the patient’s access site prior to cannulation.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the medical director failed to ensure that medication administration was not signed off prior to completion of administration for 2 of 3 observations of medication administration. Findings include: A facility policy titled, “Medication Preparation and Administration,” published 07/07/2025 indicated that “Medications must not be signed off prior to administration.” On 08/13/2025 at 3:27 PM, Registered Nurse (RN) #9 was observed to administer parenteral medication to a patient receiving treatment at Station 1. RN #9 was observed to sign off the medication, then administered the medication. Immediately after the observation, the finding was discussed with RN #9 who confirmed that the medication was signed off prior to administration. On 08/13/2025 at 3:40 PM, RN #8 was observed to administer parenteral medication to a patient receiving treatment at Station 6. RN #8 was observed to sign off the medication, then administered the medication. Immediately after the observation, the finding was discussed with RN #8 who confirmed that the medication was signed off prior to administration. On 08/15/2025 at 2:00 PM, the Medical Director confirmed that medications should be documented after administration.”