Fmc Tranquility

“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: 35561 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure one of five Patient Care Technicians (Patient Care Technician (PCT)1) and one of two Registered Nurses (RN)2) observed during care delivery, implemented proper infection control measures during monitoring, and discontinuation of dialysis. Failure to use recommended infection control practices increases the risk of cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all patients receiving treatment in the dialysis unit. Findings include: 1. During observation on the treatment floor on 08/11/25 at 12:30 PM, RN2 was observed silencing a machine alarm at Station 15 where Patient (Patient (P)9) was receiving a dialysis treatment by using a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. 2. During observation on the treatment floor on 08/12/25 at 12:15 PM, RN2 was once again observed silencing a machine alarm at Station 17 where P11 was receiving a dialysis treatment by using a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. During an interview on 08/12/25 at 3:10 PM, RN2 was asked what the correct procedure was when silencing an alarm on the treatment floor, RN2 stated, “I know the right thing to do, I’m sure I was busy and just didn’t take the time.” 3. During observation on the treatment floor on 08/12/25 at 12:25 PM, PCT1 was observed silencing a machine alarm at Station 2 where P10 was receiving a dialysis treatment by using a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. During an interview on 08/13/25 at 12:45 PM, PCT1 was asked what the correct procedure was when silencing an alarm on the treatment floor, PCT1 stated, “Put the glove on your hand.” 4. During observation on the treatment floor on 08/13/25 at 11:15 AM, PCT1 was observed silencing a machine alarm at Station 20 where P14 was receiving a dialysis treatment with a bare hand, no glove. During an interview on 08/13/25 at 12:45 PM, PCT1 was asked what the correct procedure was when silencing an alarm on the treatment floor, PCT1 stated, “Put a glove on your hand.” 5. During observation on the treatment floor on 08/13/25 at 11:40 AM, PCT 1 was observed completing a machine setup at station 18 prior to the patient’s arrival. PCT1 completed this setup without donning gloves. During an interview on 08/13/25 at 12:45 PM, PCT1 was asked why station 18 set up was completed without gloves, PCT1 stated, “I know you’re supposed to wear gloves, I must have just forgot that time.” During an interview on 08/13/25 at 3:20 PM, the Clinical Manager stated, “the RNs and PCTs have all been taught the importance of hand hygiene and when to wear gloves. These observations are not in accordance with our infection control policy.” Review of the facility’s policy’s titled, “Personal Protective Equipment” dated 11/06/23 indicated, “Personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid resistant-gowns, and gloves, must be worn to protect employee from blood or other potentially infectious materials.””

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 35561 Based on observation, interview, and review of facility policy, the facility failed to ensure one of five Patient Care Technicians (Patient Care Technician (PCT)1) observed during care delivery, wore personal protective equipment (PPE) properly when performing procedures during which risk of exposure to blood or other potentially infectious material might occur. Failure to wear appropriate protection while providing care in the treatment area, presents a potential for cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all patients receiving treatment in the dialysis unit. Findings include: During observation on the treatment floor on 08/12/25 at 11:45 AM, PCT1 was observed completing a tear down of used, bloody dialysis equipment at station 4 after the patient had been discharged. It was noted that PCT1’s hair, which was long and hung freely over the shoulders and the PPE gown, came into contact with the bloody, used equipment. When PCT1 was questioned about whether the contact was felt, PCT1 stated “oh thanks, I didn’t realize it.” On 08/13/25 at 11:45 AM, PCT1 was observed discontinuing dialysis for Patient (P)14) at station 18. When leaning over to remove needles from the patient’s arm, PCT1’s hair hung freely over the shoulders and was long enough to contact the arm and the bloody needle sites as PCT1 worked with P14. On 08/13/25 at 12:35 PM, PCT1 was observed discontinuing dialysis for P15 at station 12. P15 was a known Cimex lectularius (bed bug) carrier and was under special precautions at the facility. PCT1’s long hair remained loose and hung freely over PCT1’s shoulders and down the front of the PPE gown. When PCT1 leaned over to release the patient’s feet to a sitting position, PCT1’s hair came into direct contact with P15’s blanket. Several minutes later, when PCT1 leaned over to adjust the blood pressure cuff to obtain another post dialysis blood pressure, PCT1’s hair came into direct contact and was potentially contaminated with P15’s head and hair. During an interview on 8/13/25 at 12:45 PM, immediately after P15’s care was completed, PCT1 was informed of the above observations, and of the potential contamination to self and others by bed bugs. PCT1 stated “I never realized any of that.” Review of the facility’s policy’s titled, “Personal Protective Equipment” dated 11/06/23 indicated, “Personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid resistant-gowns, and gloves, must be worn to protect employee from blood or other potentially infectious materials.” During an interview on 08/13/25 at 2:00 PM, the bed bug protocol and the observations noted above was reviewed with the Facility Charge Nurse, who stated, “these observations do not meet the requirements of our infection control policy.””

“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: 35561 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure two of two Registered Nurses (Registered Nurse (RN)1 and RN2) for two of two patients (P)6 and P12), followed recommended procedure while administering intravenous (IV) medications . Failure to use recommended procedures by healthcare personnel while administering medications has the potential to decrease the safety and effectiveness of the prescribed medication for all patients in the facility. Findings include: On 08/11/25 at 11:15 AM, RN2 was observed administering the IV medication ceftazidime (a cephalosporin antibiotic used to treat various bacterial infections) to P6 at Station 12 who was undergoing a dialysis treatment. RN2 was observed preparing the medication in an IV bag of solution and attaching the IV tubing so that the medication could be delivered by IV pump slowly over time. RN2 was then observed attaching the tubing to the arterial bloodline pigtail port and starting the IV infusion. When questioned at the time of the observation, RN2 explained that the facility’s policy required them to administer all antibiotics through the arterial port (which is pre-dialyzer) during the last 15 minutes of the dialysis treatment. On 08/12/25 at 2:00 PM, RN1 was observed administering the IV medication ceftazidime to P12 at Station 9 who was undergoing a dialysis treatment. After preparation of the IV bag and tubing with the medication additive, RN1 was then observed attaching the tubing to the arterial bloodline pigtail port and starting the IV infusion. When questioned at the time of the observation, RN1 stated that the facility policy required them to administer all antibiotics through the arterial port (which is pre-dialyzer) during the last 15 minutes of the dialysis treatment. During a subsequent interview on 8/13/25 at 1:15 PM, RN1 was asked whether administering antibiotic medication pre dialyzer would allow that medication to be dialyzed, or filtered out to some degree, RN1 stated “I never thought about it that way, which was just the way I was taught to do it.” Review of the facility’s policy titled “Medication Preparation and Administration” dated 07/07/25 indicated, “Drug: Antibiotics ... Route of Administration: IV infusion ...Venous Drip Chamber Medication Pigtail line* ... An asterisk (*) indicates the preferred site of administration due to efficiency, efficacy, safety, or cost effectiveness.” During an interview on 8/13/25 at 3:00 PM, the Facility Charge Nurse acknowledged that the facility’s policy required the IV infusion of ceftazidime, to be given through the venous pigtail port (post dialyzer) to decrease the risk of removal by the high flux (a type of hemodialysis filter that uses a membrane with high permeability to remove molecules from the blood) dialyzer. The Charge Nurse stated, “often we even give this antibiotic after the dialysis treatment has been discontinued to ensure effectiveness of the drug.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 35561 Based on observation and interview, the facility failed to ensure one of two Registered Nurses (RN)2 implemented for two of two patients (P)2 and P8) recommended infection control measures during initiation of dialysis through a Central Venous Catheter (CVC) access, (a large plastic tube placed in a vein in the neck or groin for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment). Failure to use recommended infection control practices increases the relative risk for bacteremia in patients with dialysis catheters. This deficient practice had the potential to affect 18 current and all future facility patients that dialyzed with CVC accesses. Findings include: On 08/11/25 at 1:15 PM, RN2 was observed initiating hemodialysis for P2 with a CVC access at Station 4. In preparation to aspirate (withdraw) blood from each of the limbs of the CVC, RN2 uncapped two sterile 10-millimeter syringes at the same time and placed them on a pad at the patients chairside. While attempting to aseptically cleanse each of the catheter limbs, RN2 inadvertently, and without recognizing it, touched the sterile tip of these syringes to other unsterile equipment laying on the same pad. RN2 then proceeded to connect the two syringes, which had been contaminated, to each limb of the catheter. On 08/12/25 at 12:50 PM, RN2 was observed initiating hemodialysis for a patient, P8, with a CVC access at Station 14. In preparation to aspirate blood from each of the limbs of the CVC, RN2 uncapped two sterile 10-millimeter syringes at the same time and placed them on a pad at the patients chairside. RN2 then requested additional alcohol wipes. PCT2 brought several alcohol wipes to the chairside and without recognizing it, laid them on top of the exposed sterile tips of the 10-millimeter syringes. RN2 proceeded to connect the two syringes, which had been contaminated, to each limb of the catheter. When questioned, RN2 responded “I didn’t realize the syringes touched anything else, I couldn’t tell.” During an interview on 08/13/25 at 3:25 PM, these findings were discussed with the Facility Charge Nurse at which time the Charge Nurse responded, “We should not open the sterile supplies until we are ready to use them. These observations do not meet the requirements of our infection control policy for care of a central venous catheter.””