032561 Casa Grande Dialysis (Fmc)

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure the facility Emergency Cart and Emergency Evacuation boxes which contain emergency medications, supplies, equipment, and patients ’ personal health information were locked and secured when not in use.This deficient practice poses the potential risk of unauthorized access to protected health information (PHI), removal and/or tampering of supplies and equipment that then may not be available and accessible when needed in an emergency. Findings include: The facility policy titled “Emergency Medications, Equipment, and Supplies” requires: “...The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible and immediately available: Automated External Defibrillator ...Oxygen masks/cannulas ...Emergency medications ...Suction machine, disposable catheter, and canisters ...Disposable Ambu Bag with face mask ...IV solutions and administration sets ...Cardiac back board ...Oral Airway ...CPR pocket mask ...Emergency Cart ...The medications ans supplies outlined in this policy must be maintained at the facility for emergency use ...The emergency cart must be: ...Locked when not in use ...Emergency Evacuation Box ...An emergency evacuation box must: Be available to grab in case of fire or the immediate need to evacuate the clinic. Contain all patient and staff emergency contact information. Be locked when not in use ...Emergency Medications ...Calcium Chloride ...Sodium Bicarbonate ...Diphenhydramine ...Epinephrine ...Solu-Medrol ...Dextrose ...or Glucagon kit ...Naloxone ....” Observation on 11/17/2025, revealed two (2) emergency evacuation boxes that were unlocked and unsecured as well as an unlocked emergency cart. The boxes and cart contained various emergency medications, supplies, equipment, and patient records/information. Employee #2 confirmed on 11/17/2025, that the emergency cart and emergency evacuation boxes were not locked and secured as required.”

“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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff cleaned and disinfected the dialysis station and equipment between patients which poses a potential risk of infection through cross contamination and contact transmission of pathogenic organisms. Findings include: The facility policy titled “Cleaning and Disinfecting the Dialysis Station” requires: “ ...The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors...a dialysis station must be cleaned and disinfected between dialysis patients ...the nature of dialysis treatments with frequent exposure to blood and body fluids, close proximity of patients and staff, and the immunocompromised status of dialysis patients make dialysis a high-risk area for spreading infectious disease ...Dialysis station...Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment...Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment....” Observation on 11/17/2025, revealed Employee #10 cleaning station #4. Employee #10 used a bleach solution to disinfect the station. Employee #10 did not disinfect the Hansen hoses, acid/bicarbonate concentrate hoses, or the back of the machine. Observation on 11/17/2025, revealed Employee #33 cleaning station #7. Employee #33 used a bleach solution to disinfect the station. Employee #33 did not disinfect the Hansen hoses, acid/bicarbonate concentrate hoses, or the back of the machine. Observation on 11/17/2025, revealed Employee #19 cleaning station #16. Employee #19 used a bleach solution to disinfect the station. Employee #19 did not disinfect the acid/bicarbonate concentrate hoses or the back of the machine and missed parts of the Hansen hoses. Observation on 11/17/2025, revealed Employee #33 cleaning station #5. Employee #33 used a bleach solution to disinfect the station. Employee #33 did not disinfect the Hansen hoses, acid/bicarbonate concentrate hoses, or the back of the machine. Employees #1 and 2 confirmed on 11/17/2025, that staff did not appropriately clean and disinfect the dialysis stations as required by 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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure: staff appropriately labeled multi-dose medication vials when opened and discarded expired medication vials. This deficient practice poses a risk that patients may receive expired, ineffective, or contaminated medication. staff discarded used single dose Parsabiv vials after administration. This deficient practice of failing to discard used and open, single dose medication vials that lack an antimicrobial preservative to inhibit growth of pathogenic microorganisms poses an increased risk of infection if a patient receives a contaminated medication. Findings include: 1. and 2. The CDC “Injection Safety” guidelines revealed: “...Unsafe injection practices put patients and healthcare providers at risk of infectious and non-infectious adverse events...Safe injection practices are part of Standard Precautions and are aimed at maintaining basic levels of patient safety...Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare provider...A SINGLE-DOSE VIAL (SDV) is approved for use on a SINGLE patient for a SINGLE procedure or injection. SDVs typically lack an antimicrobial preservative. Do not save leftover medication from these vials. Harmful bacteria can grow and infect a patient. DISCARD after every use...MDVs typically contain an antimicrobial preservative to help limit the growth of bacteria...Discard MDVs when the beyond-use date has been reached....” 1. Policy titled “Medication Preparation and Administration” requires: “...When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT (if allowed by state regulations), must place the date and time the vial was opened on the medication label along with their initials ...Label any open mulit-dose vial that is not used immediately and store vial accordingly ...Any open multidose vials must be discarded 28 days after opening or per manufacturer ’ s expiration date....” Observation on 11/17/2025, revealed the following: An open, multidose vial of Lidocaine HCL dated 8/10/25 with initials, no time labeled An open, multidose vial of Lidocaine HCL dated 9/27/25 with initials, no time labeled Employee #23 confirmed on 11/17/2025, that the above listed medication vials were not labeled and discarded appropriately according to policy. The policy titled “Medication Preparation and Administration” did not delineate instructions for use of single dose vials. However, the vial label revealed that this was a single dose vial without any preservatives. Observation on 11/17/2025, revealed the following: An open, single dose vial of Parsabiv in the medication refrigerator labeled with the date 4/20/25, and not discarded as if the vial was being saved for multiple administrations. An open, unlabeled vial of Parsabiv in the medication refrigerator without any date/initials on the label, and not discarded as if the vial was being saved for multiple administrations. Employee #2 confirmed on 11/17/2025, that the above listed medication vials were not discarded after single use as required.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure medications were locked or otherwise secured when not in use. This deficient practice poses the potential risk of unauthorized access to medication and the potential for tampering or other compromise to the integrity of medications being administered to patients. Findings include: The facility policy titled “Medication Preparation and Administration” requires “...Securement...All medications will be kept in a locked cabinet except when in use...One key to the medication cabinet will be kept by the charge nurse/team leader. The Clinical Manager will retain a spare key, kept in a secure location....” Observation on 11/17/2025, revealed multiple drawers located at the nurses station that contained a combination of injectable and topical medication for in center administration that were unlocked and unsecured including Vancomycin, Cefazolin, Cefepime, Heparin, Lidocaine, Exept, Sodium Thiosulfate, Triple Antibiotic ointment, Calcium Gluconate, and Glucose. Additionally, Fresenius Rx patient home medications were found in two (2) drawers that were unlocked and unsecured. Further observation on 11/17/2025, revealed an open vial of Heparin left out on the counter at the nurses station, unattended. Employee #23 confirmed that the medication drawers were unlocked and that the vial of Heparin was not secured when not in use. Observation on 11/18/2025, revealed two (2) drawers located at the nurses station that contained a combination of injectable and topical medication for in center administration that were unlocked and unsecured Employee #1 and 2 confirmed on 11/18/2025, that staff did not secure medications when not in use as required by policy.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 37489 Based on document review and interview, it was determined that that facility failed to ensure: 1. the medical record for (2) of (4) patients (Patients #6 and 8) contained a discharge summary that was signed by the patient’s nephrologist within 30 days of the patient’s discharge or that included a description of the patient ’ s medical condition at discharge.This deficient practice poses a potential risk for an incomplete medical record and may disrupt continuity of patient care if the patient ’ s condition is not assessed within 30 days of discharge; and 2. the medical record contained against medical advice (AMA) forms for (4) of (9) shortened treatments for Patient #1. This deficient practice has the potential risk of incomplete medical records and continuity of care. Findings include: 1. The policy titled “Documenting Progress Notes, Transfers, Transplants, Discharges and Order Review” requires: “...Discharge Documentation ...The nurse will complete the discharge summary assessment in eCC for each discharged patient ...within 30 days of a patient being discharged from the facility. Additional discharge notes will be documented by other disciplines if required by state regulations (ex. AZ)....” The document titled “AZ State Regulations” requires: “...After the patient ’ s discharge from a dialysis facility the nephrologist responsible for the dialysis services provided to the patient documents the patient ’ s discharge in the patient’s medical record within 30 days after the patient ’ s discharge and includes: ...description of the patient ’ s medical condition and the dialysis services provided to the patient, and the signature of the nephrologist ....” Patient #6 Date of discharge: 09/25/2025 The “FMCNA Discharge Summary” form was completed and signed by the patient’s nephrologist on 10/28/2025. Patient #8 Date of discharge: 09/08/2025 The “FMCNA Discharge Summary” form did not contain a description of the patient ’ s medical condition and the dialysis services provided to the patient. Employee #2 confirmed on 11/17/2025, that Patients #6 and 8’s medical records did not contain a completed and signed discharge summary within 30 days as required. 2. The facility policy titled “Early Termination or Arriving Late for Treatment” requires: “...Treatment duration and frequency is prescribed by a patient’s provider...Patients requesting early termination of a treatment....will be referred to the supervising registered nurse. The registered nurse (RN) will evaluate the patient and discuss with the patient their reasons...If the patient’s reasons for terminating the treatment early are due to complications of the treatment such as cramping, discomfort, or anxiety, the RN will discuss these issues with the patient ...and provider...The RN who evaluates the patient must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment ...The RN is responsible to notify the provider, and document on the ’ AMA ’ , or Against Medical Advice form....” Patient #1 Patient #1 ’ s medical record revealed the ordered treatment time was 3 hours and 45 minutes. The treatment sheet dated 11/11/2025 revealed the treatment time delivered was 3 hours. The treatment sheet dated 10/20/2025 revealed the treatment time delivered was 3 hours and 35 minutes. The treatment sheet dated 10/15/2025 revealed the treatment time delivered was 3 hours and 33 minutes. The treatment sheet dated 10/08/2025 revealed the treatment time delivered was 3 hours and 30 minutes. The medical record did not contain AMA forms with the patient’s request to terminate treatment early on the above listed dates, nor rationale for why the treatments were not delivered as ordered. Employees #1 and 2 confirmed on 11/19/2025, that Patient #1 ’ s medical record did not contain AMA forms or documentation for rationale that treatments were not delivered as ordered.”