062585 North Greeley Dialysis (Fmc)

“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: 45020 Based on observations, document review, and interviews, the facility failed to ensure clinical staff demonstrated compliance when dispensing and administering intravenous (IV) medication from vials. Specifically, the facility failed to label an open multi-dose vial (MDV) with the date and time it was opened according to facility policy in one of two observations conducted in the medication preparation area. Findings include: Facility policy: The Medication Preparation and Administration policy read, the purpose of this policy is to administer medications with the goals of staff and patient safety, optimal therapeutic response and infection control. When preparing medications, if the vial is not used immediately in its entirety, the nurse or patient care technician (PCT) must place the date and time the vial was opened on the medication label along with their initials. To ensure all open vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the date and time the vial was opened. Label any open multi-dose vial that is not used immediately and store vial accordingly. 1. Facility staff failed to label a multi-dose vial of medication with the date and time it was opened according to facility policy. A. Observation i. On 9/15/25 at 8:57 a.m., an observation of the facility’s medications revealed an open MDV of heparin (a blood thinner) on a countertop in the medication preparation area. There was no date or time on the vial to indicate when the medication had been opened. During the observation, PCT #1 stated they were unsure of the date or time it was opened, which was a risk for infection. This observation and the statement made by PCT #1 were in contrast to the Medication Preparation and Administration policy, which stated medication must be labeled with the date, time, and initials of the person opening the vial. B. Interviews i. On 9/17/25 at 8:47 a.m., an interview was conducted with PCT #2. PCT #2 stated when a MDV was opened, the staff member was expected to label the vial with the date, time, and their initials. PCT #2 stated if the vial was not dated when it was opened, there was a risk the medication could lose effectiveness, and not perform as intended. ii. On 9/17/25 at 9:00 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated heparin was to be labeled with the date it was opened, the expiration date, time, and the initials of the staff member who opened the vial. RN #3 stated if the medication was not labeled appropriately, expired, and was then administered to the patient, there was a risk the medication could cause infection which could lead to sepsis (a life-threatening immune response to an infection which triggers widespread inflammation and organ damage).”

“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: 45020 Based on document review and interviews, the facility failed to follow the individualized dialysis prescription for blood flow rate (BFR) and dialysis flow rate (DFR) as ordered by the medical provider in five of forty-two in-center patient treatment sheets reviewed. (Patient #1, #2, #3 and #6) Findings include: Facility policies: The Unable to Achieve Prescribed Blood Flow Rate policy read, the purpose of this policy is to provide troubleshooting guidelines if unable to achieve prescribed BFR. Achieving prescribed BFR is a critical parameter in achieving adequate treatment Kt/V. Staff will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate. Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The Patient Assessment and Monitoring policy read, the purpose of this policy is to provide guidance to staff on assessment and monitoring patients before, during and after treatment. Document machine parameters and safety checks every 30 minutes or more often as needed. Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed flow. Check dialysis flow rate setting is correct, and the prescribed flow is being delivered. 1. The facility failed to ensure patient care staff followed individualized dialysis prescriptions for BFR and DFR to ensure the effectiveness of patients’ prescribed dialysis treatments. A. Document Review i. A review of Patient #1’s treatment sheet from 9/3/25 revealed a prescribed BFR of 400 milliliters (mL)/minute (min). Patient #1’s treatment started at 12:00 p.m. At 1:37 p.m., the BFR was decreased to 325 ml/min. At 2:01 p.m., the BFR was decreased to 300 ml/min, where it remained until treatment ended at 3:27 p.m. On 9/12/25, Patient #1’s treatment sheet revealed a prescribed BFR of 400 ml/min. Patient #1’s treatment started at 11:15 a.m. At 2:01 p.m., the BFR was decreased to 300 ml/min, where it remained until treatment ended at 2:46 p.m. There was no documented rationale for the changes to the prescribed BFR on 9/3/25 and 9/12/25. ii. A review of Patient #2’s treatment sheet from 9/12/25 revealed a prescribed DFR of 800 ml/min. Patient #2’s treatment started at 6:18 a.m., with the DFR at 500 ml/min until 7:36 a.m., when it was increased to the prescribed 800 ml/min. The DFR then remained at the prescribed rate of 800 ml/min until treatment ended at 10:10 a.m. There was no documented rationale for the DFR decrease from 6:18 a.m. until 7:36 a.m. iii. A review of Patient #3’s treatment sheet from 9/9/25 revealed a prescribed BFR of 400 ml/min. Patient #3’s treatment started at 10:54 a.m., with the BFR at 300 ml/min until 12:01 p.m., when it was increased to the prescribed 400 ml/min. The BFR remained at 400 ml/min until treatment ended at 2:54 p.m. There was no documented rationale for the BFR decrease from 10:54 am until 12:01 p.m. iv. A review of Patient #6’s treatment sheet from 9/8/25 revealed a prescribed BFR of 400 ml/min. Patient #6’s treatment started at 5:52 a.m., with the BFR at 300 ml/min, where it remained until treatment ended at 9:00 a.m. There was no documented rationale for the changes to the prescribed BFR. B. Interviews i. On 9/17/25 at 8:05 a.m., an interview was conducted with patient care technician (PCT) #4. PCT #4 stated it was important to follow the physician’s orders to ensure the patients received adequate treatment. PCT #4 stated BFR was a prescription and if the BFR was decreased, it was to be documented and the nurse was to be notified. PCT #4 stated if the BFR was decreased, there was a risk the patient would not get adequate dialysis which could cause their health to decline. ii. On 9/17/25 at 9:00 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated the BFR and the DFR were prescribed by the physician. RN #3 stated they expected to be notified by the PCT if the BFR or DFR was decreased. RN #3 stated the reason for the BFR or DFR decrease was to be documented. RN #3 stated if the BFR or DFR was decreased, the patient’s blood would not be cleaned as well, which could cause the patient’s blood to have increased waste products as well as possible hyperkalemia (dangerously high level of potassium in the blood). These interviews were in contrast to the treatment sheet reviews which revealed patients’ BFRs and DFR had been decreased without a documented reason.”