Fmc Dialysis Services Forestville

“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: 44675 Based on observations, facility documentation, facility policy and interviews, the facility failed to ensure staff performed hand hygiene when removing gloves inbetween patients in accordance with facility policy. The findings include: Observations conducted on 7/29/25 during physician rounding identified at 10:05 AM Physician (MD) #1 applied gloves and went into Station #10 where a patient was treating, exited the station, removed his gloves and proceeded to apply a new pair of gloves without the benefit of hand hygiene. MD#1 then went to Station #11 and re-set an alarming machine where a patient was treating, he proceeded to apply hand sanitizer to his gloves and went back to Station #10. He then removed his gloves and proceeded to apply a new pair of gloves without the benefit of hand hygiene. He then went to Station #14 where a patient was treating, removed his gloves and proceeded to apply a new pair of gloves without the benefit of hand hygiene. He then went to Station #15 where a patient was treating, removed his gloves without the benefit of hand hygiene and proceeded to the lobby. Review of the hand hygiene policy directed that hands would be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water before entering and leaving the treatment area and immediately after removing gloves.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation and interviews, the facility failed to appropriately clean and disinfect the dialysis station after a hemodialysis treatment in accordance with facility policy. The findings included: i. Observation of Station #4 disinfection on 7/28/25 at 12:13 PM identified Staff Person #1 failed to clean the television arm, outside of the chair arm, left side of the dialysis machine, blood pressure cuff and sharps containers. Staff Person #1 was further observed placing the disinfected blood pressure cuff into non-disinfected container located on the dialysis machine. ii. Observation conducted on 7/30/25 at 10:15 AM identified during disinfection of hemodialysis station #16 after a patient treatment, Staff Person #1 failed to disinfect the drain lines from the machine to the wallbox and the sharps container attached to the machine. Staff Person #1 disinfected the wallbox and without the benefit of changing gloves and performing hand hygiene, then proceeded to disinfect the station chair. iii. Observation conducted on 7/30/25 at 10:25 AM identified during disinfection of hemodialysis station #17 after a patient treatment, Staff Person #1 failed to disinfect the drain lines from the machine to the wallbox. Staff Person #1 disinfected the wallbox and without the benefit of changing gloves and performing hand hygiene, then proceeded to disinfect the station chair. iv. Observation of Station #10 disinfection on 7/30/25 at 10:28 AM identified Staff Person #2 disinfecting the right side of the dialysis machine and hoses while Patient #1, who was seated to the left of the machine, was holding his/her sites following treatment. Review of the cleaning and disinfecting the dialysis station policy directed to use a cloth wetted with 1:100 bleach solution to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind chair), and to prevent cross contamination between patients, the previous patient must completely vacate the station before staff begin cleaning and disinfecting the dialysis station. Review of the hand hygiene policy directed to decontaminate using alcohol based hand rub or by washing hands with antimicrobial soap and water after contact with the dialysis wall box, concentrate, drain or water lines.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 38422 Based on observation during tour of the facility, and documentation review with facility staff on 07/29/25 at 11:00 AM, and other times throughout the day, the facility failed to maintain the physical environment to ensure the safety of the patients, the staff and the public. The finding includes: 1. The storage of equipment within an exit access corridor, not complying with the requirements set forth by the 2021 edition of the CSFSC section 7.1.10.1. 2. Rusted HVAC vents in the wall box on the treatment floor not providing a clean and sanitary environment.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47491 Based on clinical record review, interviews, and review of facility documentation and policies for one (1) of five (5) patients (Patient #7), the facility failed to address low blood pressures in accordance with facility policy. The findings included: Patient #7 had diagnoses which included end stage renal disease. Physician’s orders directed hemodialysis three (3) times weekly for four (4) hours per treatment, using a 2.0 potassium/3.0 calcium dialysate, a blood flow rate (BFR) of 350, dialysate flow rate (DFR) of autoflow 1.5 central venous catheter (CVC). Review of Patient #7’s treatment records identified the following: i. On 4/16/25 an intradialytic blood pressure of 85/61 and heart rate of 103 was recorded at 1:04 PM. The treatment record failed to identify the patient’s blood pressure was rechecked prior to or following the administration of 200 milliliters of normal saline, nor did it indicate the patient was assessed. The next intradialytic blood pressure of 90/70 and heart rate of 117 was recorded at 1:36 PM (thirty-two (32) minutes following the previous blood pressure). Patient #7’s blood pressure was not rechecked prior to or following the administration of 100 milliliters of normal saline, nor was an assessment documented. The next intradialytic blood pressure of 83/58 and heart rate of 116 was recorded at 2:02 PM at which time 100 milliliters of normal saline was administered, however the patient’s blood pressure was not rechecked prior to or following the intervention. Documentation indicated the nurse was informed, however the treatment record failed to identify an assessment was performed. The next intradialytic blood pressure taken was at 2:32 PM (thirty (30) minutes following the intervention) at which time the patient’s blood pressure improved to 102/76, however his/her heart rate remained elevated at 117. At 3:09 PM, a blood pressure of 91/64 and heart rate of 120 was recorded, 500 milliliters of normal saline was administered per charge nurse order, however the treatment record failed to identify a blood pressure recheck or nurse assessment was performed. ii. On 4/18/25, an intradialytic blood pressure of 84/40 was recorded at 1:43 PM. The nurse was informed, 100 milliliters of normal saline was administered, and the treatment goal was reduced to minimum, however, the patient’s blood pressure was not rechecked before or after the intervention was administered until 2:06 PM [twenty-three (23) minutes following the intervention]. iii. On 4/21/25, an intradialytic blood pressure of 95/59 was documented at 2:06 PM. The treatment record failed to identify the patient’s blood pressure was rechecked or that a nurse was informed. The next intradialytic blood pressure of 91/59 was recorded at 2:35 PM and was signed off by the nurse, however documentation failed to identify the patient’s blood pressure was rechecked or that the patient was assessed. The next intradialytic blood pressure of 67/54 was recorded at 2:47 PM. The patient was administered 200 milliliters of normal saline, had their blood pressure rechecked at 2:49 PM, and was recorded at 88/66. However, documentation failed to identify a nurse was informed of the patient’s low blood pressure reading or that an assessment was performed. Interview with the Director of Operations on 7/30/25 at 3:36 PM identified staff was to follow policy and/or blood pressure parameters established by the physician, to inform the nurse of the patient’s hypotension, documentation of the nurse’s assessment in the treatment record, and to inform the physician of the situation/event. Review of the Patient Assessment and Monitoring policy directed systolic blood pressures less than or equal to 100 millimeters/mercury were to be reported to the nurse. Review of the Hypotension policy directed, when treating hypotension, to recheck blood pressure and compare to the previous blood pressures, if the blood pressure was verified low, to place the patient in a modified Trendelenburg position, reduce ultrafiltration (UF) to 300 milliliters/hour or turn UF off, administer a normal saline bolus of 100 milliliters to 200 milliliters as ordered by the physician, and to monitor and document blood pressures every five (5) minutes until the patient returns to baseline or as ordered by the treating physician.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of six (6) hemodialysis patients review for weights (Patient #8) the facility failed to address with the physician the patient not meeting the prescribed target weight in the medical record per facility policy. The findings include the following: Patient #8 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a arteriovenous fistula (AVF) with an estimated dry weight (EDW) of 124 kg. Patient #8’s care plan dated 5/27/25 identified Patient #8 had an area of focus for blood pressure and fluid management with interventions that included to monitor fluid gains and discuss high weight gains with the patient, re-evaluate and assess dry weight and educate the patient on signs and symptoms of fluid overload. Review of Patient #8’s hemodialysis treatment sheets identified the following: i.. On 7/7/25 Patient #8’s post weight was 125.2 kg (1.2 kg above prescribed EDW). Patient #8’s pretreatment nursing assessment at 5:55 AM identified Patient #8 had dyspnea on exertion and 3+ lower leg and ankle edema. Patient #8’s post treatment nursing assessment at 10:30 AM identified Patient #8 stated breathing easier at discharge and was educated to limit oral fluids. Review of the flowsheet and nursing notes failed to identify Patient #8’s EDW not being achieved, the edema was reassessed at the end of treatment and if the charge nurse and/or physician was notified. ii. On 7/9/25 Patient #8’s post weight was 125.2 kg (1.2 kg above prescribed EDW). Patient #8’s pretreatment nursing assessment at 7:26 AM identified Patient #8 had dyspnea on exertion and bilateral 1+ ankle edema. At 7:32 AM Patient #8 was given three (3) liters of oxygen. Patient #8’s post treatment nursing assessment at 10:00 AM identified Patient #8 stated breathing easier at discharge and was educated to limit oral fluids. Review of the flowsheet and nursing notes failed to identify Patient #8’s EDW not being achieved, the edema was reassessed at the end of treatment and if the charge nurse and/or physician was notified iii. On 7/11/25 Patient #8’s post weight was 125.9 kg (1.9 kg above prescribed EDW). Patient #8’s pretreatment nursing assessment at 8:41 AM identified Patient #8 had dyspnea on exertion and bilateral 1+ ankle edema. It identified Patient #8 was on three (3) liters of oxygen during treatment for shortness of breath. Review of the flowsheet and nursing notes failed to identify Patient #8’s EDW not being achieved, the edema was reassessed at the end of treatment and if the charge nurse and/or physician was notified. iv. On 7/14/25 Patient #8’s post weight was 127.8 kg (2.8 kg above prescribed EDW). Patient #8’s pretreatment nursing assessment at 5:53 AM identified Patient #8 had dyspnea on exertion, bilateral 3+ lower leg edema and bilateral 2+ ankle edema. At 5:40 AM Patient #8 was given three (3) liters of oxygen. Patient #8’s post treatment nursing assessment at 10:43 AM identified Patient #8 stated breathing easier at discharge. Review of the flowsheet and nursing notes failed to identify Patient #8’s EDW not being achieved, the edema was reassessed at the end of treatment and if the charge nurse and/or physician was notified. Review of the patient assessment and monitoring policy identified that the nurse will reassess any edema at the end of the treatment. Review of the nursing supervision and delegation policy directed that the team leader/charge nurse should be notified of any post weight with a variance of 1.0 kg. The team leader/charge nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions are necessary.”

“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: 47491 Based on review of clinical records, interview, and review of facility policy and documentation for one (1) of five (5) patients (Patient #9) reviewed for adequacy, the facility failed to ensure a patient’s hemodialysis treatment was administered in accordance with physician’s orders. The findings included: Patient #9 had diagnoses which included end stage renal disease. Physician’s orders directed to hemodialysis three (3) times weekly for four (4) hours per treatment, using a 3.0 potassium/2.5 calcium dialysate, a blood flow rate (BFR) of 450, dialysate flow rate (DFR) of 800, utilizing a central venous catheter (CVC). Review of Patient #9’s Care Plan dated 4/29/25 identified an adequacy goal of 1.4 and that the patient will continue to meet adequacy. Review of Patient #9’s treatment sheets identified the following: On 6/17/25, Patient #9 treatment was administered at a BFR of 320 for the entirety of the treatment and a DFR of 500 from 2:41 PM to 3:47 PM without documentation of the rationale the physician’s ordered BFR of 450 and DFR of 800 were not achieved. Review of Patient #9’s adequacy identified a result of 0.97 on 6/17/25. Interview with the Director of Operations on 7/30/25 3:32 PM identified dialysis treatments should be run at the prescribed BFR, and if unachievable, staff should be documenting reason the prescribed BFR/DFR could not be attained in the electronic medical record. Review of the Patient Assessment and Monitoring policy directed to check that the prescribed blood flow is being achieved or to document, in the medical record, if unable to meet the prescribed blood flow rate, to check the dialysate flow rate setting was correct, and that the prescribed flow was being delivered.”

“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: 44675 Based on clinical records, facility policy and interviews for two (3) of five (5) patients, (Patient #3, #6,) reviewed for intradialytic vital signs, the facility failed to ensure vitals and/or machine parameters were addressed every thirty (30) minutes, for one (1) of five (5) patients reviewed for treatments (Patient #5), the facility failed to ensure the Against Medical Advice (AMA) form was completed according to facility policy, and nursing assessments were entered timely, and for two (2) of five (5) patients, (Patient #3 and #5), reviewed for treatment adherence, the facility failed to administer the patient’s dialysis treatment in accordance with physician’s orders, and during a flash tour of the treatment area, the facility failed to dispose of expired supplies that were located in the medication and crash cart. The findings included: . 1. Patient #3 had diagnoses which included end stage renal disease. Physician’s orders directed to hemodialysis three (3) times weekly for four (4) hours per treatment, using a 2.0 potassium/2.5 calcium dialysate, a blood flow rate (BFR) of 400 (which was changed to 350 on 6/5/25), dialysate flow rate (DFR) of autoflow 1.5, utilizing a central venous catheter (CVC). Review of Patient #3’s treatment records identified the following: i. On 5/31/25, an intradialytic blood pressure of 122/78 was administered at 6:30 AM, however the next intradialytic blood pressure was not taken until 7:37 AM (one (1) hour and seven (7) minutes following the previous reading). An intradialytic blood pressure of 143/122 was taken at 9:03 AM, however the next intradialytic blood pressure was not taken until 9:54 AM (fifty-one (51) minutes following the previous reading). ii. On 6/5/25, treatment was initiated at 6:23 AM and a blood pressure of 136/92 was taken, however, the next intradialytic blood pressure of 134/98 was not taken until 7:35 AM (one (1) hour and twelve (12) minutes following the previous reading). iii. On 6/7/25, treatment was initiated at 5:33 AM and a blood pressure of 144/113 was taken, however, the next intradialytic blood pressure of 128/89 was not taken until 6:30 AM (fifty-seven (57) following the previous reading). Further review of the treatment sheets identified: iv. On 5/29/25, Patient #3’s treatment was administered at a BFR of 350 for the entirety of the treatment without documentation identifying the reason the ordered DFR of 400 was not achieved. v. On 5/31/25, Patient #3’s treatment was initiated at a BFR of 400, but was lowered to 350 from 6:30 AM to 8:34 AM, then to 300 from 9:03 AM to 9:53 AM without documentation identifying the reason the ordered BFR of 400 was not achieved. vi. On 6/2/25, Patient #3’s treatment was initiated at a BFR of 400, but was lowered to 350 from 1:04 PM to 4:10 AM without documentation identifying the reason the ordered BFR of 400 was not achieved. vii. On 6/5/25, Patient #3’s treatment was initiated at a BFR of 400, but was lowered to 350 from 6:30 AM to 8:34 AM, then to 300 from 9:03 AM to 9:53 AM without documentation identifying the reason the ordered BFR of 400 was not achieved. viii. On 6/7/25, Patient #3’s treatment was administered at a BFR of 400 without documentation identifying the reason the ordered BFR of 350 was not entered. 2. Patient #6 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a left upper arteriovenous fistula (AVF) and 500 blood flow rate (BFR). A sample review of Patient #6’s hemodialysis flowsheets identified the following: i. On 7/3/25 at 9:33 AM Patient #6 had a vital sign check (blood pressure and pulse). The next vital signs and machine check was completed at 10:20 PM (47 minutes later). The flowsheet failed to identify whether a check was completed in between. ii. On 7/8/25 at 9:33 AM Patient #6 had a vital sign check (blood pressure and pulse). The next vital signs and machine check was completed at 10:24 PM (51 minutes later). The flowsheet failed to identify whether a check was completed in between. iii. On 7/19/25 at 9:03 AM Patient #6 had a vital sign check (blood pressure and pulse). The next vital signs and machine check was completed at 10:05 PM (1 hour and 2 minutes later). The flowsheet failed to identify whether a check was completed in between. iv. On 7/23/25 at 1:36 PM Patient #6 had a vital sign check (blood pressure and pulse). The next vital signs and machine check was completed at 2:35 PM (49 minutes later). The flowsheet failed to identify whether a check was completed in between. Review of the patient assessment and monitoring policy identified that vital signs should be checked every 30 minutes, not to exceed 45 minutes. Review of the patient assessment and monitoring policy identified that staff should check the prescribed BFR is being achieved, if not, document why the prescribed BFR is unable to be obtained. 3. Patient #5 had diagnoses which included end stage renal disease. Physician’s orders directed to hemodialysis three (3) times weekly for four (4) hours per treatment, using a 2.0 potassium/2.5 calcium dialysate, a blood flow rate (BFR) of 450, dialysate flow rate (DFR) of 800, utilizing a left upper arm arteriovenous fistula (AVF). Review of Patient #5’s treatment records identified the following: i. On 6/25/25, Patient #5’s treatment was initiated at 12:08 PM, however his/her pre-treatment assessment was entered into electronic medical record at 4:41 PM (four (4) hours and thirty-three (33) minutes after treatment was initiated). ii. On 6/27/25, Patient #5’s treatment was initiated at 11:10 AM, however his/her pre-treatment assessment was entered into the electronic medical record at 5:05 PM (five (5) hours and fifty-five (55) minutes after treatment was initiated). iii. On 7/11/25, Patient #5’s treatment was initiated at 10:54 AM, however his/her pre-treatment assessment was entered into the electronic medical record at 1:52 PM (two (2) hours and fifty-eight (58) minutes after treatment was initiated). Review of the nurse delegation policy identified that the nursing assessment will be completed within one (1) hour of treatment initiation. Further review of the treatment sheets identified the following: i. On 6/25/25, Patient #5 was administered treatment for three (3) hours and one (1) minute (fifty-nine (59) minutes short of the prescribed treatment time), however the facility was unable to provide a completed Against Medical Advice (AMA) form for the shortened treatment. ii. On 7/14/25, Patient #5 was administered treatment for two (2) hours and forty-five (45) minutes (one (1) hour and fifteen (15) minutes short of the prescribed treatment time), however, the facility was unable to provide a completed AMA form for the shortened treatment. iii. On 6/25/25, Patient #5 was administered treatment for three (3) hours and one (1) minute (fifty-nine (59) minutes short of the prescribed treatment time), however the facility was unable to provide a completed Against Medical Advice (AMA) form for the shortened treatment. iv. On 7/14/25, Patient #5 was administered treatment for two (2) hours and forty-five (45) minutes (one (1) hour and fifteen (15) minutes short of the prescribed treatment time), however, the facility was unable to provide a completed AMA form for the shortened treatment. Interview with the Director of Operations on 7/30/25 at 3:35 PM identified patients that shorten their treatments by greater than fifteen (15) minutes need to complete an AMA form. Review of the Early Termination or Arriving Late for Treatment policy directed the nurse, who evaluates the patient, to document the rationale for early termination, reinforce the consequences of not receiving the entire prescribed treatment, and was responsible to notify the physician and document on the Against Medical Advice (AMA) form. 6. During flash tour of the treatment area, the following observations were made: i. Thirteen (13) BD Safety Needles (22 gauge, 1.5 inch) in the medication cart with an expiration date of 12/31/24. ii. Two (2) nasal cannulas with an expiration date of 8/1/24. iii. Two (2) nasal cannulas with an expiration date of 8/10/24. Interview with the Charge Nurse on 7/28/25 at 10:00 AM identified supplies should be disposed of once expired. Review of the Expiration Dates of Sterile Supplies policy directed to appropriately dispose of sterile items that have reached their expiration date.”