Fkc Middletown

“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: 52387 Based on observation, interview and review of facility’s policy and procedure, facility’s staff failed to maintain emergency supplies in one of one emergency cart located in the facility’s home dialysis suite. Findings include: 1.Observation on 02/11/25 at 9:22 AM in the facility’s home dialysis suite revealed an emergency cart containing emergency supplies. Observation in a drawer labelled “six” of the emergency cart revealed a Bemis suction container (reference number 424410) with and expiration date of 08/01/20. Interview with Registered Nurse (RN) 18 who was present during the observation stated, “ I did not know the Bemis suction container was expired.” 2. Observation on 02/11/25 at 9:28 AM of the facility’s home hemodialysis treatment room revealed a storage cupboard. Observation of the cupboard revealed three standard infusion sets with Lot #s (32483401) and expiration date of 11/30/24, The infusion sets were co-mingled with unexpired patients’ supplies. Interview with RN18 revealed he/she had checked the cupboard but did not identify that the infusions sets were expired. Review of the facility’s policy and procedure titled “Emergency Medications, Equipment and Supplies,” revised on 02/03/25 directs staff as follows: “Purpose. The purpose of this policy is to provide guidelines for staff when determining and maintaining emergency equipment and supplies. . .The following minimum emergency supplies and equipment must be on the premises at all times, clean functional accessible and immediately available: Automated External Defibrillator (AED) Oxygen, tubing, and masks/cannulas Emergency medications Suction machine, disposable catheter, and canisters Disposable Ambu Bag with face mask IV solutions and administrative sets Cardiac {back board} Oral airway CPR pocket mask.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22676 Based on review of glucometer logs, interview, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the correct control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results for all 69 incenter patients receiving care at the facility. Findings included: Review of electronic “Blood Glucose Logs” for the treatment unit, from 01/02/25 through 01/31/25 revealed the following: Review of the meter for the treatment unit labeled serial number AN-GM-04084-907 for January revealed: on 01/18/25, the recorded acceptable low control range was 86-116, the recorded low control was 118. There was no documentation that the low-level and high-level control had been repeated. During an interview on 02/11/25 at 1:30 PM, the Facility Administrator confirmed the findings and agreed the staff did not repeat the low-level and high-level control as required by the manufacturer’s instruction. Review of the facility’s policy titled, “Blood Glucose Monitoring Device,” dated 11/06/2023, revealed ...Reviewing the glucometer instructions for use ... Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision date 09/2020 revealed, “ ...p. eleven, if the “test fall outside the range printed on the test strip vial, repeat the test ...””

“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: 22676 Based on medical record reviews, interviews, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for one of five sampled in-center dialysis patients (Patient (P)3). Failure to follow the medical providers’ plan for the dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 69 patients receiving in-center dialysis treatments at this facility. Findings include: A review of P3’s electronic medical record (EMR) revealed a prescribed Blood Flow Rate (BFR) of 400 milliliters per minute (ml/min). A review of two of six “Post Treatment” flowsheets from 02/01/25/ through 02/12/25 in the EMR indicated the following: a. On 02/01/25, the BFR was documented at 350 ml/min from 07:49 AM until 11:39 AM. b. On 02/04/25. The BFR was documented at 350 ml/min from 8:300AM until 11:47 AM. There was no documentation for the change to the prescribed BFR. During an interview on 02/12/25 at 10:30 AM, the Charge Nurse II 3, confirmed the above findings and confirmed that the staff did not follow the physician’s plan for the dialysis treatments. A review of the facility’s policy titled, “Unable to Achieve Prescribed Blood Flow Rate” dated 11/01/21, revealed, “Notify physician/extender if unable to achieve prescribed blood flow rate. Document in the patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician’s orders.””