Fmc - South Miami

“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: 47207 Based on observation, policy review and interviews, the facility failed to ensure that a Patient Care Technician (PCT) followed the standard infection control precautions for 1 out of 17 sampled patients by not cleaning a chair properly after the patient left the dialysis area. Patient #7 Findings include: On August 12, 2025, at approximately 10:05 AM, Staff G / PCT was observed cleaning Station #12 which had been previously used by Patient #7. Staff G/ PCT had taken the patient back out to the lobby area and had begun to clean the chair. Staff G/ PCT stopped and then came back to cleaning the chair, but she did not open up the sides of the chair. The surveyor then asked Staff G/ PCT if the sides opened up, she stated, “yes”. Staff G/ PCT opened the sides up, cleaned the inside areas and then closed them without allowing them to air dry. On August 12, 2025, at approximately 3:00 PM, the Clinical Manager was made aware of this as well as the Director of Operations who did an in-service with the staff. Review of the facility’s policy titled Clinical Services Cleaning and Disinfecting the Dialysis Station published on 09/05/2023, Reference number 47806 revealed it included but was not limited to: Procedure 3. Place the chair in the Trendelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. 4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by the manufacturer.”

“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: 47207 Based on observation, policy review and interviews, the facility failed to ensure that a Registered Nurse (RN) followed appropriate hand hygiene standard for 1 out of 17 sampled patients during the initiation of dialysis via a Central Venous Catheter (CVC). Patient #8 Findings include: On August 12, 2025, at approximately 9:50 AM, Staff E/ RN was observed setting up Patient #8 for dialysis. During the process of disinfecting the CVC hubs, Staff E/ RN stopped, went to the dialysis machine, touched the screen and came back to the patient; Before touching the patient, Staff E/ RN removed his gloves and then put on another pair of gloves without cleaning his hands. At this point, Staff E/ RN connected sterile syringes to the ports. Review of the facility’s policy titled Clinical Services Hand Hygiene published on 11/06/2023, reference number 47664 revealed it included but was not limited to: Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Policy Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water when: .Before and after direct contact with patients .Entering and leaving the treatment area .Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications .Immediately after removing gloves .After contact with inanimate objects near the patient .When moving from a contaminated body site to a clean body site of the same patient. On August 12, 2025 at approximately 2:30 PM, the Clinical Manager was made aware of this as well as the Director of Operations who did an in-service with staff.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 47207 Based on medical record review, policy review and interviews, the facility failed to complete an unstable monthly Plan of Care (POC) report for 1 out of 17 sampled patients. Patient #2 Findings include: During a record review on August 15, 2025, at approximately 1:30 PM, Patient #2’s record was reviewed. A POC documented an unstable POC meeting was completed on 06/26/2024. Further record review revealed the POC was signed on 08/30/2024 by the staff and on 09/10/2024 by the patient. Additionally, there was no follow up POC for July 2024 indicating if the patient had been found to be stable or unstable in July 2024. During an interview on August 15, 2025, at approximately 2:00 PM, the Clinical Manager was asked why the POC from June 26, 2024 was not signed until 08/30/2024 by staff and not until 09/10/2024 by the patient, she stated that Patient #2 had not been in the facility between the months of June and July of 2024 which was why there was no POC for July 2024. The Clinical manager was shown physician’s notes from July 27, 2024 that indicated Patient #2 had been seen by the physician in the facility that day. She stated, we missed that chance to have the POC signed by staff and the patient.”

“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: 47207 Based on medical record review, policy review and interviews, the facility failed to ensure that staff completed an initial assessment for 1 out 17 sampled patients prior to starting In-Center Hemodialysis. Patient #4 Findings include. During a record review on August 15, 2025, at approximately 11:30 AM, Patient #4’s record was reviewed. A Plan of Care (POC) documented a 90 days was being completed for the patient. A note on the final page of the POC document states,”Reason for Overdue: Patient was hospitalized during the last meeting, this meeting is being held due to a change in modality from Home to In-center.” A review of Patient #4’s chart showed no Initial Assessment was completed prior to the patient going to In-Center Hemodialysis treatment. A review of the facility’s titled Policy Comprehensive Interdisciplinary Assessment and Plan of Care revealed under Documents provided by the Patient’s Attending Physician prior to Admission, “Provide documentation including a current history and physical or hospital or clinic discharge summary prior to the patient’s first visit.” During an interview conducted on August 12, 2025, at approximately 3:10 PM, the Clinical Manager was asked if there had been an initial assessment completed by nursing prior to Patient #4 starting In-Center Hemodialysis, she reviewed the patient’s records stating, “No, we did not do one.””