Bma - Gainesville

“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: 53073 Based on observation and interview, the facility failed to ensure 1 of 6 staff, Staff A, ARNP (Advanced Registered Nurse Practitioner), followed acceptable infection control practices during the provision of dialysis care to include hand hygiene after doffing and before donning gloves. Findings include: During an observation on 9/9/25 at 9:10 AM, Staff A, ARNP was observed with a glove over her index finger only when reviewing the dialysis information on the chairside dialysis machine for Patient #22. Staff A then went to the next station for Patient #23, Staff A did not change the glove that was covering her index finger, did not perform hand hygiene, and engaged the buttons on the chairside dialysis machine for Patient #23 to retrieve dialysis information. Staff A then went to Patient #24’s station, removed the glove that was covering her index finger, did not perform hand hygiene, placed a new glove over her index finger, and engaged the buttons to the chairside dialysis machine for Patient #17 to retrieve information. Staff A then went to Patient #14’s station, removed the glove that was covering her index finger, did not perform hand hygiene, placed a new glove over her index finger, and engaged the buttons on the chairside dialysis machine to retrieve information. During an interview on 9/9/25 at 1:00 PM the Clinical Manager stated, “I have discussed this with [Medical Director’s name] many times as well as discussing it with my Director, [name of the Director]. I cannot write her up because she is not my employee. During an interview on 9/10/25 at 1:00 PM the Medical Director stated, “It is my expectation that staff perform hand hygiene and change gloves after they touch a dialysis machine and move in between seeing patients. I do not touch machines without having gloves on.” Review of the policy and procedure titled “Hand Hygiene,” last reviewed on 02/2025 read, “The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. All staff, patients, patient care givers, including physicians and non-physician practitioners, social workers, dieticians and any other indirect patient care staff must follow the same requirements for hand hygiene. Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Hands should be washed with soap and water or when alcohol-based rubs could be used as hands would be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water 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 parental medications, immediately after removing gloves, after contact with body fluids or excretion, mucous membranes, non-intact skin, and would dressings, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with the dialysis wall box, concentrate, drain, or water lines and after contact with other objects within the patient station or treatment space.””

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 53073 Based on observation and interview, the facility failed to ensure gloves were stored in a clean dry area to prevent contamination and the possible spread of infection for 1 of 6 staff, Staff C, Registered Nurse (RN). Findings Include: During an observation on 9/8/25 at 10:00 AM, Staff C, RN was observed to be storing gloves in her left side pants pocket, reaching into her pocket to get clean gloves three times after performing hand hygiene with alcohol-based gel. During an interview on 9/9/25 at 1:00 PM, the Charge Nurse stated, “Clean supplies should not be stored in the pockets, they should only be stored on the clean supply cart. We keep the clean supplies separate from the dirty supplies.” Asked Clinical Manager for policy that addressed glove use, was not provided with policy prior to the end of the survey. Review of the HSC (Health and Social Care) Public Health Agency Infection Control Manual Updated in June 2025, reviewed on 9/11/2025 read, “Gloves should be worn when exposed to blood and/or body fluids, secretions or excretions and when handling contaminated items and equipment. Inappropriate use of gloves is common among health workers. Gloves should be stored in their original packaging on a clean, dry surface away from sunlight or in a wall-mounted unit. Health care workers should not carry gloves in their clothes/uniform pockets.”

“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: 49777 Based on interview and record review the facility failed to ensure the monitoring of intradialytic blood pressures for 6 of 8 patients, Patients #2, #4, #5, #6, #7, and #8, sampled for dialysis treatment record reviews. Finding include: 1) Review of Patient #2’s dialysis treatment record dated 8/30/2025 documented intradialytic blood pressure readings of 95/69 at 6:35 AM; 84/58 at 7:02 AM; 91/58 at 8:00 AM; 93/67 at 9:31 AM and 90/65 at 10:04 AM. The record does not contain documentation that the nurse was notified of Patient’s #2’s hypotension by the Patient Care Technician (PCT). Dated 9/2/2025, documented intradialytic blood pressure readings of 92/59 at 9:30 AM and 95/60 at 10:01 AM. The record does not contain documentation the nurse was notified of Patient’s #2’s hypotension by the PCT. Dated 9/4/2025, documented intradialytic blood pressure readings of 98/67 at 8:31 AM; 93/66 at 9:32 AM; and 92/64 at 10:01 AM. The record does not contain documentation the nurse was notified of Patient’s #2’s hypotension by the PCT. Dated 9/8/2025, documented intradialytic blood pressure reading of 92/67 at 12:03 PM and 89/64 at 1:13 PM. The record does not contain documentation the nurse was notified of Patient’s #2’s hypotension by the PCT. During an interview on 9/9/2025 at 11:30 AM, the Charge Nurse stated, “[Patient #2’s name’s] blood pressures identified during the record review were outside of the parameters and should have been reported by the Patient Care Technician to the nurse for further assessment.” 53073 2) Review of Patient #4’s dialysis treatment record dated 9/1/25, documented a blood pressure reading at 8:01 AM with the subsequent documented blood pressure reading at 9:00 AM resulting in a gap of 61 minutes between blood pressure readings. Dated 9/5/25, documented a blood pressure reading at 7:04 AM with the subsequent documented blood pressure reading at 8:05 AM resulting in a gap of 64 minutes between blood pressure readings. Dated 9/8/25, documented a blood pressure reading at 8:39 AM with a subsequent documented blood pressure reading at 9:42 AM resulting in a gap of 63 minutes between blood pressure readings. 3) Review of Patient #5’s dialysis treatment record dated 8/27/25 at 12:31 PM documented a blood pressure reading of 97/59 and at 2:32 PM a blood pressure reading of 87/38. The treatment record did not contain documentation the nurse was notified of the blood pressure readings during the dialysis treatment. Dated 8/29/25 at 12:34 PM documented a blood pressure reading of 96/55. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Dated 9/03/25 at 11:43 AM documented a blood pressure reading of 133/37, at 12:03 PM documented a blood pressure reading of 150/37, at 12:32 PM documented a blood pressure reading of 89/60; a second check of the blood pressure reading taken at 12:32 PM documented a blood pressure reading of 93/48, at 1:32 PM documented a blood pressure reading of 160/40. The treatment record did not contain documentation the nurse was notified of the blood pressure readings during the dialysis treatment. 4) Review of Patient #6’s dialysis treatment record dated 8/18/25 at 7:10 PM documented a blood pressure reading of 186/104, at 8:01 PM documented a blood pressure reading of 96/70. The treatment record did not contain documentation the nurse was notified of the blood pressure readings during the dialysis treatment. Review of Patient #6’s dialysis treatment record dated 8/29/25, documented a blood pressure reading at 7:32 PM with a subsequent documented blood pressure reading at 8:37 PM resulting in a gap of 65 minutes between blood pressure readings. 5) Review of Patient #7’s dialysis treatment record dated 9/4/25, documented a blood pressure reading at 12:05 PM with a subsequent documented blood pressure reading at 1:01 PM resulting is a gap of 56 minutes between blood pressure readings. 6) Record review of Patient #8’s dialysis treatment record, dated 8/18/25 at 11:07 AM documented a blood pressure of 93/54, at 11:32 AM documented a blood pressure of 96/48, at 12:33 PM documented a blood pressure of 90/53. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Dated 8/22/25 at 11:31 AM documented a blood pressure of 88/62 and at 1:30 PM documented a blood pressure of 92/56. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Dated 9/1/25 at 11:03 AM documented a blood pressure reading of 96/55, at 11:30 PM documented a blood pressure reading of 96/55, and at 2:32 PM documented a blood pressure reading of 98/55. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Dated 9/5/25 at 11:07 AM documented a blood pressure reading of 97/66 and at 1:01 PM documented a blood pressure reading of 96/70. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Dated 9/8/25 at 11:30 AM documented a blood pressure reading of 98/56. The treatment record did not contain documentation the nurse was notified of the blood pressure reading during the dialysis treatment. Review of Patient #8’s dialysis treatment record for 8/22/25, documented a blood pressure at 12:07 PM with a subsequent blood pressure reading at 1:00 PM resulting in a gap of 67 minutes between blood pressure readings. During an interview on 09/10/25 at 12:30 PM, Staff D, RN stated, “The PCT should notify me when the patient has a low blood pressure. I will assess the patient and adjust the goal if needed and notify the physician and he will make changes to the patients’ blood pressure medications if needed or adjust the patients EDW [estimated dry weight] and I would document this in the treatment record.” During an interview on 09/10/25 at 1:30 PM, the charge nurse stated, “It is my expectation that when a low blood pressure reading is obtained that the PCT adjust the blood pressure cuff, recheck the blood pressure, and if no improvement they would notify the nurse. There should be documentation of the interventions that the RN [Registered Nurse] took. It is also my expectation that patients be checked [for blood pressure values] every 30-45 minutes like the policy states, we should be checking the blood pressure and machine settings.” Review of the policy and procedure titled “Patient Assessment and Monitoring”, with a last review date of April, 2025 read. “Purpose: The purpose of this policy is to provide guidance to FKC [Fresenius Kidney Care] direct care staff on assessment and monitoring patients before, during and after treatment. Data Collection: Direct patient care staff may collect data such as weight, BP [blood pressure], pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN [Licensed Practical Nurse] note any changes or abnormal findings in the patient’s condition or vascular access are observed and reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. Blood Pressure: Record blood pressure. Recheck blood pressure after a drop that requires interventions such as administering normal saline. Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: Systolic blood pressures greater than 180 mm/hg (millimeters of mercury). Diastolic blood pressures greater than 100 mm/hg. Blood Pressure less than or equal to 100 mm/hg systolic.” Review of the policy and procedure titled, “Patient Assessment and Monitoring” read, “The purpose of this policy is to provide guidance to FKC direct patient care staff on assessment monitoring patient before, during, and after treatment. During treatment obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes.””

“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: 49777 Based on record review and interview the facility failed to ensure the prescribed blood flow rate (BFR) was followed for 5 of 8 patients, Patients #2, #4, #5, #7, and #8, in-center hemodialysis patients reviewed, failed to ensure the prescribed dialysate flow rate (DFR) was followed for 3 of 8 patients, Patients #3, #4, and #8, in-center hemodialysis patients reviewed, and failed to ensure the physician was notified a prescribed post estimated dry weight was over the prescribed dry weight for 1 of 8 patients, Patient #6, in-center hemodialysis patients reviewed. Findings Include: 1) Review of Patient #2’s physician ordered dialysis treatment record dated 8/21/2025, documented a prescribed blood flow rate of 450. Review of Patient #2’s dialysis treatment record dated 8/21/2025, documented Patient #2’s blood flow rate was set at 300 eight times during the dialysis treatment. The dialysis treatment record dated 8/21/2025 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. During an interview on 9/8/2025 at 11:24 AM, the Charge Nurse stated, “Staff should have documented the reason why the blood flow rate was lowered [for Patient #2] and there is no documentation in the record to show why it was lowered.” Review of Patient #3’s dialysis treatment order dated 8/13/2025, documented a physician prescribed dialysate flow rate of 500. Review of Patient #3’s dialysis treatment record, dated 8/18/2025, documented the dialysate flow rate was set at 800 eight times during the dialysis treatment. The dialysis treatment record dated 8/18/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. Dated 8/22/2025 the dialysis treatment record documented the dialysate flow rate was set at 800 eight times during the dialysis treatment. The dialysis treatment record dated 8/22/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. Dated 8/25/2025 the dialysis treatment record documented the dialysate flow rate was set at 800 nine times during the dialysis treatment. The dialysis treatment record dated 8/25/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. Dated 8/29/2025 the dialysis treatment record documented the dialysate flow rate was set at 800 seven times during the dialysis treatment. The dialysis treatment record dated 8/29/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. Dated 9/03/2025 the dialysis treatment record documented the dialysate flow rate was set at 800 seven times during the dialysis treatment. The dialysis treatment record dated 9/03/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. During an interview on 9/10/2025 at 1:30 PM, the Charge Nurse stated, “Staff should have documented the reason why the dialysate flow rate was set at 800 [for Patient #3] and there is no documentation in the record to show why the treatment prescription was not followed.” 53073 2) Review of Patient #4’s dialysis treatment order dated 7/11/25, documented a prescribed dialysate flow rate (DFR) of 500. Review of Patient #4’s dialysis treatment record dated 8/25/25, documented the dialysate flow rate was set at 700 nine times during the dialysis treatment. The dialysis treatment record dated 8/25/2025 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. 3) Review of Patient #5’s dialysis treatment order dated 7/16/25, documented Patient #5 was prescribed a BFR of 450 and prescribed a DFR of 800. Review of Patient #5’s dialysis treatment record, dated 9/3/25, documented the blood flow rate was set at 400 two times and set at 300 four times during the dialysis treatment. The dialysis treatment record dated 9/3/25 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. Dated 9/8/25 the dialysis treatment record documented the blood flow rate was set at 400 five times. The dialysis treatment record dated 9/8/2025 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. 4) Review of Patient #7’s dialysis treatment order dated 8/28/25 documented a prescribed BFR of 450. Review of the dialysis treatment record documented on 8/28/25 the BFR was set at 400 seven times during the dialysis treatment. The dialysis treatment record dated 8/28/2025 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. Dated 9/4/25 the BFR was set at 300 two times, set at 350 four times, and set at 400 two times during the dialysis treatment. The dialysis treatment record dated 9/4/25 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. Dated 9/6/25 the BFR was set at 400 six times. The treatment record dated 9/6/25 contained documentation the nurse was made aware of the decrease in the BFR once during the dialysis treatment. 5) Review of Patient #8’s dialysis treatment order dated 6/27/25, documented a prescribed BFR of 400. Review of the dialysis treatment record for Patient #8 dated 8/18/25 documented the BFR was set to 450 two times during the dialysis treatment. The dialysis treatment record dated 8/18/25 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. Dated 9/8/25 the BFR was set to 350 six times during the dialysis treatment. The dialysis treatment record dated 9/8/25 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. 6) Review of Patient #4’s dialysis treatment order dated 7/11/25, documented a prescribed BFR of 450. Review of Patient #4’s dialysis treatment record dated 8/25/25 documented the BFR was set at 700 nine times during the dialysis treatment on 8/25/25. The dialysis treatment record dated 8/25/25 did not contain documentation of the change in the blood flow rate from the physician prescribed rate. Review of Patient #8’s dialysis treatment order dated 6/27/25, documented a prescribed dialysate flow rate (DFR) of 800. Review of Patient #8’s dialysis treatment record dated 8/18/25 documented the dialysate flow rate was set at 500 eight times during the dialysis treatment. The dialysis treatment record dated 8/18/25 did not contain documentation of the change in the dialysate flow rate from the physician prescribed rate. Dated 9/8/25 the dialysis treatment record documented the dialysate flow rate was set at 500 six times during the dialysis treatment. The dialysis treatment record dated 9/8/25 did not contain documentation of the change in the dialysis flow rate from the physician prescribed rate. Review of Patient #6’s dialysis treatment order dated 7/4/25 documented Patient #6 was prescribed a post estimated dry weight (EDW) of 104.6 kg (kilograms). Review of Patient #6’s dialysis treatment record dated 8/18/25, documented Patient #6’s post weight as 106.3 kg. The dialysis treatment record did not contain documentation of the nurse notification to the physician of Patient #6’s post weight being above the prescribed EDW. Dated 8/27/25 the dialysis treatment record documented Patient #6’s post weight as 105.9 kg. The dialysis treatment record did not contain documentation of the nurse notification to the physician of Patient #6’s post weight being above the prescribed EDW. Dated 9/3/25 the dialysis treatment record documented Patient #6’s post weight as 106.1 kg. Review of the dialysis treatment record did not contain documentation of the nurse notification to the physician of Patient #6’s post weight being above the prescribed EDW. During an interview on 9/10/25 at 1:30 PM the Charge Nurse stated “I expect the nurse to talk to the patient about fluids after every treatment if it is needed and if they [patients] are leaving greater than their EDW, I expect them [the nurse] to call the doctor and get an order for an extra treatment. I try to review the EDW’s every week.” Review of the policy and procedure titled, “Patient Assessment and Monitoring” read, “Purpose: The purpose of this policy is to provide guidance to FKC [Fresenius Kidney Care] direct patient care staff on assessment and monitoring patients before, during and after treatment. E. Machine Parameters and Extracorporeal Circuit: Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. Post-Treatment: Follow the steps below for obtaining post-treatment assessment data: 1. The direct patient care staff may obtain the following: Weight: Obtain the patient’s post weight. Ensure the post weight is consistent with the goal set of the machine.””

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 49777 Based on interview and record review, the facility failed to ensure clinical information pertaining to a patient is centralized in the patient’s record for advance directives, and failed to maintain the clinical information in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment for 2 of 13 patients, (Patient #2 and #17) in-center patients reviewed. Findings include: Review of Patient #2’s advance directives documented a State of Florida Do Not Resuscitate form (DNR) signed by Patient #2’s health care proxy and physician on 4/1/2025. Review of Patient #2’s current advance directive resuscitation order reads, “Full Code” dated 4/3/2025. During an interview on 9/9/2025 at 12:35 PM, the Charge Nurse stated, “The order for resuscitation is accessible at chair side in the dialysis machine. In our file cabinet, we have the names of patients who are DNRs posted in red and each of these patients have a red folder. The order should be DNR not Full Resuscitation.” Review of Patient #17’s advance directive documented a State of Florida Do Not Resuscitate form signed by the patient and nephrologist on 7/18/2016. Review of Patient #17’s current advance directive resuscitation order reads, “Full Code” dated 8/9/2022. Review of the electronic medical record screen shot for Patient #17 reads, “DNR expired on 6/25/2021 and was not renewed with a DNR status.” During an interview on 9/9/2025 at 12:40 PM the Social Worker stated, “During the patient’s initial assessment, annual assessment, and when requested, the patient’s resuscitation status is discussed. I document updates in the medical record. I am not flagged when resuscitation orders come up for renewal. There was a question voiced by the rehabilitation center where [Patient #2’s name] resides about [Patient #2’s name] capability to make decisions. The brother of [Patient #2’s name] was contacted and he completed the DNR section of the Florida form. I cannot speak to why the medical record order does not reflect the DNR status.” During an interview on 9/10/2025 at 12:55 PM, the Medical Director stated, “Code Status needs to be accurate in the medical record and at chair side.” Review of the policy and procedure titled, “Florida State Specific: Do Not Resuscitate” with a last review date of February, 2025, read, “Policy: A Do Not Resuscitate (DNR) Order or Advance Directive that complies with state law and is provided to the dialysis facility will be honored. A patient may change or revoke his/her resuscitative status at any time and in accordance with the Do Not Resuscitate Policy. Florida State Specific Types of Do Not Resuscitate Orders: Florida only recognized the DNR Order (otherwise know as the Department of Public Health (DH) Form 1896) (DNRO) issued by the Florida Department of Health. Requirements for Do Not Resuscitate Orders: The patient’s attending physician may issue a DNRO. The DNRO form is approved by the Florida Department of Health and is printed on yellow paper with “DO NOT RESUSCITATE ORDER” printed in black across the top. The DNRO requires the: - Signature of the patient, or if the patient is incapable of providing informed consent, the patient’s surrogate, proxy, court appointed guardian, or durable power of attorney. - Name, date, signature, license number and telephone for the patient’s physician. NOTE: Any copies of the DNRO should be made on yellow paper.””