Fresenius Kidney Care Imperial Point

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 51535 Based on observation and interview, the dialysis facility failed to provide a sanitary environment as evidenced by dust and dirt located through out the treatment room and failure to ensure proper storage of the dialysate calcium acetate. The findings included: An observational tour of the facility and treatment areas was conducted on 04/16/25 at 11:29 AM An observation was made of a sink labeled as “Dirty” located in front of the nurse’s station. Underneath the sink has scattered debris, a large container of cloudy gray water with large black particles, and cardboard covered with black debris. An interview was conducted with Staff A at the time of the observation and he acknowledges the container of water. He immediately removed, emptied, and returned the empty container underneath the sink. An observation conducted on 04/16/25 at 11:35 AM of the windowsill (upper and lower) near the emergency crash cart revealed a thick coat of gray dust and debris present inside of the windowsills. An observation of the nurse’s station base (right corner) covered with gray dust, copious amounts of black specks of debris, and two (half-filled) dialysate acetate jugs housed in the right corner of nurse’s station. Interview was conducted with the Registered Nurse at the time and she acknowledges dust, debris, and dialysate acetate. She immediately removed the two jugs, discarded content, and cleaned the area to remove dust and debris. Review of administrative policy “General cleanliness and infection control guidelines”, dated 11/04/2024, documented all areas must be kept clean and organized, including but not limited to treatment areas ... must be kept clear of debris and free of clutter.”

“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: 51535 Based on observation , and review of facility policy, the facility staff failed to perform hand hygiene as evidence by lack of hand hygiene when removing gloves. The findings included: Observation at 04/17/25 at 12:57 PM of patient care technician (PCT) POD 2 initiating dialysis procedure, ungloved one hand, went to the supply cabinet, obtain supply with ungloved hand, returned to dialysis station, placed glove on ungloved hand and resumed patient care with assistance from other staff members. During general observation, at 1:15 PM 1 RN and 2-3 PCT were centrally located in POD 2 and POD 3 initiating procedure, terminating procedures, answering machine alarms and assisting patients. The staff sanitize and wash hands inconsistently while assisting patients, touching patient equipment, and answering machine alarms at other stations. Review of Administrative policy “Hand Hygiene”, published 11/06/2023, document, Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water: Before and after direct contact with patient, before performing vascular access cannulation, immediately after removing gloves, and after contact with inanimate objects near the patient.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 51535 Based on observation and interview , the facility failed to ensure the patients in view of staff during hemodialysis treatment to ensure patient safety. This affected the POD 1 area. Observation conducted on 04/16/25 at 11:07 AM of POD 1, patients receiving dialysis, Staff B left the floor area at 11:07 AM and returned 11:12 AM (5 minutes); no staff observed in the area to monitor or observe patients while receiving dialysis. On 04/16/25 at 12:45 PM - 1:00 PM, an observation of the patient at station #1, station #2, and station #5, receiving hemodialysis treatment. During observation, the surveyor did not observe any staff member in or near POD 1 for at least 15 minutes. An interview was conducted with Staff member A on 04/16/25 at 1:05 PM. The surveyor informed staff member A, that the patients have not been in view or observed by staff a member for at least 15 minutes (12:45 PM - 1:00 PM). He stated, “the tech is here but he is in back”. 1:12 PM- Patient Care Technician (PCT) at station #1, station #2, and station #5 is here speaking with the patients, and documenting on treatment sheet. She stated that she is covering for the tech which is on his lunch break. And she was busy with another patient who needed assistance. Additional interview with the PCT reports patient/ staff ratio 5:1 is not safe. “I am putting a patient on the machine and I’m relieving someone for lunch at the same time. It’s not safe, it’s too much. I start my day at 3:45 AM. I am unable to go to lunch until 3:45 PM ... no breaks. I have asked CM (A) and Director of Operations for us to return to patient/staff ratio 4:1 for patient safety. It’s hard to be in two places at one time. For example, Station #1 passing out, Station #5 machine alarming, Station 3 bleeding out. The floater is not assigned. PCT staff running around like crazy. Turn overtime- the RN does not provide assistance to staff at shift change. Patients are unhappy because of the switched times and switched techs.” 4/16/25 at 5:45 PM- An interview was conducted on 4/16/25 at 5:45 PM with Clinical Manager regarding patient /staff ratio. Per Clinical Manager, currently patient/staff ration is 5:1. Surveyor requested administrative policy for staffing ratio; policy not available. CM states 5:1 ratio is temporary.”

“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: 51535 Based on clinical record review, policy review and staff interview,the facility failed to monitor patients per policy for 3 of 3 clinical record reviews. (Patient #1, Patient #2 and Patient #3) The findings included: Patient #1 was admitted to the facility 03/12/25, a review of the patient’s treatment sheets revealed the blood pressure was not monitored every 30 minutes. 04/11/25- (15:30- 16:33) 1 hour 33 minutes 04/09/25- (16:32- 17:42) 1 hour 10 minutes 04/07/25- (14:59- 16:00) 1 hour 1 minute 04/04/25- (17:02- 17:56) 54 minutes Patient #2 was admitted to the facility 12/10/2022, a review of treatment sheets revealed the blood pressure was not monitored every 30 minutes. 04/16/25- (07:36- 08:36) 1 hour 0 minutes 07:36 - blood pressure 95/59 (no intervention noted) 04/14/25- (08:03- 08:41) 38 minutes Patient #3 was admitted to the facility 03/12/25, a review of the patient’s treatment sheets revealed the blood pressure was not monitored every 30 minutes. 04/14/25- (08:03- 08:42) 39 minutes 04/07/25- (08:04- 10:17) Blood Flow Rate/ Dialysate Flow Rate (BFR/DFR) not monitored 1 hour 47 minutes 04/04/25-(07:08- 08:01) 53 minutes 04/02/25-(09:04- 09:44) 40 minutes Review of administrative policy “Patient Assessment and Monitoring” published 05/01/2023, documents, 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. On 04/16/25 at 5:50 PM during an interview, an interview with clinical managers (A, B) who acknowledged and confirmed blood pressure monitoring exceeded 30-45 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: 51535 Based on clinical record review, the clinical staff failed to check prescribed blood flow rate/ dialysate flow rate is being achieved, or reason documented in the medical record if unable to meet prescribed blood flow for 2 of 3 patients reviewed for 2 of 3 clinical records reviewed (Patient #1, Patient #3) The findings included: The clinical record review conducted on 04/16/25 revealed patient #1 has physician orders for Blood Flow Rate (BFR) of 300 and Dialysate Flow Rate (DFR) 700. Treatment Records dated 04/09/25 indicate the patient did not receive the prescribed BFR 300 for 1 hour 10 minutes of 3 hours of treatment. The treatment records do not provide an explanation for the deviation from the dialysis prescription. Clinical record review conducted on 04/16/25 revealed patient #3 has physician orders for Blood Flow Rate (BFR) of 350 and Dialysate Flow Rate (DFR) 800. Treatment Records dated 04/07/25 indicate the patient did not receive the prescribed BFR 350 for 1 hour 47 minutes of 3 hours 30 minutes of treatment. The treatment records do not provide an explanation for the deviation from the dialysis prescription.”