Donate Medical Center

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 47207 Based on observations and interview, the facility failed to ensure their staff securely stored parenteral medications for 3 out of 15 sampled patients (Patient #4, Patient #7 and Patient# 11). Findings include: On June 24, 2025, at approximately 10:30 AM, the surveyor observed the patients being prepared for dialysis treatment. Further observation revealed that Patient# 4, Patient# 7 and Patient# 11’s tables had saline syringes which were left unattended for approximately 10 minutes on their respective patient tables. During an interview at approximately 10:45 AM, the surveyor asked the Registered Nurse (RN) / Staff B about the saline syringes, he stated, “The Patient Care Technicians (PCTs) probably brought them out to get the patients ready”. The RN/ Staff B then asked the PCTs to remove the syringes from the tables until they were ready to be used.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 47207 Based on observations and interviews, the facility failed to ensure that 1 out of 15 sampled patients followed proper hand hygiene before dialysis treatment. Patient #12 Findings include: Observations were made on 06/24/2025 at approximately 10:25 AM. Patient #12 came into the dialysis center and proceeded to sit in the dialysis chair after being greeted by the Patient Care Technician (PCT)/ Staff H. The surveyor observed that the graft site looked wet. The Facility Administrator asked Patient #12 in Spanish, why the graft site was wet and if she had just washed it? Patient #12 replied she had washed her hands and graft site at home and then applied a numbing agent to the area at home. When the surveyor asked if the patients wash their hands in the facility, the Facility Administrator stated, “We ask them to, usually they will tell us they washed their hands at home”. On 6/27/2025 at approximately 2:00 PM, the Facility Administrator and Owner both stated that Patient #12 is a transient patient, and she is going back home, and her home facility should have told her about washing her hands and graft site. The surveyor stated that this facility should have made sure the patient washed her hands and graft in the center before dialysis and then applied the pain killing ointment.”