Fresenius Kidney Care Southern Broward

“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: 40153 Based on observations, interviews, and chart review, the facility failed to ensure proper hand hygiene during initiation of dialysis via a central venous catheter (CVC) for 1 of 9 patients observed (Patient #15). The findings included: A chart review revealed that Patient #15 was admitted to the facility on 10/28/2024 for in-center hemodialysis. In an observation conducted on 08/04/25 at noon, Staff R, Licensed Practical Nurse, was observed initiating dialysis via CVC for Patient #15. She washed her hands, placed a pile of new gloves and supplies on the chairside bare surface without placing the clean items on a clean surface. She then put on a pair of gloves from the pile and touched the dialysis machine and dialyzer. She removed her dirty gloves and proceeded to touch the access site without washing her hands in between. During this entire observation, she replaced her gloves 3 times using the pile of gloves on the bare surface of the chairside. In an interview conducted on 08/05/25 at 2:00 PM with the Clinical Manager, she was made aware of the findings.”

“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: 51535 Based on observation and staff interview, the facility failed to ensure all equipment was maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by the staff failure to ensure the emergency supplies are readily available for use prior to the manufacturers documented expiration date. The findings included: An observation of the Home Hemodialysis Emergency Cart conducted on 08/04/25 at 2:30 PM revealed 10 cc normal saline (NS) flush x 12 syringes expired 06/25/25, non-woven gauze expired 5/27/25, and Island Dressing ZD Pore x 10 expired 02/2025. An interview conducted on 08/04/25 at 2:30 PM with the Clinical Manager (CM) who confirmed the expired supplies.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 40153 Based on interviews and record reviews, the facility failed to ensure that staff monitored dialysis treatments in a timely manner for 3 of 10 patients reviewed (Patient #1, Patient #2, and Patient #8). The findings included: 1) A review of the facility ’ s policy titled “Patient Assessment and Monitoring” dated 05/01/2023 documents the following: “obtain blood pressure and pulse rate every 30 minutes or more as needed, but not to exceed 45 minutes or per state regulations.” A chart review revealed Patient #1 was admitted to the facility on 04/29/2025 for in-center hemodialysis. The dialysis treatment sheet for Patient #1 dated 07/31/2025 revealed that staff monitored and documented data at 2:03 PM and again at 2:51 PM, 48 minutes later. A chart review revealed Patient #8 was admitted to the facility on 08/08/2023 for in-center hemodialysis. The dialysis treatment sheet for Patient #8 dated 07/23/2025 revealed that staff monitored and documented data at 8:00 AM and again at 8:51 AM, 51 minutes later. In an interview conducted on 08/05/25 at 2:00 PM with the Clinical Manager she was made aware of the findings. 51535 2) A clinical record review conducted on 08/04/25 at 4:00 PM, revealed Patient #2, treatment record dated 07/22/2025 and 05/13/25 indicates the patient vital signs were not monitored every 30-45 minutes. On 07/22/2025 during dialysis treatment for Patient #2, the vital signs were documented at 15:31 and 16:30 which is a total of 59 minutes interval during the dialysis procedure. On 05/13/2025 during dialysis treatment for Patient #2, the vital signs were documented at 17:05 and 18:09 which is a total of 1 hour and 5 minutes interval during the dialysis procedure. The treatment records do not provide an explanation for the deviation of clinical monitoring every 30-45 minutes during the dialysis procedure.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 40153 Based on interviews and record review, the facility failed to ensure an initial nursing assessment was completed before the first dialysis treatment for 1 of 10 patients reviewed (Patient #1). The findings included: A review of the facility policy titled Comprehensive Interdisciplinary Assessment and Plan of Care dated 07/02/2023 documents the following: “a Registered Nurse must perform an assessment on patients new to dialysis and before initiation of their first treatment to determine immediate need.” A chart review revealed Patient #1 was admitted to the facility on 04/29/2025 for in-center dialysis. Further record review did not show an initial nurse screening was completed before the start of the first dialysis treatment. In an interview conducted on 08/05/25 at 2:00 PM with the Clinical Manager she was made aware of the findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 51535 Based on clinical record review, administrative record review and staff interview, the facility failed to provide evidence of developing a completed annual plan of care. This failure affected 1 of 10 sample patients reviewed (Patient #5). The findings included: A clinical records review on 08/04/25 at 5:30 PM for Patient #5 revealed an incomplete Plan of Care dated 01/03/25 without a patient signature. The review of the facility policy Comprehensive Interdisciplinary Assessment and Plan of Care, published 07/03/2023, documented, “The patient’s level of participation is determined by the patient. The patient must sign the plan of care to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” An interview conducted with Clinical Manager (helper) 08/04/25 at 5:45 PM, who confirmed the hard copy labeled Plan of Care, does not have the patient’s signature.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 40153 Based on interview and chart review, the facility failed to ensure a monthly physician’s notes were completed for 2 of 10 patients reviewed (Patient #9 and Patient #5). The findings included: 1. A review of the facility policy titled Comprehensive Interdisciplinary Assessment and Plan of Care” dated 07/02/2023 documents the following: “a minimum, monthly medical progress notes must be in every patient’s medical record that document that a physician or a non-physician has seen each patient. A record review revealed Patient #9 was admitted to the facility on 11/21/2024 for in-center hemodialysis. Further reviews revealed a monthly MD note was not completed for July 2025. In an interview conducted on 08/05/25 at 2:00 PM with the Clinical Manager she was made aware of the findings. 51535 2) Record review revealed Patient #5 started Home Hemodialysis (HHD) on 08/29/2019. A review of clinical records revealed no physician notes for March 2025, April 2025, and July 2025. An interview with the Clinical Manager (helper) on 08/05/25 at 9:00 AM, she acknowledges the months of March 2025, April 2025, and July 2025 are missing the physician monthly notes.”