Fresenius Kidney Care Parkland

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to have a readily functional emergency suction equipment available, and failed to identify and remove expired items in the emergency evacuation cart. The findings included: An observation of the emergency cart was conducted on 10/30/28 at 11:00 AM with the Registered Nurse (RN). The RN was instructed to demonstrate that the emergency suction equipment was operational. The RN could not get the emergency suction equipment to operate. The RN stated the emergency suction equipment was missing “a piece”. An observation of the emergency evacuation cart was conducted with the RN on 10/30/24 at 11:30 AM. The observation revealed a Cardiopulmonary (CPR) mask with an expiration date of 06/18/22, and a bag of alcohol wipes with an expiration date of 05/2023. The acting Facility Administrator was informed of the above on 10/30/24 at 12:00 PM.”

“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: 36734 Based on observation and interview, the facility failed to maintain a sanitary treatment area. The findings included: An observation of the treatment area was conducted on 10/28/24 at 11:00 AM. A countertop was observed with multiple card board boxes containing supplies. Further observation of the counter drawer revealed an open bag of crackers. An interview was conducted with the Registered Nurse (RN) on 10 28/24 at 12:00 AM. The RN acknowledged the card board boxes should be discarded. The RN further stated she did not know where the opened bag of crackers came from, and they should not be in the treatment area.”

“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: 36734 Based on observation and staff interview, the facility failed to ensure that expired blood tubes and disposable gloves be identified and discarded prior to its use. This failed practice placed 1 of 5 patients (patient #2) reviewed at risk for cross-contamination. The findings included: An observation of the treatment area on 10/28/24 at 12:55 PM revealed red top lab tubes with an expiration date of 07/31/24 and blue top lab tubes with an expiration date of 05/02/24 were in the supply cabinet. Five boxes of gloves were observed with an expiration date of 02/2024. The expired gloves were observed donned and worn by Staff A, a Patient Care Tech (PCT) to provide care for Patient #2. disposable face shield and alcohol pads in the ambulatory emergency supply cart were expired. In an interview on 10/30/24 at 2 PM, the charge nurse stated “I will remove and discard these items. I also informed Biomed about the expired gloves and he has removed them from the area.””

“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: 36734 Based on record review and interview, the facility failed to complete an initial assessment prior to the start of treatment for 1 of 5 patients reviewed (Patient #3). The findings included: Patient #3 was admitted to the facility for treatment on 08/19/24. Record review revealed Patient #3 did not have an initial assessment prior to the start of treatment. An interview was conducted with the acting Facility Administrator (FA) on 10/29/24 at 3:00 PM. The FA acknowledged the above.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to identify a patient as unstable for 1 of 5 patients reviewed (Patient #1). The findings included: A review of the facility’s policy Comprehensive Interdisciplinary Assessment, dated 04/24/19, documented: Unstable patients must be reassessed by the Interdisciplinary Team (IDT) monthly. Monthly reassessment and any Plan of Care (POC) updates related to the reason the patient is considered “unstable” must be documented until the issues have been resolved or the IDT determines that the condition is chronic. The following are unstable criteria: Extended or frequent hospitalizations: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days, or b. More than 3 admissions in the last 30 days OR Marked deterioration in health status- IDT to identify and document the specific reason. Patient #1 was admitted to the facility on 03/06/23. A record review revealed Patient #1 was admitted to the hospital on 04/01/24, 04/17/24, and 05/01/24. A review of Patient #1’s last Plan of Care (POC) meeting date, dated 06/28/24, documented an annual POC deeming the patient as stable. There was no documentation of Patient #1 being deemed as unstable for the month of 05/2024. An interview was conducted with the acting Facility Administrator (FA) on 10/30/24 at 10:00 AM. The FA stated Patient #1 should have been identified as unstable.”

“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: 36734 Based on record review and interview, the facility failed to use the prescribed treatment for 1 of 5 patients reviewed (Patient #2). The findings included: Patient #2 was admitted to the facility for treatment on 03/13/23. Record review revealed a “special attentions” order dated 08/05/24 for 1.0 K (potassium) bath for 1 hour if the potassium level was above 5.3, and 1.0 K bath the entire treatment if potassium is 6.0 and higher. A review of Patient #2’s records revealed the patient had a potassium level of 5.4 level on 10/14/224. A review of Patient #2’s treatment record dated 10/21/24 documented the patient received 2.0 bath the entire treatment. Further review of Patient #2’s record revealed the patient had a potassium level of 6.2 on 10/21/24. A review of Patient #2’s treatment record dated 10/23/24 revealed the patient received a potassium treatment of 2.0 K the entire treatment. An interview was conducted with the acting Facility Administrator (FA) on 10/29/24 at 3:00 PM. The FA acknowledged the above.”