Usrc Central Valdosta

“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: 52051 Based on observation, staff interviews, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility Policies and Procedures (P & P), it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN BB), and two of two Patient Care Technicians (PCT AA and PCT BB) observed, consistently performed hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) after removing contaminated gloves, between glove changes, and after touching contaminated equipment. Failure to wear gloves when touching contaminated surfaces and failure to perform hand hygiene increased the risk for cross contamination with the potential to expose all patients and staff to bloodborne pathogens in the dialysis environment. This deficient practice had the potential to negatively affect the health and safety of 47 in-center hemodialysis patients who were dialyzing at this facility and all direct patient care staff (RNs and PCTs) who worked at this facility. Findings include: During observation in the Patient Treatment Room between 8:41 a.m. and 10:41 a.m., the following was revealed: - At 9:09 a.m., PCT BB was charting on the terminal computer (considered dirty) located between Station (S) 5 and S6 without gloves on. - At 10:21 a.m., PCT AA was talking with Patient (P) #6 at S16 while wearing a glove only on her right hand. She subsequently removed the glove without sanitizing her hands immediately afterward. She then approached the terminal computer (considered dirty) located between S17 and S18 and began charting with her ungloved hands. PCT AA then left the area without sanitizing her hands. - At 10:23 a.m., RN BB was charting on the terminal computer located between S17 and S18 with ungloved hands. Afterward, she left the terminal without sanitizing her hands and proceeded to another terminal computer located between S13 and S14, where she continued to chart without wearing gloves. During staff interviews on 8/6/25 between 1:10 p.m. and 3:00 p.m., the following was revealed: At 1:10 p.m., RN BB stated that she was unsure of the policy regarding whether to wear gloves while charting on terminal computers. She acknowledged the importance of hand hygiene between glove changes. At 1:57 p.m., PCT AA recognized the observation and mentioned that staff members were making efforts to improve infection control practices. At 2:34 p.m., PCT BB indicated that she would begin wearing gloves when using the terminal computer and also acknowledged the previous observation. The CDC recommended healthcare workers to wash their hands immediately before touching a patient, after glove removal, after touching a patient’s equipment or surface, and after contact with body, bodily fluids, or contaminated surfaces. Additionally, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal. A review of Policy #C-IC-0060 titled, “Hand Hygiene” with latest revision date of August 2020, stated: HAND HYGIENE will be performed: 8. After touching patient surroundings (e.g., dialysis machine, any items in the dialysis area or chairside computers). 9. After gloves are removed. 11. After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station. A review of Policy #C-IC-0025 titled, “Personal Protective Equipment (PPE)”, with latest revision date of July 2023, stated: 5. Gloves: all individuals must wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. a. Clean gloves will be worn when documenting on integrated keyboard. 10. Hand hygiene is performed before donning and after doffing PPE. During a discussion with the Facility Administrator on 8/7/25 at 10:00 a.m., she confirmed that gloves should be worn by staff when using the terminal computer/integrated keyboard.”

“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: 52051 Based on a review of medical records, staff interviews, and a review of facility Policy and Procedures (P&P), it was determined that the facility failed to ensure that one of one patient (P) (P#4) sampled who experienced elevated blood pressure (BP) readings, received medical care/interventions appropriate to P#4’s dialysis needs. The professionally accepted clinical practice standards for volume status for an adult hemodialysis patient were euvolemic (normal volume of blood or fluids in the body) and BP below 140/90 mmHg (millimeters of mercury) before dialysis and below 130/80 mmHg after dialysis. This was based on the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations and the Measures Assessment Tool (MAT) per Centers for Medicare and Medicaid Services (CMS) - Version 2.5. Uncontrolled BP in dialysis patients can lead to severe consequences such as increased risk of heart attack, stroke, and heart failure, as the damaged kidneys are unable to regulate fluid and BP effectively, making cardiovascular complications a major concern for dialysis patients. The facility census was 47. Findings include: A review of P#4’s “Hemodialysis Flowsheet” from 7/23/25 to 8/6/25 revealed the following: On 7/30/25, P#4’s pre-treatment BP was 192/118 mmHg, and the pre-treatment assessment was conducted by Licensed Practical Nurse (LPN) AA. - At 4:23 a.m., LPN AA initiated P#4’s Hemodialysis (HD) treatment with a BP reading of 214/116 mmHg. It was documented that LPN AA notified the Charge Nurse. - At 4:24 a.m., BP was 184/114 mmHg - At 4:57 a.m., BP was 188/103 mmHg - At 5:24 a.m., BP was 200/114 mmHg - At 5:54 a.m., BP was 187/107 mmHg - At 6:24 a.m., BP was recorded at 200/111 mmHg by Patient Care Technician (PCT) CC and noted “B/P elevated”. However, there was no documentation indicating that the Charge Nurse was notified. - Post-treatment sitting and standing BP were 180/96 mmHg and 165/83 mmHg, respectively. P#4 was discharged to home. During the two-hour window shown above, there was no documentary evidence that the Charge Nurse assessed or reevaluated P#4, nor notified the doctor. On 8/1/25, during P#4’s HD treatment the following was recorded: - At 5:21 a.m., BP was 186/107 mmHg, obtained by PCT DD. , with no mention of P#4’s high BP reading. - At 5:50 a.m., BP was 186/111 mmHg, PCT DD then documented “BP elevated”. However, there was no mention that the Charge Nurse was notified. - At 6:20 a.m., BP was 186/114 mmHg, recorded by LPN AA. Throughout P#4’s HD treatment, there was no documentation if RN AA was notified of P#4’s high BP readings or if any assessment/intervention/education was offered by a licensed nurse. On 8/6/25, P#4’s pre-treatment BP was 182/107 mmHg, and the pre-treatment assessment was conducted by LPN AA. - At 4:21 a.m., LPN AA initiated P#4’s HD treatment, with a BP reading of 176/105 mmHg. There was no mention of P#4’s high diastolic BP reading. - At 4:23 a.m., BP was 171/103 mmHg - At 4:53 a.m., BP was 173/110 mmHg, and with documentation that LPN AA notified the Charge Nurse. - At 6:23 a.m., BP was 192/106 mmHg - At 7:23 a.m., BP was 191/106 mmHg - At 8:02 a.m., BP 195/114 mmHg - Post-treatment sitting and standing BP were 186/110 mmHg and 175/98 mmHg, respectively. P#4 was discharged to home. During the entire duration of P#4’s HD treatment, there was no documented evidence that the Charge Nurse reassessed P#4 concerning high BP readings. This included evaluating whether further patient education was needed. Additionally, there was no documented evidence that the physician was informed, nor any evidence that the Charge Nurse offered P#4 clonidine (used to treat high BP) 0.1 milligram as needed (PRN), in accordance with the physician’s standing order for high BP. During a discussion with the Facility Administrator on 8/7/25 at 10:00 a.m., she stated that a licensed nurse could administer an anti-hypertensive drug according to the facility’s protocol if a patient’s BP was too high. A review of Policy #C-FORMS-0081 titled, “Reportable Parameters to CN (Charge Nurse)”, with latest revision date of January 2020, stated: PCT/CCHT/LPN: Report to Charge Nurse Pre-dialysis - BP: Systolic less than 100 or greater than 180 and Diastolic less than100. Intra-dialysis - BP: Systolic less than 100 or greater than 180 and Diastolic less than100. Post-dialysis - BP: Systolic less than 100 or greater than 180 and Diastolic less than100. A review of Policy #A-CO-0200 titled, “Complications During Hemodialysis Grid”, with latest revision date of January 2020, stated: Hypertension (high BP) - Intervention Options: Monitor vital signs closely Use vigorous ultrafiltration (UF) if fluid overload is present Medications (i.e. nifedipine maybe necessary if hypertension is significant and prolonged). Notify nephrologist if pre-diastolic BP is greater than 120 or diastolic greater than 110 after one hour of treatment. Notify nephrologist if pre-systolic BP is greater than 200. Prevention: Encourage patient to follow fluid/sodium restrictions and to take prescribed antihypertensive. Rationale: Untreated hypertension can lead to stroke and other significant cardiovascular complications. A review of Policy #C-FORMS-0070 titled, “Standing Orders - Hemodialysis” with latest revision date of December 2024, stated: Prescription 9. Hypertension: Clonidine 0.1 milligrams (mg) PO (by mouth) x 1 PRN (as necessary) for systolic BP greater than 180. Repeat BP every 15 minutes for one hour after giving medication. Additional Information: Notify MD if post sitting systolic BP is greater than 180. - During an interview with LPN AA on 8/8/25 at 9:15 a.m., he stated that he notified the Charge Nurse regarding P#4’s high BP on 8/6/25. He also mentioned that he could have administered an anti-hypertensive medication himself but failed to do so. LPN AA acknowledged the risks associated with uncontrolled blood pressure for dialysis patients, especially when not addressed in a timely manner. - In an interview on 8/8/25, at 9:42 a.m., RN AA was asked about how elevated blood pressure readings were handled. RN AA stated that the PCTs were supposed to notify the Charge Nurse of elevated BP readings, and that a licensed nurse could administer clonidine 0.1 mg and notify the doctor. RN AA also added that she could not recall being notified on 8/6/25 about P#4’s high BP readings, as mentioned in the previous findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 52051 1. Based on observations, staff interviews, and a review of the Food and Drug Administration (FDA) recommendations, the Centers for Disease Control and Prevention (CDC) guidelines, facility’s Policies and Procedures (P & P), and the manufacturer’s Directions for Use (DFU), it was determined that the Medical Director failed to ensure that two of two Registered Nurses (RN AA and RN BB), who were responsible for administering medications, timely discarded five of five opened and accessed medication vials on one of one Medication Preparation Counter per P & P. Additionally, one of one expired Intradialytic Parenteral Nutrition (IDPN - a specialized nutrient solution delivered directly into patients’ bloodstream during dialysis via infusion) in one of one Medication Refrigerators, was not immediately discarded and not made available for use. This failure could compromise the safety and effectiveness of the medications and supplies, posing a potential risk to the health and safety of all 47 in-center hemodialysis patients under the facility’s care. Findings were include: During a tour of the Patient Treatment Room with the Facility Administrator on 8/6/25 at 9:24 a.m., the following was revealed: On the Medication Preparation Counter: - There were five opened and accessed single-dose vials of Defencath (catheter locking solution) 3 milliLiter (mL), containing taurolidine 40.5 milligrams (mg)/3 mL, and heparin 3,000 Units/3 mL. There was no time and date indicating when they were opened. In the Medication Refrigerator: - There was one bag of IDPN solution of 425 mL, expired 8/1/25 During an interview with the Facility Administrator who was present at the time of observation on 8/6/25 at 9:28 a.m., she acknowledged that the IDPN bag had expired and should not have been kept in the medication refrigerator. Additionally, she stated that the single-use medication vials should have been discarded. According to FDA recommendations dated 2/08/21, drug expiration dates indicate the timeframe during which the product is expected to remain stable. This means it retains its strength, quality, and purity when stored according to the specified conditions on the label. Utilizing expired medications or supplies can pose various potential risks. Once the expiration date has elapsed, there is no assurance that the medication or supplies will continue to be safe or effective. According to CDC, once a needle has entered a vial labeled for single-use, the sterility of the product can no longer be guaranteed. Residual medication from two or more vials should not be pooled into a single vial. A review of Policy #C-MA-0010 titled, “Guidelines for Administration of Medication” with latest revision date of February 2025, stated: Medication Storage: c. Ensure expired items are discarded appropriately. This ensures that medication is replaced prior to expiration date. A review of the Manufacturer’s DFU stated: - Each DEFENCATH single-dose vial is designed for use with a single patient as a single instillation in Central Venous Catheter (CVC - a soft plastic tube inserted into a large vein in the neck or groin, used to provide hemodialysis [HD] for patients). Discard any unused portion of DEFENCATH remaining in the vial. During an interview with RN AA (Charge Nurse) on 8/6/25 at 1:30 p.m., she stated that she should have discarded those medications that were mentioned above. 2. Based on observation, staff interviews, and a review of the facility’s P & P, it was determined that the Medical Director failed to ensure that one of one Registered Nurse (RN BB), who was responsible for preparing medications on 8/8/25, labeled one of one heparin (blood thinner used in dialysis to prevent clotting in the bloodlines and artificial kidney) multi-dose vial, and one of one sodium citrate 4% (intended for use as a blood thinner locking solution for catheters) multi-dose vial with the date and time they were opened, along with her initials in accordance with facility P & P. This deficient practice increased the risk for medication errors. The facility had 47 in-center hemodialysis patients. Findings include: During observation at the medication preparation area on 8/8/25 at 8:10 a.m., the following was revealed: - There was an opened and accessed vial of heparin sodium injection, 30 mL, with no staff’s initials and the time and date it was opened. - An opened vial of sodium citrate 4% containing gentamicin (used to treat serious bacterial infections) injection (9.6 mg/mL), was also not labeled with staff’s initials and the time and date it was opened. During an interview with RN BB on 8/8/25 at approximately 8:20 a.m., she acknowledged the observation and stated that she could have labeled those vials mentioned previously. A review of Policy #C-MA-0010 titled, “Guidelines for Administration of Medication” with latest revision date of February 2025, stated: 18. Multi-dose vials: b. Date and initial vials when opened as a point of reference for staff utilizing the medications. The Facility Administrator was notified of this observation on 8/8/25 at 9:59 a.m. and acknowledged that opened and accessed medication vials should be labeled with time and date they were opened, along with staff initials.”

“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: 49321 Based on observation, staff interviews, and a review of the Centers for Disease Control and Prevention (CDC) recommendations, it was determined that the infection control committee failed to ensure that three of four Patient Care Technicians (PCT AA, PCT DD, and PCT BB) and one of two Registered Nurses (RN BB) observed, practiced infection control techniques, to prevent cross contamination. The facility census was 48. Findings include: During observation in the Patient Treatment Room on 2/26/25 from 9:30 a.m. to 12:00 p.m., the following was observed: - PCT AA touched Patient (P) #12’s treatment chair (dirty) at Station (S) 9. Then she touched the keyboard and documented (clean task) without performing hand hygiene. During an interview on 2/26/25 at 10:40 a.m., PCT AA stated she was moving too fast. - PCT DD silenced an alarm on a machine at S13. PCT DD then went to S16 and silenced the machine alarm while she wore the same gloves used at S13. During an interview on 2/26/25 at 10:50 a.m., PCT DD stated she was not paying attention at that moment. - PCT BB silenced the dialysis machine alarm at S13 while she held a glove and touched the machine but did not wear the glove. When finished, she did not perform hand hygiene. PCT BB then put on a pair of gloves and initiated dialysis treatment on a patient at S1. - RN BB was observed at S14. RN BB removed the old dressing of P#15’s catheter site (dirty task), performed catheter care and applied new dressing (clean task). RN BB did not change gloves when going from a “dirty” task to a “clean” task. During an interview on 2/26/25 at 11:00 a.m., RN BB stated she thought she changed her gloves once before she took the dirty dressing off. According to the CDC, hand hygiene/handwashing is the most important measure to prevent contaminant transmission; and cross-contamination (going from dirty to clean equipment/tasks/area) could cause the spread of bacteria/infections.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 49321 Based on observation, staff interviews, and a review of policy and procedures (P&P), it was determined that the facility failed to ensure that two of two clean sinks for handwashing which had motion detectors to initiate the water flow, in one of one Treatment Room, had warm water to encourage patients and staff to wash their hands. This deficient practice had the potential to discourage eight of eight patients, (P) (P#13, P#14, P#15, P#16, P#17, P#18, P#19, and P#20, who were undergoing hemodialysis at the time of this observation and five of five Direct Patient Care staff to wash their hands, which would increase the risk of infection transmission. The facility census was 48. During observation in the Treatment Room on 2/26/25 from 9:30 a.m. to 12:00 p.m., the following was revealed: - Two of two handwashing sinks which were designated as “clean sinks” between Station (S) 6 and S7 and between S12 and S13 did not have warm water after running for 3 minutes. During an interview on 2/26/25 at 1:49 p.m., PCT DD stated the water at those sinks are so cold she sometimes uses hand sanitizer rather than washing hands at the sink. A review of Policy # C-AD-0380 titled, “Facility Space/Design and Saftey Requirements” dated 4/2023 stated: 10. Patients and staff will have access to a restroom and a sink for handwashing with tempered water (85 F -105 F).”

“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: 49321 Based on observation, staff interviews, a review of policy and procedures, it was determined that the Infection Control Committee failed to ensure that two of four Patient Care Technicians (PCT BB and PCT DD) observed, failed to ensure that clean equipment/areas were separated from dirty equipment/areas. This deficient practice increased the risk for cross contamination with the potential to expose 48 patients and staff to bloodborne pathogens in the dialysis environment. Findings include: During observation in the treatment area on 2/26/25 from 9:30 a.m. to 12:00 p.m., the following was revealed: - The Tri-station (docking station and calibration solutions) for three of three pHoenix XL meters was on the counter behind Station (S) 3. The dialysis treatment chair in S3 was against the Tri-station. - There was a clean sink (designated for hand washing) between S6 and S7. The dialysis machines (dirty) at S6 and S7 were pushed against the sink from both sides (½ inch between the dialysis machines and the sink). - There was a clean sink between S12 and S13. The dialysis machines at S12 and S13 were pushed against the clean sink from both sides (½ inch between the dialysis machine and the sink). . - The pHoenix XL meter #1 was stored on the counter of dirty sink #1. PCT BB used pHoenix XL meter #1 at S8. When finished, PCT BB cleaned and disinfected the meter and placed it back on the counter of dirty sink #1. During an interview with PCT BB on 2/26/25 at 9:47 a.m., PCT BB confirmed that she cleaned the pHoenix meter and then placed it on the dirty sink counter. PCT BB stated the treatment chair at S3 was pushed against the docking station where the pHoenix meters were kept. Stated, the treatment room is very cramped, and it was easy for her to keep it on that sink. - The pHoenix Meter #3 was stored on the counter of dirty sink #2. PCT DD obtained the meter from the dirty sink counter and used it at S13. When finished, PCT DD returned the meter back to the counter of dirty sink #2 without disinfecting the meter. PCT DD was also observed while she washed her hands at dirty sink #2. During an interview with PCT DD on 2/26/25 at 10:15 a.m., PCT DD stated the pHoenix meter was kept at the dirty sink and no one told her she had to keep it “any place else”. PCT DD also stated she did not keep it on the docking station behind S3, because the treatment chair was against the Tri-station, and it was easier to keep the pHoenix meter next to her work area where she washes her hands at the dirty sink. During an interview with the Director of Nursing of Home Dialysis Program (DON, Home Program) on 2/26/25 at 10:45 a.m., DON, Home Program acknowledged that the dialysis machines were against the clean sinks and the treatment chair at S3 touched the Tri-station. The DON, Home Program stated, the physical layout of the treatment area was the problem. A review of policy # C-IC-0010 titled, “Infection Control and Precautions for All Patients” dated 7/2023 showed the following: 3. Clean areas will be clearly designated and separated from contaminated areas and unused supplies and equipment. 13. Items in the dialysis station will either be disposed of, dedicated for use only on a single patient or cleaned and disinfected before being taken to a common CLEAN area or used on another patient.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 49321 Based on observation, staff interviews, and a review of policy and procedures, it was determined that the facility failed to ensure that the building in which dialysis services were furnished were maintained free from damage/defects and hazards to ensure safety and functionality as evidenced by damaged drywall in one of one treatment area. Failure to maintain the integrity of all surfaces, could hinder effective cleaning and disinfection of surfaces and could promote microbial growth. The facility census was 48. Findings include: During observation in the treatment area on 2/26/25 from 9:30 a.m. to 12:00 p.m., the following was revealed: - There was a cloudy liquid substance on the floor that was leaking from the floor level of the drain box at Station (S) 3. - The drywall at floor level from S1 that extended to S2, and ended at S3 was soft, swollen, warped, and disintegrated. - Approximately 2 feet of the thick wall trim at the floor level at S7 was soft and easily manipulated when touched. - The wood which the drywall sits on at S17 and S18 was moist. The beige paint had raised areas and blisters (paint bubbling) on drywall. The wall trim was detached and laid on the floor. - Approximately 9 feet of the drywall at floor level in a small storage room on the other side of S18, was soft, swollen, and disintegrated. The wall trim was detached and laid on the floor. - The second door that led into the treatment area had 1½ feet of vinyl floor trim that was missing. During an interview with the Biomedical Technician (BMT) on 2/26/25 at 1:09 p.m., the BMT stated the facility had a massive leak a month ago (January) that flooded the treatment area and the lobby. The BMT also stated, instead of fixing all the damage you see, the flooring people just covered it up with a cove base (a trim piece used in the transition between a wall and floor). The BMT stated “I am not sure when the last environment audit was done, and I don’t know who cleans the building.” During an interview on 2/26/25 at 1:49 p.m., Patient Care Technician (PCT) DD stated, there has been a leak at S18 “all last year”. Stated she told the BMT but every day she came to work, the floor was wet. PCT DD also stated, “We got an interim Facility Administrator, and she visited the clinic the first week of January and I have not seen her since.” During an interview with PCT CC on 2/26/25 at 3:15 p.m., PCT CC stated the building is dirty and needs to be deep cleaned. “Every morning when we came to work, acid was on the floor at S3.” She also stated, the interim Facility Administrator visited the facility in January and has not been back.” During a telephonic interview on 2/26/25 at 4:00 p.m., the Medical Director stated he was not aware of any leaking issues in the building. On 2/26/25 at 4:12 p.m., the Director of Nursing of Home Therapy Program stated she was not covering this facility. “I was called to come while the state was in the building. I don’t know much about this facility. The Facility Administrator resigned in November and there was an interim Facility Administrator, and a charge nurse assigned to this clinic.” A review of Policy # C- AD _ 0380 titled, “Facility Space/Design and Safety Requirements” showed the following: Purpose: Facilities will provide a physical environment that protects the health and safety of the patients, staff and the public. 14. Floors will be kept free of liquid and debris: a. Inform staff and patients of the wet floor. b. Place wet floor sign near or on the affected area c. Clean wet floor immediately d. Evaluate the source of wet floor(s)”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 49321 Based on a review of records and staff interviews, it was determined that the governing body failed to ensure that this facility had a full-time registered nurse (RN) who was responsible for nursing services and provided oversight and direction to four of four unlicensed Patient Care Technicians (PCT AA, PCT BB, PCT CC, and PCT DD), who provided dialysis care to 36 in-center hemodialysis patients who dialyzed at this facility. Findings include: A review of the Governing Body meeting minutes from October 2024 to January 31, 2025, revealed that the Facility Administrator resigned on 11/12/24. The governing body appointed an interim Facility Administrator and an RN in charge of nursing services effective 11/12/24. On 1/21/25, the nurse in charge of nursing services went out on Family Medical Leave Act (FMLA). On 1/31/25, the interim Facility Administrator was appointed as the Facility Administrator and the nurse in charge of Nursing Services was appointed to the Infection Control Committee while out on FMLA. During an interview on 2/26/25 at 12:39 p.m., Registered Nurse (RN) AA stated he is a traveling nurse and has been at this facility since 1/17/25. The nurse in charge of Nursing Services took a leave of absence since 1/21/25. RN AA stated this made him the charge nurse at this facility. He also stated he had seen the Facility Administrator only once since he came to this facility. During an interview on 2/26/25 at 1:25 p.m., PCT BB stated the Facility Administrator resigned in November, and the Facility Administrator from a sister facility was at this facility in January. Stated “The place is cluttered, and no one is assigned to do anything.” An interview with RN BB on 2/26/25 at 2:28 p.m., revealed that RN BB did not know who the nurse in charge of nursing services was. RN BB stated both she and RN AA are traveling nurses and did not know much about who adjusts the patient medications. There was a lack of documented evidence that a full-time RN was delegated as an interim nurse responsible for nursing services while the RN appointed by the governing body as the nurse responsible for nursing services was out on FMLA. During an interview on 2/26/25 at 3:15 p.m., PCT CC stated the clinic was running itself. The nurses are new to the facility and the staff do what they want. During a telephonic interview on 2/26/25 at 4:00 p.m., the Medical Director (MD) stated there is a person assigned to this facility who is aware of what is going on. The MD was unable to tell this surveyor the name of the “person”.”