Fmc - Northcenter Dialysis

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 1 of 1 (Pt #8) patient observed receiving intravenous antibiotics, the Facility failed to ensure that the algorithm and orders for suspected bloodstream infection, was adhered to, as required. Findings include: 1. The facility’s “CMAB Recommended Evaluation and Treatment of Central Venous Catheter (CVC) Related Bloodstream Infection” Algorithm, was reviewed and required, “Goal: Provide guidelines for treatment of suspected catheter-related bloodstream infections (CRBSI) in patients dialyzing three times per week ...Suspected catheter-related bloodstream infection (CRBSI) as evidenced by ...Fever [greater than 37.5 (99.5 F)] ...Step 1. Obtain Blood Cultures and Administer Empiric Antibiotics ...Obtain 2 sets of blood cultures ...” 2. The clinical record for Pt #8 was reviewed on 3/19/2024. Pt #8 was admitted on 12/19/2023, with a diagnosis of ESRD (end stage renal disease). Pt #8’s physician orders indicated that Pt #8 had a CVC catheter. An order for Vancomycin (antibiotic) 1000 mg (milligrams) intravenous, was entered on 3/19/2024. - The physician’s progress note (dated 3/19/2024), included, “Pt has fever and cough for 3 days ...1 gm [gram] Vanco[mycin]...Blood culture sent ...” -Pt #8’s treatment sheet (dated 3/19/2024), included a pre-dialysis temperature of 100.6 (F). The treatment sheet indicated that Vancomycin 1000 mg was given at 9:00 AM, per Registered Nurse/RN (E #2). Pt #8’s clinical record lacked documentation that blood cultures were obtained, as ordered. There was no RN note indicating that the MD was made aware of Pt #8 not getting blood cultures drawn. 3. On 3/19/2024 between 9:55 AM and 11:30 AM, an observational tour of the hemodialysis treatment floor was conducted. At Station #2, Pt #8 was receiving an IV antibiotic (Vancomycin 1000 mg) directly through the CVC venous port. During the tour at 10:15 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that the Attending Physician/Medical Director (MD #1), made rounds this morning and verbally ordered blood cultures and Vancomycin for Pt #8. E #2 stated that E #2 did not obtain the blood cultures (as ordered), as there were no culture bottles available to obtain the sample. - The supply room was toured and there were blood culture bottles available for use. 4. On 3/20/2024 at 10:40 AM, an interview was conducted with a Registered Nurse (E #5). E #5 stated that there is a bloodstream infection protocol that the nurses follow for suspected infection. E #5 stated, however, if the doctor has specific orders outside of the protocol, then the nurse should follow those MD orders. E #5 stated that generally for suspected bloodstream infections, the nurse obtains 2 sets of blood cultures and administer antibiotics empirically. E #5 stated that if the nurse is unable to obtain the blood cultures, then the MD should be notified. 5. On 3/21/2024 at 10:35 AM, a telephone interview was conducted with the Medical Director (MD #1). MD #1 stated that MD #1 rounded on Pt #8 on 3/19/2024. MD #1 stated that MD #1 ordered blood cultures, Vancomycin, and Gentamycin since Pt #8 had a fever. MD #1 stated that obtaining blood cultures is part of the septic workup so that we can identify the source of infection.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that 1 of 1 medication storage area and refrigerator, the Facility failed to ensure that expired medications were discarded and not available for patient use. Findings include: 1. The facility’s policy titled, “Medication Preparation and Administration” (dated 2/6/2023), was reviewed, and required, “...Monitoring Expired Medications: Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via [Facility] off-site return program or in accordance with local and/or state law. Any open multi dose vials must be discarded 28 days after opening or per manufacturer’s expiration date...” 2. On 3/19/2024 between 9:55 AM and 11:30 AM, an observational tour of the medication storage area and medication refrigerator was conducted, and the following was observed: - 1 of 1 tuberculin (TB) vial was opened and dated on 12/2023. - 1 box of Adrenalin with the manufacturer’s expiration date of 2/2024. 3. On 3/19/2024 at 10:45 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that the TB vial is good for 28 days once it is opened and should be discarded after expiration. E #2 acknowledged that the box of Adrenalin was expired.”