Fmc - Southwest Illinois

“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: 50645 Based on observation, document review, and interview, it was determined for 1 of 4 (E #11) PCT’s observed providing patient care, the Facility failed to ensure infection control procedures were followed to prevent the potential for cross-contamination. Findings include: 1. On 10/16/24 at approximately 12:15 PM, E#11 was observed leaving station #13 donned with gloves, raising the lid on the red biohazard container with a gloved left hand, and disposing used tubing into the container. E #11 then re-entered station #13 and touched the gauze pad covering the patient’s right upper arm fistula with her same gloved left hand. E #11 failed to remove soiled gloves, perform hand hygiene, and don clean gloves before touching the patient’s fistula site. 2. On 10/17/24 at approximately 2:30 PM, the Facility policy titled, “ General Cleanliness and Infection Control Guidelines” (Published on 7/1/24) was reviewed. The policy required, “Decontamination using alcohol-based hand rub or by washing hands with antimicrobial soap and water after contact with inanimate objects near the patient.” 3. On 10/16/24 at approximately 1:00 PM, an interview was conducted with the E #11. E #11 stated, “Yes, I did do that. I didn’t even think about it.””

“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: 51190 Based on document review, observation, and staff interview, it was determined for 6 of 6 heparin syringes, the Facility failed to ensure staff followed proper labeling of medication per policy. 1. On 10/15/24 at 12:10 PM, an observational tour was conducted. 6 out of 6 syringes of heparin were found pre-drawn in the medication drawer. The medication was not labeled with the time it was drawn. 2. On 10/16/24, a document titled, “Medication Preparation and Administration (Published 2/6/2023)”, was reviewed. It noted, “All medications and syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication.” 3. On 10/15/24 at 12:16 PM, an interview was conducted with the Charge Nurse (E#10), who verbally stated that the medication was drawn up at 10:00 AM this morning and that medication drawn up in a syringe should not be drawn up more than 4 hours before administration. E #10 also acknowledged that the syringes should be labeled per policy.”