Fmc - Rai - Centre West Springfield

“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: 45565 Based on observation, document review, and interview, it was determined the facility failed to label patient medications per facility policy. Findings include: 1. On 4/1/25 at approximately 11:30 am, an observational tour was conducted. During the observational tour the following was noted in the medication prep area: a) six (6) medication cups with medication in them and patient labels lying on the counter near the cups. b) 4 of 6 pre-drawn heparin syringes were labeled with patient information but were not dated, timed, or initialed by the person who prepared the syringes. 2. On 4/2/25 at approximately 11:15 am, an observational tour was conducted. During the observational tour the following was noted in the medication prep area: a) Eight (8) medication cups with medication in them and patient labels lying on the counter near the cups. 3. On 4/2/25 a document review of the policy titled, “Medication Preparation and Administration (ver.9 pub:2/23)” was completed. The policy states, “Labeling Reconstituted Medication Solutions and Syringes .... - All medications in 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 .....- Oral medications not being administered immediately must also be labeled as indicated above.” 4. On 4/2/25 at approximately 11:40 am during the observational tour, an interview with Facility Administrator (E #1) was conducted. E #1 verbally agreed that medication should have the label affixed to the med cup and/or syringe if prepared per policy””

“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: 50688 Based on observation, document review, and staff interview, it was determined the facility failed to ensure outdated biologicals were not available for patient use. Findings Include: 1. On 4/1/2025 at approximately 11:25AM - 12:20 PM, an observational tour of the treatment area was completed. During inspection of the emergency evacuation box, 2 of 16 disposable fistula needles displayed an expiration date of 11/18/2024. 2. On 4/1/2025 at approximately 2:05 PM, the policy “Storage of Supplies” (published 4/5/2021) was reviewed. The policy states, “Policy... Supplies must be rotated First-in-First-out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.” 3. On 4/1/2025 at approximately 12:00 PM, E #2 reviewed the expired biologicals, agreed the biologicals were expired and removed them from the treatment area.”

“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: 45565 Based on observation, document review, and interview, it was determined the Facility failed to ensure patient safety by restricting access to the patient medication drawers to authorized personnel only. Findings include: 1. On 4/1/25 at approximately 11:30 AM, an observational tour of the Dialysis Clinic treatment floor was conducted. During the observational tour, it was noted that the medication cabinets were unlocked allowing unlimited access to medications. 2. On 4/2/25 a document review of the policy titled, “Medication Preparation and Administration (ver.9 pub:2/23)” was completed. The policy states, “Securement..... - All medications will be kept in a locked cabinet except when in use. - One key to the medication cabinet will be kept by the charge nurse/ team leader. The clinical manager will retain a spare key, kept in a secure location. - The key to the medication cabinet will be kept in a secure location when the facility is closed. Only the Clinical Manager, charge nurse and team leader will have access to the location. - When the charge nurse/ team leader leaves the treatment area, the key will be left in the possession of other qualified, licensed personnel.” 3. An interview was conducted on 4/2/25 during an observational tour with Facility Administrator (E#1). E #1 stated, “we thought that if we were on the floor they could be kept open. We will follow our policy from now on.””