Fmc - East Peoria Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 45565 A. Based on observation, document review, and interview the Facility failed to ensure 2 of 4 bleach filled containers, used for disinfecting dialysis chairs, machines, and equipment were covered. Findings include: 1. During the observation tour of the treatment area on 2/25/25 at approximately 12:10 PM, the following was noted: a. 2 containers labeled 1:100 (1 part bleach: 99 parts water) did not have lids covering them from 12:15 PM to 12:45 PM. This gives the potential to allow for the bleach solution to evaporate and lose its proper disinfection strength and prevents complete disinfection of dialysis stations/chairs, machines, and equipment. 2. On 2/27/25 at approximately 12:24 PM, the policy titled “Mixing Bleach” (ver.6; pub: 2/25) was reviewed. The policy states, “5. Cover opaque container with lid.” 3. On 2/25/2025 at approximately 12:45 PM, during the observational tour, an interview was conducted with the Charge Registered Nurse (E #4). E #4 verbally agreed the containers should have been covered with lids to prevent evaporation of the solution. B. Based on observation, document review, and interview, it was determined that for 3 of 3 Patient Care Technicians/ CCHT’s (E #5, E #6, E #7) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting the dialysis station as required by policy. Findings Include: 1. On 2/25/26 from approximately 12:00 PM to 2:30 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 12:15 PM, the Patient Care Technician (E #5) did not clean/ disinfect the Chaise wall in dialysis station # 11. - At approximately 12:40 PM, the Patient Care Technician (E #5) did not clean/ disinfect the Chaise wall in dialysis station # 12. 2. On 2/26/26 from approximately 9:30 AM to 1:00 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 10:00 AM, the Patient Care Technician (E #5) did not clean/ disinfect the Chaise wall in dialysis station # 17. - At approximately 10:20 AM, the Patient Care Technician (E #6 ) did not clean/ disinfect the Chaise wall in dialysis station # 8. - At approximately 10:30 AM, the CCHT (E # 6) did not clean/ disinfect the Chaise wall in dialysis station # 11. - At approximately 10:40 AM, the Patient Care Technician (E #6 ) did not clean/ disinfect the Chaise wall in dialysis station # 11. - At approximately 11:00 AM, the Patient Care Technician (E #8) did not clean/ disinfect the Chaise wall in dialysis station # 14. 3. On 2/27/25 at approximately 12:35 PM, the policy “Cleaning and Disinfecting the Dialysis Station” (ver.14, pub:9/23) was reviewed. The policy states, “Procedure .... 3. Use a cloth wetted with 1:100 bleach solution or EPA-Approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind chair)... 4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by the manufacturer.” 4. On 2/27/25 at approximately 12:45 PM an interview with Director of Operations (E #1) was conducted. E #1 verbally confirmed that the wall behind the dialysis chairs is part of the station and should be cleaned/disinfected.”

“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 2/25/25 at approximately 10:15 AM, a observational tour of the Dialysis Clinic treatment floor was conducted. During the observational tour, it was noted that the medication drawers were locked except one that contained the keys to open the other medication drawers. 2. On 2/26/25 a document review of the policy titled, “Medication Preparation and Administration (ver.9 pub:2/23)” was completed. The policy states, “Securement..... - 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 2/25/25 during the observational tour with Registered Nurse (E#3). E #3 stated, “we keep the keys in there because I am a float and don’t have my own keys to these drawers. But I was keeping an eye on you.” When asked why they do not have a set of keys for each RN, E #3 stated, “I don’t know, we just have 1 set of keys.” 4. On 2/27/25 an interview was conducted with the Director of Operations (E #1). E #1 verbally confirmed that policy was not being followed and stated, “we are working on a solution currently.””