Fmc - Peoria Downtown

“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: 50688 Based on observation, document review, and interview the Facility failed to ensure 8 of 8 bleach filled containers, used for disinfecting dialysis chairs/machines and clamps (used for clamping and securing lines), were properly covered. Findings include: 1. During observation of the dialysis treatment floor on 2/18/2025 at approximately 1:00 PM, the following was noted: -8 containers of 1:100 (1 part bleach: 99 parts water) of bleach water solution were present on the treatment floor, in two separate “Clean” areas and two separate “Dirty” areas. Areas designated as “dirty”, are for placing reusable items that have been used on a patient and require cleaning/disinfection before being used again. -4 of the containers were labeled “Clean” and used for disinfection of dialysis chairs/machines, and 4 of the containers were labeled “Dirty”, and used for disinfection of clamps. -Of the four containers labeled “Clean”, the lids of two containers were not closed tightly; for one container, one side of the hinged lid was fully open; and for one container, both sides of the hinged lid were fully open, and was observed to remain in this state for over one hour. -Of the four containers labeled “Dirty”, the lids of two containers were not closed tightly; for two containers, one side of the hinged lids were fully open. All of these occurrences had the potential to allow for the bleach solution to evaporate and lose its proper disinfection strength and prevents complete disinfection of dialysis stations/chairs and clamps. 2. On 2/19/2025 at approximately 3:00 PM, the policy titled “Mixing Bleach” (Published 02/03/2025) was reviewed. The policy states, “ ...5. Cover opaque container with lid ....” 3. On 2/18/2025 at approximately 12:45 PM, during the observation of the dialysis treatment floor, an interview was conducted with the Director of Operations (E #1). E #1 agreed the lids of the bleach containers should have been closed.”

“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: 50771 Based on document review and interview, it was determined in 5 of 10 in-center clinical records reviewed (Pt # 1, Pt #2, Pt #4, Pt #5, Pt # 10) the Facility failed to ensure vital signs were monitored at least every 30 minutes, as required by policy. Findings include: 1. Pt #1 SOC: 12/17/2024 Diagnosis: End Stage Renal Disease. The record was reviewed on 2/19/2025 at approximately 10:00 AM. Between 1/21/2025 to 2/15/25, 2 of 12 treatments lacked vital sign monitoring every 30-45 minutes, which ranged from 66 minutes to 84 minutes. 2. Pt#2 SOC: 11/8/2024 Diagnosis: End Stage Renal Disease. The record was reviewed on 11/8/2025 at approximately 11:00 AM. Between 1/22/25 to 2/17/25, 6 of 12 treatments lacked vital sign monitoring every 30-45 minutes, which ranged from 45 minutes to 91 minutes. 3. Pt #4 SOC: 12/17/2024 Diagnosis: End Stage Renal Disease. The record was reviewed on 2/19/2025 at approximately 10:00 AM. Between 1/21/2025 to 2/15/25, 5 of 12 treatments lacked vital sign monitoring every 30-45 minutes, which ranged from 57 minutes to 91 minutes. 4. Pt #5 SOC 5/30/2024 Diagnosis: End Stage Renal Disease. The record was reviewed on 2/20/2025 at approximately 9:00 AM. Between 1/21/25 to 2/15/25, 2 of 12 treatments lacked vital sign monitoring every 30-45 minutes, which ranged from 60 minutes to 64 minutes. 5. Pt #10 SOC 6/26/2024 Diagnosis: End Stage Renal Disease. The record was reviewed on 2/20/2025 at approximately 3:00 PM. Between 1/24/25 to 2/19/2025, 5 of 12 treatments lacked vital sign monitoring every 30-45 minutes, which ranged from 56 minutes to 123 minutes. 6. The Facility policy titled “Patient Assessment and Monitoring (Published 5/1/2023)” was reviewed on 2/19/25 at approximately 2:00 PM. The policy stated, “During Treatment ....Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” 7. On 2/20/2025 at approximately 1:45 PM, an interview was conducted with the Director of Operations (E #1). E #1 reviewed the records above and confirmed the vital signs were not monitored as required and should have been. 30383”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 30383 Based on observation, document review, and interview, it was determined for 1 of 1 patients observed for initiation of hemodialysis assess using topical numbing spray, the Facility failed to ensure physician’s orders was obtained prior to use of the medication administration. Findings include: 1. Pt #6 Start of Care (SOC): 8/19/24 Diagnosis: End Stage Renal Disease. The record was reviewed on 2/20/25 at approximately 10:15 AM. During an observation tour on 2/19/25 at approximately 1:15 PM, the PCT (patient care technician) was observed using topical numbing spray to Pt. #6’s vascular assess prior to needle insertion. The record lacked a physician’s order for the spray. 2. The policy titled “Access Assessment and Cannulation (published 05/06/2024)” was reviewed on 2/20/25 at approximately 10:30 AM. The policy noted “...Anesthetic Consideration...staff should facilitate implementation of the patient’s anesthetic choice in accordance with physician orders...” 3. During an interview with E#1 (Director of Operations) on 2/20/25 at approximately 11:00 AM, E#1 verbally confirmed the lack of the order for the topical numbing spray.”