Fmc - Streator

“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: 50645 Based on observation, document review, and interview, it was determined that the Facility failed to ensure all inventory of patient care supplies was discarded when they expired. Findings include: 1. A tour of the treatment and storage areas was completed on 7/28/25 between 11:30 AM and 1:00 PM. During the tour, the following supplies were found to be outdated and were available for patient use. a. Eighteen Immunostics INC Heme-screen slide test for fecal occult blood (tests for blood in the feces) had expired. The manufacturer’s expiration date was 10/31/24. b. Three Cirrus 800 Non-Sterile Nitrile Exam Gloves had expired. The manufacturer’s expiration date was 1/2022. c. Two B/BRAUN IV (Intravenous) Administration Sets had expired. The manufacturer’s expiration date was 4/30/25. 2. The policy titled “Storage of Supplies” (published 4/5/2021) was reviewed. The policy stated, “ ...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 7/28//2025 at approximately 1:15 PM, an interview was conducted with the Director of Operations (E #1). E #1 verbally agreed that the supplies had expired and should have been removed.”

“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: 50771 Based on observation, document review, and interview, it was determined that for 2 of 2 Patient Care Techs (PCT) (E #3 and E #4) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. Findings Include: 1. An observational tour was conducted in the dialysis treatment area on 7/29/2025 and 7/30/2025 from approximately 10:00 AM to 11:35 AM. The following was observed: - At approximately 10:15 AM on 7/29/2025, the PCT (E#3) was observed cleaning a dialysis station. E #3 did not allow the dialysis chair to fully air dry prior to setting up the chair for the next patient and did not disinfect the chaise wall behind the chair. The chair was immediately closed after being wiped clean by E #3. -At approximately 10:50 AM on 7/30/2025, The PCT (E#4) was observed cleaning a dialysis station. E#4 did not allow the dialysis chair to fully dry prior to setting up the chair for the next patient and did not disinfect the chaise wall behind the chair. The chair was immediately closed after being wiped clean by E #4. 2. On 07/30/2025 at 11:40 AM, the Facility’s policy titled, “Cleaning and Disinfecting the Dialysis Station (published 9/5/2023)” was reviewed and noted on page 6 “Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: ...3. Use a cloth wetted with...disinfectant to clean and disinfect the dialysis station (chair/bed...chaise wall behind chair). ...4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by manufacturer.” 3. On 07/30/2025 at approximately 11:45 AM, an interview was conducted with the Facility Administrator (E #2). E #2 verbally agreed the dialysis chair should be allowed to air dry to complete disinfection of all surfaces of the dialysis chair and the area surrounding the chair should have been disinfected. E #2 did state they spoke with E #3 and E #3 stated “it was dry”.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50645 Based on a document review and staff interview, it was determined that for 2 of 4 (Pt #2 and Pt #4) patient records reviewed for BFR and DFR, the ESRD Facility failed to ensure that the patient’s BFR and DFR were achieved and maintained per the dialysis prescription. Findings include: 1. On 7/30/25, the clinical record of Pt #2 was reviewed. Pt #2 was admitted to the facility on 7/4/25, with a diagnosis of ESRD. A physician’s order dated 7/4/25, prescribed a BFR of 450. Pt #2’s treatment sheet dated 7/7/25 indicated Pt #2 was dialyzed at 400. Pt #2’s clinical record contained a physician order dated 7/16/25 that noted the BFR of 450. Pt #2’s treatment sheet dated 7/18/25 indicated Pt #2 was dialyzed at a BFR of 400. The record lacked documentation as to why the BFR was not achieved as prescribed or that the licensed nurse was notified. 2. On 7/30/25, Pt #4’s record was reviewed. Pt #4 was admitted to the facility on 11/19/24 with a diagnosis of ESRD. Pt #4’s clinical record contained a physician order dated 6/30/25 that noted the BFR of 400. Pt #4’s treatment sheet dated 7/7/25 indicated Pt #4 was dialyzed at a BFR of 365. Pt #4’s clinical record contained a physician order dated 7/16/25 that noted BFR 450. Pt #4’s treatment sheets dated 7/18/25 and 7/25/25 indicated Pt #4 was dialyzed at a BFR of 400. The record lacked documentation as to why the DFR was not achieved as prescribed or that the licensed nurse was notified. 3. The Facility policy titled “Unable to Achieve Prescribed Blood Flow Rate” (Published 11/1/21) was reviewed on 7/30/25 at approximately 12:00 PM and stated, “ ...Policy: Staff, patient, and/or care partner will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate ...Notification: Notify physician/extender if unable to achieve prescribed blood flow rate. Documentation: Document in patient’s treatment record what action taken to address the inadequate blood flow, and if unable to resolve. The nurse shall document any physician orders.” 4. During an interview with the Facility Administrator (E #2) on 7/30/25, at approximately 12:15 PM. E #2 verbally agreed that the DFR for Pt #2 and Pt #4’s prescription was not delivered as prescribed and lacked documentation regarding actions taken to address the inadequate blood flow and acknowledged that the physician or nurse was not notified.”