Fmc - Beverly Ridge

“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: 40079 Based on observation, document review, and interview, it was determined that for 1 of 3 staff (E#3) observed for hand hygiene, the Facility failed to ensure that staff changed gloves and/or performed hand hygiene as required. Findings include: 1. During a tour of the dialysis treatment area on 04/21/2025 between 11:10 AM and 12:10 PM, the following was observed: -At 11:30 AM, a Patient Care Technician/PCT (E#3) was initiating dialysis for a patient (Pt.#1) at station #8. E #3 was observed working on the dialysis machine’s computer screen with gloved hands, while holding the dialysis lines. E #3 then turned to (Pt.#1) and connected the lines to a Fistula Graft ports, E #3 did not change gloves and perform hand hygiene prior. -At 12:00 PM, E#3 (PCT) was at station #7 working on the dialysis machine’s computer screen, then went to station #9 and worked on that station’s computer. E#3 then removed gloves and applied new gloves without performing hand hygiene and went to work on station #9’s computer screen. 2. The facility’s policy titled, “Hand Hygiene” (revised 11/06/2023) was reviewed and required, “All staff ... must follow the same requirements for hand hygiene: ... Before and after direct contact with patients ... Immediately after removing gloves... After contact with inanimate objects near the patient ...” 3. An interview was conducted with the Clinical Manager (E #1) on 04/21/2025, at approximately 1:00 PM. E #1 stated that all staff must perform hand hygiene after touching the dialysis screens or inanimate objects and before accessing any vascular access or performing a new task.”

“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: 40079 Based on document review, and interview, it was determined that for 1 of 3 (Pt. #2) in-center hemodialysis clinical records reviewed for intradialytic monitoring, the Facility failed to ensure that the staff provided necessary care and services to manage the patient’s volume status when abnormal blood pressures were identified. Findings include: 1. On 04/22/2025, the Facility’s policy titled, “Patient Assessment and Monitoring” (dated 05/01/2023) was reviewed and required, “During Treatment: Obtain blood pressure ... every 30 minutes or more as noted but not to exceed 45 minutes ... Report to the nurse: Systolic blood pressures greater than 180 ... diastolic blood pressure greater than 100 ...” 2. On 04/22/2025, Pt. #2’s clinical record was reviewed. Pt. #2 was admitted on 03/22/2021 with a diagnosis of end stage renal disease (ESRD). Pt. #2’s treatment flowsheets dated 4/09/2025 through 4/18/2025 were reviewed and the following was noted: -Pt. #2’s treatment flowsheet dated 04/09/2025 included documentation that Pt. #2’s blood pressure was 202/94 (high) at 12:17 PM and blood pressure was 194/139 (high) at 12:31 PM, and the blood pressure was not re-checked until 1:32 PM (61 minutes later). Pt. #2’s clinical record lacked documentation of nurse notification and if any interventions were implemented to address the elevated blood pressures on 04/09/2025. 3. On 04/22/2025 at 2:00 PM, an interview was conducted with the Clinical Manager (E #1). E #1 stated that abnormal blood pressures should be reported to the Registered Nurse.”