Fmc - Indianapolis

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure items were stored without risk of exposure to contaminants in 4 of 4 treatment room observations. Findings Include: 1. A review of a Fresenius Kidney Care policy dated 11/04/2024, titled “General Cleanliness and Infection Control Guidelines” indicated but was not limited to, “ ... The purpose of this policy is to provide guidance for the FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors ... Supplies or patient’s belongings should not be kept or stored behind the machine at the patient station ... “ 2. On 03/10/2025 at 9:26 AM, observed during a flash tour of the dialysis treatment floor a blood pressure cuff on the wall unit box shelf between Stations #11 and 12. 3. On 03/11/2025 at 12:02 PM, observed the following: a small blood pressure cuff on the wall unit shelf between Stations #33 and 24, a blood pressure cuff on the wall unit shelf between Stations #11 and 12, and a blood pressure cuff on the wall unit between Stations #6 and 7. Observed a takeoff pack (a blue barrier wrapped around supplies containing two 10 milliliter syringes filled with normal saline, 2 x 2 gauze, and two heparin filled syringes used for disconnection after dialysis completion) on top of the dialysis machine at Station #22. 4. On 03/12/2025 at 8:10 AM, observed the following: a takeoff pack (a blue barrier wrapped around supplies containing two 10 milliliter syringes filled with normal saline, 2 x 2 gauze, and two heparin-filled syringes used for disconnection post dialysis treatment) on top of the dialysis machine at Station #23, a one-inch stack of unwrapped 2 x 2s on top of the dialysis machine at Station #22, a half inch stack of unwrapped 2 x 2s on top of the dialysis machine at Station #20, a stack of three blue gloves and a tourniquet on top the dialysis machine at Station #16; patient bags on the wall unit shelf behind Stations #21, 28, and 31; blood pressure cuffs on the wall unit shelf behind Stations #34, 7, 11, and 12, and a wooden slide board on the wall unit shelf behind Station #25. During an interview on 03/12/2025 at 8:35 AM, when queried regarding infection control and the items they had placed on top of the dialysis machines today and yesterday, PCT 9 indicated they could move the items off the machines. PCT 6 stated, “No you must throw them all away. Nothing is to be on top of the dialysis machines.” 5. During an interview on 03/12/2025 at 8:40 AM, when queried about patient items and blood pressure cuffs being on the wall unit shelves, PCT 8 stated, “No nothing is to be on the surround shelf.” 6. During an interview on 03/12/2025 at 10:45 AM, when queried RN 2, the Charge Nurse, regarding supplies and patient items being on the dialysis machines or wall unit shelves, RN 2, indicated nothing should have been on top of the dialysis machines or the wall unit shelves, and staff had been reeducated.”