Fresenius Medical Care Shelby County

“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: 44715 Based on observation, record review, and interview the agency failed to ensure patients completed hand hygiene following their dialysis treatment in 4 of 4 observaions. (Patient 5, 9, 14 and 15). Findings inlcude: 1. A Fresenius Kidney Care policy published November 2023, titled, “Hand Hygiene” indicated but was not limited to, “ ... Patients should perform hand hygiene if able, prior to and after each dialysis treatment. ... holding access sites post treatment to achieve hemostasis. ... To help ensure the prevention of cross contamination to their family members or other patient, hand hygiene must be performed. 2. On 1/05/2026 at 9:25 AM, Patient #5 from station #9 was observed using their wheelchair to move to the scale following their treatment and achieving hemostasis. Patient #5 was weighed and not offered hand hygiene prior to exiting the treatment floor. 3. On 1/05/2026 at 9:35 AM, Patient #9 at station #2 was observed having their right upper access site discontinued and pressure held by RN 1. Once hemostasis was achieved, Patient #9 was assisted to the scale, was weighed and not offered hand hygiene. 4. On 1/05/2026 at 10:00 AM, Patient #14 at station #10 was observed holding pressure with a gloved right hand to their access site of their left thigh. Patient #14 removed their glove and ambulated to the scale without assistance once hemostasis was achieved. Patient #14 was not offered hand hygiene. 5. On 1/05/2026 at 10:15 AM, Patient #15 at station #12 was observed holding pressure with a gloved right hand to their access site of the left upper extremity. Once hemostasis was achieved, Patient #15 ambulated to the scale to be weighed. They exited the treatment floor without being offered hand hygiene. 6. On 1/07/2026 at 04:00 AM, PCT 1 was queried about hand hygiene for patients post treatment. PCT 1 indicated all patients should be offered hand hygiene prior to exiting the treatment floor.”

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure systems were in place to maintain the integrity of the facility structure of the floors to allow for effective cleaning for 1 of 1 stand alone dialysis in-center facilities. Findings Include: 1. A dated 02-07-2022 Fresenius Kidney Care policy titled, “ General Cleanliness and Infection Control Guidelines” indicated but was not limited to, “ ... The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a cleans, safe, aesthetically pleasant environment for patients, staffs, and visitors ...” 2. A dated 07-06-2021 Fresenius Kidney Care policy titled, “Equipment Installation-Operation-Maintenance-Repair-And Disposal” was provided by the DO. The policy indicated but was not limited to, “ ... Any equipment or device that is not fully functioning ... must be repaired or replaced as soon a reasonably possible ... Identified issues may include fluid leaks: nonfunctional, broken, or misadjusted parts and components; or aesthetic damages ....” 3. On 01-31-2024 at 7:55 AM, observed broken and cracked tiles on the floor surrounding the base of the toilet in the front lobby bathroom upon entering the facility. 4. On 01-31-2024 at 8:10 AM, during a flash tour, observed in the hallway across from the storage area cracked floor tiles in front of the double doors leading to the hallway exit door. 5. On 01-31-2024 at 8:20 AM, during a flash tour of the water room, observed the floor cracked and crumbled in front of the 3K and 2K tank fills to the back wall drain, cracked and crumbled floor under the crate holding the bags of dry bicarbonate, and observed the floor cracked and crumbled surrounding the area of the dry acid dissolution unit to the floor drain. During an interview on 01-31-2024 at 1:15 PM, the Clinical Manager confirmed they were aware of the crumbled floor condition of the water room. The Clinical Manager further indicated they had a work order for the hallway floor cracks and cracks around the lobby’s bathroom toilet. 6. A review of a facility document dated 01-31-2024 at 1:19 PM, titled, “Active Repair Requests” indicated the Clinical Manager submitted a work order for the hallway floor cracks, cracks around the toilet in the front lobby, and the water room’s crumbled and crack flooring.”