Fmc - Bloomington Monroe

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 44230 Based on record review and interview, the facility failed to ensure that a two-step TST (tuberculin skin test) (a test used to diagnose latent tuberculosis infection) was administered in 1 of 3 personnel records reviewed (Facility Administrator). Findings include: 1. A policy titled “Employee Tuberculosis Testing” indicated, but was not limited to: “TB testing using the two-step tuberculin skin test (TST) method is required upon hire...” 2. The personnel record for the Facility Administrator was reviewed on 06/19/2024. The record failed to include documentation of a two-step TST upon hire. 3. During an interview on 06/19/2024 at 10:56 AM, the Director of Operations (DOO) indicated new staff are required to have the two-step TST upon hire. He indicated the Facility Administrator only received one dose of the TST upon hire and that he had restarted the two-step TST process for the Facility Administrator at this time.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview the facility failed to ensure aseptic technique was maintained when initiating a Central Venous Catheter (CVC) at the start of treatment for 1 of 2 CVC’s observed. (Patient #4) Findings Include: 1. A policy titled, “Apply mask to patient and caregiver to help prevent contamination by airborne nasal bacteria”. 2. During an observation on 06/17/2024 at 10:11 AM, RN 1 performed a dessing change for Patient #4. RN 1 failed to wear a mask when performing exit site care. 3. During an interview on 06/17/2024 at 10:32 AM, RN 1 indicated that she should have worn a mask during exit site care.”

“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: 44230 Based on record review and interview, the facility failed to maintain the physician-ordered BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate) aiding in maintaining the Kt/V (adequacy of hemodialysis) for 4 of 5 in-center hemodialysis patient record reviews (Patient #1, #2, #3, #4). Findings include: 1. A policy titled, “Patient Assessment and Monitoring” indicated but was not limited to, “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. 2. The treatment record for Patient #4 indicated a Physician ordered BFR of 450 and a DFR of Auto 2x (twice the blood flow rate). A treatment record dated 06/10/2024 indicated a BFR of 350 and 700 during the entire 4 hour and 30 minute treatment without a documented reason of change in the physician ordered prescription. A treatment record dated 06/12/2024 indicated a BFR of 350 & 400 and a DFR of 700 & 800 for the entire 4 hour and 30 minute treatment without a documented reason of change in the physician ordered prescription. 3. The treatment record for Patient #3 indicated a Physician ordered BFR of 450. A treatment record dated 06/04/2024 indicated a BFR of 300 for the first 1 hour and 40 minutes of treatment and a BFR of 400 after the first 1 hour and 40 minutes of treatment, throughout the remaining treatment, without a documented reason of change in the physician ordered prescription. A treatment record dated 06/07/2024 indicated a BFR of 400 throughout the treatment, without a documented reason of change in the physician ordered prescription. A treatment record dated 06/14/2024 indicated a BFR of 400 after 1 hour and 30 minutes of treatment, without a documented reason of change in the physician ordered prescription. 4. The treatment record for Patient #2 indicated a Physician ordered BFR of 350. A treatment record dated 06/03/2024 indicated a BFR of 300 for the first 34 minutes of treatment, without a documented reason of change in the physician ordered prescription. A treatment record dated 06/05/2024 indicated a BFR of 300 for the first 47 minutes of treatment, a BFR of 250 after the first 1 hour and 17 minutes of treatment and a BFR of 200 for the last 1 hour and 17 minutes of treatment, without a documented reason of change in the physician ordered prescription. 5. The treatment record for Patient #1 indicated a Physician ordered BFR of 400. A treatment record dated 06/03/2024 indicated a BFR of 300 for the first 45 minutes of treatment, without a documented reason of change in the physician ordered prescription. 6. During an interview on 06/18/2024 at 12:30 PM, PCT (Patient Care Tech) 1 indicated if a patient’s BFR or DFR are changed to anything other than the physician’s order, it should be documented why and what interventions were put in place. 7. During an interview on 06/18/2024 at 10:20 AM, the Home Area Team Lead indicated when staff make changes to the BFR and DFR that differ from the physician’s order, it should be documented in the patient’s clinical record.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, the facility failed to follow policy ensuring expired medications and supplies were discarded and medications were properly secured for 1 of 1 ESRD (End Stage Renal Disease) facility. Findings include: 1. A policy titled “Storage of Supplies” indicated but was not limited to, “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”. 2. A policy titled, “Medication Preparation and Administration” indicated but was not limited to, “Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via Fresenius Kidney Care off-site return program or in accordance with local and/or state law” ... “All medications will be kept in a locked cabinet except when in use. One key to the medication cabinet will be kept by the charge nurse/team leader. The Clinical Manager will retain a spare key, kept in a secure location”. 3. During an observation on 06/17/2024 at 9:36 AM, the following supplies were found to be expired: 2 bottles of Aniosgel hand sanitizer in the “dirty lab area” of the in-center treatment unit with an expiration date of 11/2023 and an additional 7 bottles of Aniosgel hand sanitizer on the supply carts on the in-center treatment unit in the patient care area with an expiration date of 11/2023. 4. During an observation on 06/17/2024 at 9:51 AM, the bottom drawer of the in-center treatment unit medication station at the front of the unit was found unlocked. Inside the drawer were the following medications: 2 boxes of Nitroglycerin (medication to treat and prevent chest pain) 0.4 mg tablets, 3 boxes of diphenhydramine hydrochloride (medication used to treat allergic reactions) 50mg/ml single-dose vials, 1 box of Solu-Medrol (medication used to treat allergic reactions) 40 mg single dose vials, and 3 boxes of Naloxone (medication used to rapidly reverse an opioid overdose) 0.4mg/ml single dose injections. 5. . During an observation on 06/17/2024 at 9:51 AM, the following expired medication was found in the in-center dialysis unit: 3 unopened bottles of Acetaminophen (medication used to treat pain and/or fever) 325 mg tablets indicated an expiration date of 04/2024. 6. During an interview on 06/17/2024 at 10:24 AM, RN 2 indicated that facility expectation is to lock any drawers used to store medications, and expired medications and supplies should be appropriately discarded. 7. During an interview on 06/17/2024 at 4:10 PM, the Director of Operations (DOO) indicated that medications are to be secured and further indicated that the medication doors are to be locked and the key with the nurse. The DOO indicated that all expired hand sanitizers found during the flash tour have been discarded and replaced.”