Fmc - Connersville

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, the facility failed to secure oxygen cylinders in stands and/or racks in 1 of 1 facility reviewed. Findings Include: 1. A policy titled, “Emergency Administration of Oxygen” indicated but was not limited to, “Unless in use, secondary (reverse) cylinders/tanks must me: Secured in racks or rolling stands in a storage area or dedicated area for oxygen”. 2. During an observation on 07/23/2024 at 10:50 AM, one oxygen cylinder located next to the emergency crash cart was found sitting directly on the floor and not secured in a rack or rolling stand. 3. During an interview on 07/23/2024 at 4:13 PM, the Area Team Lead and Clinical Manager indicated that oxygen should be stored up off the floor in rack or stand.”

“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: 44230 Based on record review and interview the facility failed to ensure safety checks were completed during dialysis that included patient blood pressures and pulse rates every 30 minutes for 3 of 7 records reviewed. (Patient #1, #4, #7) Findings Include: 1. A policy titled, “Patient Assessment and Monitoring” indicated but was not limited to, “During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations”. 2. A treatment sheet for Patient #1, dated 07/13/2024 indicated a blood pressure/pulse rate check completed at 12:34 PM. The next blood pressure/pulse rate was completed at 1:38 PM, 1 hour and 4 minutes later. 3. A treatment sheet for Patient #1, dated 07/16/2024 indicated a blood pressure/pulse rate check completed at 12:32 PM. The next blood pressure/pulse rate was completed at 1:30 PM, 58 minutes later. 4. A treatment sheet for Patient #4, dated 07/11/2024 indicated a blood pressure/pulse rate check completed at 1:30 PM. The next blood pressure/pulse rate was completed at 2:31 PM, 1 hour and 1 minute later. 5. A treatment sheet for Patient #7, dated 07/20/2024 indicated a blood pressure/pulse rate check completed at 7:01 AM. The next blood pressure/pulse rate was completed at 8:08 AM, 1 hour and 7 minutes later. 6. During an interview on 07/25/2024 at 10:08 AM, Registered Nurse (RN) 4 indicated that the expectation is for blood pressure and pulse rates to be assessed and documented every 30 minutes. 7. During an interview on 07/25/2023 at 10:32 AM, Patient Care Technician (PCT) 2 indicated that the expectations is for blood pressure and pulse rates to be assessed and documented every 30 minutes.”

“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 regarding monitoring supplies for expiration dates, securement of medications, and labeling pre-drawn medications for 1 of 1 facility reviewed. Findings Include: 1. A policy titled, “Expiration Dates of Sterile 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, “Securement: The following steps must be taken for the securement: All medications will be kept in a locked cabinet except when in use ... Medications may be pre-drawn up to 4 hours prior to the administration ... These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration ... All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time, and initials of the person who prepared the medication”. 3. During on observation on 07/23/2024 at 10:17 AM the following laboratory supplies on the treatment floor located in the laboratory area were found to be expired: 2 Blood Cultures Sets, (used to culture blood for infections), expired 07/13/2024, 1 opened box of Embrace Pressure Activated Safety Lancets, (used to check blood sugar levels), expired 11/23/2022, and 7 Hema Screen Slides Test (used to check stool for blood), expired 06/30/2023. 4. During an observation on 07/23/2024 at 10:12 AM sixteen vials of Heparin (an intravenous medication used to prevent clotting during dialysis) were found in an unlocked drawer at the nurse’s station. Two additional syringes of pre-drawn Heparin were found in the same drawer with labels attached identifying what medication was in the syringes, Heparin. The labels failed to identify the staff member that drew up the medications along with the time. An additional drawer at the medication prep area was found unlocked with the following medications inside: Venofer (medication used to treat anemia) 50 milligrams (mg) and 100 mg, Sterile Water, Vancomycin (used to treat infections), Cefazolin (used to treat infections), Cefepime (used to treat infections), Zofran (used to treat nausea), Benadryl (used to treat allergic reactions), Doxercalciferol (used to lower parathyroid hormone levels), Korsuva (used to treat itching), Calcitriol (used to treat low calcium levels/parathyroid gland conditions), Sensipar (used to treat elevated parathyroid levels), Clonidine (used to treat high blood pressure), Glutose (used to treat low blood glucose levels), and Tylenol (pain reliever). 5. During an observation on 07/23/2024 at 11:00 AM one bottle of Mesa Labs Standard Buffer Solution 7.0 (used to calibrate conductivity meters) was found in the water room area with an expiration date of 07/18/2024. 6. During an interview on 07/23/2024 at 10:07 AM, Patient Care Technician (PCT) 2 indicated that medications are unlocked at the beginning of each day, then relocked at the end of the day. 7. During an interview on 07/23/2024 at 10:12 AM, PCT 2 indicated she had pre-drawn the two syringes of Heparin located in the drawer at the nurse’s station and that she failed to include her initials and time of draw-up on the labels, further indicating that would be the expectation. 8. During an interview on 07/23/2024 at 10:52, PCT 3 indicated that the Biomed checks all supplies for expiration and appropriately disposes as needed. PCT 3 indicated checking expiration dates of all supplies prior to using them. 9. During an interview on 07/23/2024 at 10:55 AM, Registered Nurse (RN) 3 indicated that the expectation is that all medications are to be locked at all times and that supplies are inventoried by the Administrative Assistant for expiration and disposed of appropriately. 10. During an interview on 07/23/2024 at 11:00 AM, the Biomed indicated that all expired supplies should not be used and discarded of appropriately. 11. During an interview on 07/23/2024 at 12:50 PM, the Clinical Manager indicated that all staff are responsible for checking supplies for expiration. Biomed orders all supplies, excluding medications and lab supplies. Biomed ordered supplies are monitored for expiration dates when in the storage room by Biomed and once items are brought out to the treatment floor, then all staff are responsible for monitoring expiration dates. The Clinical Manager indicated the expectation is that all medications are to be locked at all times when not in use. The Clinical Manager found today that the lock on the medication drawer at the medication prep area was broken and Biomed was able to fix it. Denied knowledge of broken drawer prior to surveyor mentioning the medication drawer was unlocked, unsure how long it was broken. Further indicated that the medication drawer that housed the Heparin was not broken and again the expectation is that all medications should be locked at all times. The Medical Director was present via phone.”