Fmc - Corydon

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility failed to follow facility policy regarding labeling bleach solution containers for 1 of 1 observation of a 1:10 bleach solution bottle. Findings include: A policy titled “Cleaning and Disinfecting the Dialysis Station” was provided by the Facility Administrator (FA) on 05/31/2024. The policy indicated that the 1:10 (add 1 part bleach to 10 parts of water) bleach solution will be stored in a labeled bottle. During an observation on 05/31/2024 at 8:10 AM, Patient Care Technician (PCT) 4 sprayed a clear solution from a bottle to clean up blood on the floor at station 3. At that time, PCT 4 stated that it was a 1:10 bleach solution. She was unsure why the bottle had no label indicating it was a 1:10 bleach solution. During an interview on 05/31/2024 at 9:10 AM, the Clinical Manager (CM) was unsure why the spray bottle was not labeled 1:10 bleach solution. She stated that the staff knew what was in the bottle.”

“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: 38262 Based on observation, record review, and interview, the facility staff failed to ensure patients removed gloves and performed hand hygiene after applying pressure to the atrioventricular (AV) access site for 1 of 2 AV discontinuation observations (Patient #10) and failed to ensure clean items (medical tape) were stored in a designated clean area for 1 of 4 facility observation days. (Treatment floor) Findings include: 1. A policy titled “Access Assessment and Cannulation” was provided by the Facility Administrator (FA) on 05/31/2024. The policy indicated that a multi-use tape roll must be prepared in a clean area. The tape can be torn into strips, tabbed at one end, and stacked on top of one another. The policy indicated the last strip serves as a barrier and should not be placed on the patient. When ready to cannulate (insert tube into vein), the stacked torn tape should be retrieved from the clean area. The policy indicated that once gloves are removed, hand hygiene should be performed. 2. During the flash tour on 05/28/2024 at 9:00 AM, staff had applied stacked pre-torn paper tape to the front of the dialysis machine at station 9. The staff failed to retrieve the pre-torn tape from a clean area and place the tape on the chair side table. During an interview on 05/31/2024 at 12:00 PM, the Director of Nursing stated staff were not to stick the pre-torn paper tape to the front of the dialysis machine. 3. During an observation on 05/30/2024 at 9:45 AM, Patient #10 removed their glove but did not perform hand hygiene after applying pressure to their AV access site during discontinuation. Patient Care Technician (PCT) 1 failed to ensure Patient #10 performed hand hygiene and failed to offer hand sanitizer after glove removal and before leaving the station. During an interview on 05/30/2024 at 3:00 PM, the Director of Operations and the Clinical Manager stated Patient #10 should perform hand hygiene after holding pressure to their access site. During an interview on 06/03/2024 at 12:20 PM, the Medical Director stated that the expectation was for staff to follow the facility policy regarding infection control procedures.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49228 Based on observation, record review, and interview, the facility failed to ensure cleaning and disinfecting of stethoscopes between patient uses for 3 of 3 observations. Findings include: 1. A policy titled “Cleaning and Disinfecting the Dialysis Station” indicated that reusable equipment, such as a stethoscope, should be cleaned and disinfected between patient use. 2. During an observation on 05/29/2024 at 11:57 AM, Registered Nurse (RN) 1 failed to clean and disinfect the stethoscope used between patients at station #11 and station #1. 3. During an observation on 05/30/2024 at 7:07 AM, RN 1 failed to clean and disinfect the stethoscope after completing a nursing assessment on patient #7. 4. During an observation on 05/31/2024 at 7:53 AM, RN 1 failed to clean and disinfect the stethoscope used between patients at station #6 and station #9. 5. During an interview on 05/31/2024 at 10:58 AM, RN 1 indicated placing a glove over the stethoscope as a barrier when assessing patients and cleaning the stethoscope with alcohol after. 6. During an interview on 05/31/2024 at 12:00 PM, the Director of Operations (DOO) stated that staff should not use a glove over the end of a stethoscope as a barrier. She noted that the stethoscope should be disinfected between patient use.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility failed to follow applicable infection control procedures when cleaning and disinfecting contaminated surfaces and equipment for 2 of 2 staff observations of treatment stations being cleaned and disinfected. (RN 1, RN 2) Findings include: 1. A policy titled “Cleaning and Disinfecting the Dialysis Station” was provided by the Facility Administrator (FA) on 05/31/2024. The policy indicated that after a patient leaves the station, staff should disinfect the TV, counter, and oxygen concentrator with a bleach solution consisting of 1:100 (1 parts bleach to 100 parts water). 2. During an observation on 05/30/2024 at 8:12 AM, Registered Nurse (RN) 2 failed to disinfect station #6’s TV screen and countertop behind the dialysis machine. 3. During an observation on 05/31/2024 at 10:47 AM, RN 1 failed to disinfect station #8’s TV screen, the countertop behind the dialysis machine, and the oxygen concentrator. RN 1 stated she had finished cleaning the station despite the three areas not being disinfected. 4. During an interview on 05/31/2024 at 12:00 PM, the Clinical Manager (CM) and Director of Operations (DOO) stated the TV, countertops, and oxygen concentrator should be disinfected after the patient leaves the station. 5. During an interview on 06/03/2024 at 12:20 PM, the Medical Director stated that the expectation was for staff to follow the facility policy regarding infection control procedures.”

“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: 49228 Based on observation, record review, and interview, the facility failed to maintain a secure building to ensure staff and patient safety for 1 of 4 facility observation days. Findings include: 1. A policy titled “Physical Security and Facility Access” indicated, but was not limited to, all external employee entrance doors to remain closed and locked. 2. During an observation on 06/03/2024 at 8:25 AM, the external employee entrance door was propped open. 3. During an observation on 06/03/2024 at 8:43 AM, Registered Nurse (RN) 2 and Patient Care Technician (PCT) 5 discussed the external door being propped open. PCT 5 indicated that the external staff door had been propped open by PCT 5 on break but was no longer propped open when PCT 5 went to re-enter the building. 4. During an interview on 06/03/2024 at 8:44 AM, PCT 5 indicated not knowing the code to get in the building and had propped the door open. 5. During an interview on 06/03/2024 at 8:55 AM, the Director of Operations indicated the external doors to facility to remain closed and locked at all times. 6. During an interview on 06/03/2024 at 12:20 PM, the Medical Director indicated the external doors should not be propped open, as these doors should remain closed and locked.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility staff failed to ensure cannulation sites were not touched again after skin antisepsis for 2 of 2 staff observations of an arteriovenous (AV) fistula initiation. (RN 2, PCT 4) Findings include: 1. A policy titled “Access Assessment and Cannulation” was provided by the Facility Administrator (FA) on 05/31/2024. The policy indicated the correct practice was to avoid touching the cannulation (insert the tube into a vein) site after disinfection. 2. During an observation on 05/30/2024 at 7:15 AM, Registered Nurse (RN) 2 failed to avoid touching Patient #7’s AV cannulation site after she cleaned with alcohol and before inserting a needle. 3. During an observation on 05/31/2024 at 6:20 AM, Patient Care Technician (PCT) 4 failed to avoid touching Patient #11’s AV cannulation site after she cleaned with alcohol and before inserting the needle. 4. During an interview on 05/31/2024 at 12:00 PM, the Clinical Manager (CM) and Director of Operations stated staff are not to touch the AV access site after cleaning and before accessing with a needle. 5. During an interview on 06/03/2024 at 12:20 PM, the Medical Director stated that the expectation was for staff to follow the facility policy regarding infection control procedures.”

“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: 49228 Based on observation, record review, and interview, the Medical Director failed to ensure the facility followed their own policies and procedures regarding medication administration for 3 of 3 patient medication administration observations. (Patient #6, Patient #8, & Patient #15) Findings include: 1. A policy titled “Medication Preparation and Administration” indicated, but was not limited to, “Follow the principles below for medication preparation and administration. Right Drug. Right Dose. Right Route. Right Time. Right Patient. Right Documentation ...The person who prepares the medication must be the person who will administer the medication.” 2. During an observation on 05/30/2024 at 10:07 AM, RN 1 failed to observe patient #8 taking the medication provided. 3. During an observation on 05/31/2024 at 10:04 AM, RN 1 failed to observe patient #15 taking the medication provided. 4. During an observation on 05/31/2024 at 10:13 AM, RN 1 failed to observe patient #6 taking the medication provided. 5. During an interview on 05/31/2024 at 12:00 PM, the Director of Operations (DOO) and the Clinical Manager (CM) stated that they expected the nurse to observe the patient taking their medication.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 49228 Based on observation, record review, and interview, the facility failed to ensure patients’ medical records were secured for 3 of 4 facility observation days. Findings include: 1. A policy titled “Storing, Filing, Thinning, and Retrieving of Medical Records” indicated, but was not limited to, “Hard charts must be placed in chart racks or carts or medical record rooms that are locked during nonwork hours ...Responsibility: Authorized employees who oversee and maintain facility medical records.” 2. During an observation on 05/29/2024 at 8:25 AM, the door to patient medical records was propped open without personnel present. 3. During an observation on 05/30/2024 at 6:40 AM, the door to patient medical records was propped open without personnel present. 4. During an observation on 05/31/2024 at 4:44 AM, the door to patient medical records was propped open without personnel present. 5. During an observation on 05/31/2024 at 6:15 AM, Patient #6 left the restroom located next to where patient records are kept, the door to patient medical records was propped open, and there were no employees present monitoring the door or patient records. 6. During an interview on 05/31/2024 at 6:58 AM, Patient Care Technician (PCT) 3 indicated the door to patient medical records does not have to be shut, but is locked when facility is closed. 7. During an observation on 05/31/2024 at 7:00 AM, the Facility Administrator (FA) closed the door to the patient’s medical records. 8. During an interview on 05/31/2024 at 7:00 AM, the FA indicated the door to patient medical records does not have to be closed and is usually open and has a receptionist in that area. The FA believed patients would not enter the opened medical record room if personnel were not around. The FA stated that the door was left open the previous night before leaving the facility, but it was closed when the last employee left. The FA stated she called PCT 1 who confirmed that the door to the patient medical records was open when they arrived to open the facility.”