Fresenius Kidney Care Southport

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure patient and staff information was current in the Emergency Preparedness tote for 1 of 1 stand alone in-center dialysis facilities. Findings Include: 1. A review of a dated 07-03-2023, Fresenius Kidney Care policy titled, “Guidelines for Emergency Preparedness,” indicated but was not limited to “ ... Create and maintain staff, patient, and facility emergency information contact list ... “ 2. On 12-18-2023 at 9:45 AM, during a flash tour, the Emergency Evacuation box was reviewed. The Emergency Evacuation box failed to contain an updated list of the patient’s and staff’s emergency contact information. During an interview on 12-18-2023 at 9:45 AM, the Interim Clinical Manager, Admin 3, indicated the documents had fallen off the box and handed me the documents dated 09-23-2023. Admin 3 further confirmed the Emergency Evacuation box is audited monthly. 3. During an interview on 12-18-2023 at 9:55 AM, the Director of Operations, Admin 1, confirmed the Emergency Evacuation box should have contained the updated list of the patient’s and staff’s emergency contact information. 4. On 12-19-2023 at 11:11 AM, facility documents dated 05-14-203 to 12-19-2023, titled, “Fresenius Kidney Care Clinical Log Readings Report” was provided by Admin 1. The documents indicated a review of the contents of the Emergency Evacuation box contents. The log was completed on 12-19-2023, and signed by Admin 3.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure the Emergency Cart medications were checked for expiration dates for 1 of 2 Emergency Carts observed. Findings include: 1. A review of a dated 05-01-2023, Fresenius Kidney Care policy titled, “Emergency Medications, Equipment, and Supplies” indicated but was not limited to, “ ... The medications ... must be checked monthly or after use for contents, and expiration dates ... An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date ....” 2. During the flash tour observation on 12-18-2023 at 9:35 AM, 19 vials of Adrenaline (a medication used for emergency treatment of severe allergic reactions) 1milligram (mg)/milliliter (ml), and 2 vials of Calcium Chloride ( a medication used for treatment of low calcium levels) 1 gram/10 ml were found in the Emergency Cart by the nurse’s station of the in-center treatment floor. During an interview on 12-18-2023 at 9:45 AM, The Interim Clinical Manager, Admin 3, confirmed the medications had expired. Admin 3 further indicated the Emergency Cart is audited monthly. 3. On 12-19-2023 at 11:11 AM, facility documents dated 05-14-203 to 12-19-2023, titled, “Fresenius Kidney Care Clinical Log Readings Report” was provided by Admin 1. The documents indicated a review of the contents of the Emergency Cart contents. The log was completed on 12-19-2023 and signed by Admin 3.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to provide the patients with a safe, aesthetically pleasant environment with treatment chairs free of torn and unstained upholstery to allow proper effective cleaning and disinfection for 1 of 1 stand alone dialysis in-center facilities. Findings include: 1. A review of 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 ... maintaining a clean, safe, aesthetically pleasant environment for patients, staff, and visitors .... “ 2. During treatment room observations on 12-19-2023 from 8:30 AM to 1055 AM, observed the following on the treatment floor: A. Observed the isolation room patient’s treatment chair with brown spots and splatters on the right arm tray and the base of the dialysate machine #4. B. Observed at Station #12 the patient’s treatment chair with brown and yellow splatters on the right arm tray and armrest. C. Observed at Station #13 the patient’s treatment chair with brown and yellow splatters on the right arm tray and armrest. D. Observed at Station #11 the patient’s treatment chair with brown and yellow splatters on the right arm tray and the base of dialysis machine #16. E. Observed at Station #10 the patient’s treatment chair with brown and yellow splatters on the right arm tray and the base of dialysis machine #10. F. Observed at Station #9 the patient’s treatment chair with brown and yellow splatters on the right arm tray and the base of dialysis machine #14. G. Observed at Station #8 the patient’s treatment chair with brown and yellow splatters on the right and left arm trays and the base of dialysis machine #18. H. Observed at Station #7 the patient’s treatment chair with brown splatters on the right and left arm trays and the base of dialysis machine #2. I. Observed at Station #6 the patient’s treatment chair with brown splatters on the right arm tray and the base of dialysis machine #5. J. Observed at Station #5 the patient’s treatment chair with brown splatters on the right and left arm trays and yellow stains at the base of dialysis machine #27. K. Observed at Station #3 the patient’s treatment chair with brown and yellow splatters on the right arm tray and the base of dialysis machine #11. L. Observed at Station #2 the patient’s treatment chair with brown splatters on the right arm tray and yellow and brown stains at the base of dialysis machine #21. M. Observed at Station #1 the patient’s treatment chair with brown splatters on the right arm tray and the base of dialysis machine #17. N. Observed at Station #23 the patient’s treatment chair with brown splatters on the right and left arm trays and the base of dialysis machine #6. O. Observed at Station #22 the patient’s treatment chair with brown splatters on the left and right arm trays and yellow and brown splatters on the base of dialysis machine #26. P. Observed at Station #19 the patient’s treatment chair with brown splatters on the right armrest and arm tray and the base of dialysis machine #20. Q. Observed at Station #17 the patient’s treatment chair with brown splatters on the left and right arm trays. During an interview on 12-18-2023 at 9:30 AM, the Patient Care Technicians, PCT 5 and PCT 7, when queried regarding the brown splatters and droplets on the patient’s treatment chairs and machines, indicated the stains were betadine and would not come off. 3. During an interview on 12-19-2023 at 3:20 PM, Patient #25 was receiving their dialysis at Station #18. Patient #25 confirmed the chairs looked worn and stained. 4. During an interview on 12-19-2023 at 4:00 PM, the Director of Operations, Admin 1, when queried regarding the patient’s treatment chairs and machines, indicated they would think they were dirty. Admin 1 confirmed the chairs were old and stained.”

“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: 47343 Based on record review and interview, the facility failed to ensure direct patient care staff monitored the patients according to the facility policy in 5 of 10 records reviewed. (Patients #1, 4, 5, 6, and 9) Findings Include: 1. A review of a Fresenius Kidney Care policy dated 09-05-2023 titled “Patient Monitoring and Safety Checks During Hemodialysis Treatment” indicated but was not limited to, “ ... Patient Monitoring: Monitor and document every 30 minutes or more frequently as needed but not to exceed 45 minutes ... Safety Check-Machine Checks ... DFR (sic Dialysis Flow Rate), BFR (Blood Flow Rate), and UFR (Ultrafiltration rate) is set and functioning per treating physician order ...” 2. The clinical record of Patient #4 was reviewed with a total of 6 treatment records reviewed from 09-20-2023 to 10-02-2023. The treatment records failed to evidence safety checks were performed every 30-45 minutes for the treatment records dated 09-20-2023 and 09-27-2023. The treatment document dated 09-20-2023 failed to evidence a safety check was performed in between the safety checks at 13:43 and at 15:03 and the safety checks at 15:03 and 16:32. The treatment document dated 09-27-2023 failed to evidence a safety check was performed in between the safety checks at 13:05 and 14:04 and the safety checks at 14:04 and 15:08. 3. The clinical record of Patient #5 was reviewed with a total of 10 treatment records reviewed from 11-27-2023 to 12-18-2023. The treatment records failed to evidence safety checks were performed every 30-45 minutes for the treatment records dated 11-27-2023, 11-29-2023, 12-01-2023, 12-04-2023, and 12-06-2023. The treatment document dated 11-27-2023 failed to evidence a safety check was performed in between the safety checks at 15:10 and 16:15. The treatment document dated 11-29-2023 failed to evidence a safety check was performed in between the safety checks at 15:01 and 16:05. The treatment document dated 12-01-2023 failed to evidence a safety check was performed in between the safety checks at 14:05 and 15:02. The treatment document dated 12-04-2023 failed to evidence a safety check was performed in between the safety checks at 15:12 and 16:19. The treatment document dated 12-06-2023 failed to evidence a safety check was performed in between the safety checks at 14:36 and 16:53. The clinical record of Patient #5 evidenced treatment records from 11-27-2023 to 12-18-2023. The treatment records indicated the patient’s BFR was ordered at 350. The treatment documents dated 12-01-2023, 12-04-203, and 12-06-2023 evidenced the BFR was set at 400. The agency failed to ensure the BFR was set according to the physician’s orders for the 3 treatments. During an interview with the Director of Operations (DO) on 12-20-2023 at 2:00 PM, they indicated the staff had not looked at the orders to ensure the BFR was running at the physician-prescribed rate. 4. The clinical record of Patient #6 was reviewed with a total of 12 treatment records reviewed from 11-22-2023 to 12-18-2023. The treatment records failed to evidence safety checks were performed every 30-45 minutes for the treatment record dated 12-15-2023. The treatment document failed to evidence a safety check was performed in between the safety checks at 07:30 and 09:04. During an interview with the DO on 12-20-2023 at 4:15 PM, they indicated the staff were to include why the BFR was changed in the treatment notes. The DO indicated they were unable to find any notes indicating why the BFR was not running at the prescribed rate. 44232 5. The medical record/treatment sheets for Patient #1 were reviewed on 12-19-2023. The treatment sheets from 11-27-2023 through 12-18-2023 evidenced the following: A. Treatment sheet dated 12-18-2023, a blood pressure, and pulse check at 10:00 AM by the Patient Care Technician (PCT). The following patient assessment was completed by the Registered Nurse (RN) at 11:43 AM. 6. The medical record/treatment sheets for Patient #9 were reviewed on 12-19-2023. The treatment sheets from 11-27-2023 through 12-18-2023 evidenced the following: A. Treatment sheet dated 11-27-2023, a blood pressure, and pulse check at 3:08 PM by the PCT. The PCT completed the following blood pressure, and pulse check at 4:15 PM. B. Treatment sheet dated 11-29-2023, a blood pressure, and pulse check at 3:00 PM by the PCT. The following patient assessment was completed by the RN at 4:03 PM. C. Treatment sheet dated 12-01-2023, a blood pressure, and pulse check at 2:03 PM by the PCT. The following blood pressure and pulse check was completed by the PCT at 3:00 PM. D. Treatment sheet dated 12-06-2023, a blood pressure, and pulse check at 12:42 PM by the PCT. The following patient assessment was completed by the PCT at 1:33 PM. The PCT completed a blood pressure, and pulse check at 3:02 PM, and then at 4:27 PM. E. Treatment sheet dated 12-08-2023, a blood pressure, and pulse check at 2:01 PM by the RN. The following blood pressure and pulse check was completed by the PCT at 3:03 PM, and then at 4:01 PM, by the PCT. F. Treatment sheet dated 12-11-2023, a blood pressure, and pulse check at 12:46 PM by the PCT. The following patient assessment was completed by the RN at 1:14 PM. G. Treatment sheet dated 12-13-2023, a blood pressure, and pulse check at 2:09 PM by the RN. The following blood pressure and pulse check was completed by the PCT at 3:05 PM. During an interview on 12-19-2023 at 1:00 PM, the Director of Operations, Admin 1, confirmed the patients are to be monitored every 30 minutes with a maximum of 45 minutes during their dialysis treatment by the direct care staff.”