Fmc-South Central Louisville

“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: 50873 Based on observation, staff interview, and facility policy review, 3 of 7 staff (Patient Care Technicians [PCTs] #1, #3, and #5) observed performing patient care activities failed to perform hand hygiene per facility policy. The findings include: Review of facility policy titled, “Hand Hygiene,” published 11/06/2023, indicated staff should perform hand hygiene “Before and after direct contact with patients. Entering and leaving the treatment area. Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications. Immediately after removing gloves. After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. After contact with inanimate objects near the patient. When moving from a contaminated body site to a clean body site of the same patient. After contact with the dialysis wall box, concentrate, drain, or water lines. After contact with other objects within the patient station or treatment space.” On 08/26/2025 at 11:28 AM, PCT #5 was observed at treatment station #13. The PCT left the treatment station and went to the nurses’ station and obtained needles and returned to the treatment station. The PCT then left the treatment station at 11:36 AM to gather additional supplies at the nursing station and returned to the treatment station. The PCT failed to perform hand hygiene and change their gloves upon entering and leaving the treatment station. The PCT then palpated the patient’s access, cleaned the access with alcohol, and then changed gloves. The PCT failed to perform hand hygiene when changing gloves. On 08/26/2025 at 12:00 PM, PCT #1 was observed at treatment station #4. The PCT auscultated then palpated the patient’s access, applied antiseptic, and then cannulated the access. The PCT failed to perform hand hygiene and change gloves prior to performing an invasive procedure. During interview on 08/28/2025 at 3:58 PM, PCT #1 stated that changing gloves and using hand sanitizer should be done when leaving the patient station, if visibly dirty, after going to the bathroom, when entering the treatment floor, and when going from the machine to the patient. The PCT confirmed that they did not change gloves after assessing the patient’s access and prior to cannulation at treatment station #1 on 08/26/2025. The PCT stated that a co-worker was nervous so the PCT was helping the co-worker by cannulating the patient, and the PCT stated that was probably why they forgot to perform hand hygiene. On 08/26/2025 at 1:08 PM, PCT #3 was observed at treatment station #6. The PCT removed their gloves, left the treatment station, and donned new gloves. The PCT failed to perform hand hygiene when changing gloves. On 08/26/2025 at 1:20 PM, PCT #3 was observed wearing gloves and working at the dialysis machine at treatment station #3. The PCT left the treatment station, obtained gauze from the clean cart, set the gauze on the chairside table of station #3, left the treatment station and went to the nurses’ station and obtained tape, then returned to treatment station #3. The PCT failed to change gloves and perform hand hygiene when entering and leaving the treatment station. The PCT then disconnected the patient’s bloodlines, gave the patient a glove, then removed their gloves and donned new gloves. The PCT then went to patient treatment station #8, touched the dialysis machine, and changed gloves. The PCT returned to treatment station #3 and removed the patient’s needles and had the patient apply pressure to the sites where the needles had been removed (to stop the bleeding). The PCT removed their gloves, donned new gloves, then went to the clean cart with gloves on then went to treatment station #8. The PCT failed to perform hand hygiene when changing gloves. During interview on 08/27/2025 at 1:35 PM, PCT #7 stated that hand hygiene should be performed when going from dirty areas to clean, when going from one machine to another, from machine to patient, on entering and leaving the treatment station, when changing gloves, and after using the restroom. The PCT also stated that staff should wear gloves at the clean station when preparing supplies. On 08/29/2025 at 3:27 PM, the Clinic Manager confirmed the facility expectation would be for staff to perform hand hygiene per policy to include entering and leaving the treatment station. The Clinic Manager stated, “The staff know they are not supposed to wear gloves at the clean cart.” On 08/29/2025 at 4:06 PM, the Medical Director confirmed the facility expectation for the staff to follow all hand hygiene policies.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces were disinfected at the end of each dialysis treatment for 2 of 2 observations of post-treatment station disinfection. The findings included: Review of a facility policy titled, “Cleaning and Disinfection of the Dialysis Station,” published on 11/02/2020, revealed “Background - The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses.” During an observation of the hemodialysis treatment area on 08/26/2025 at 11:05 AM, Patient Care Technician (PCT) #1 was observed disinfecting Station #2 following a dialysis treatment. The PCT failed to disinfect the counter behind the treatment chair. During an observation of the hemodialysis treatment area on 08/26/2025 at 11:05 AM, PCT #7 was observed disinfecting Station #1 following a dialysis treatment. The PCT failed to disinfect the counter behind the treatment chair. During interview on 08/27/2025 at 1:35 PM, PCT #13 stated that dialysis treatment station disinfection was done after every treatment after the patient left and prior to the next patient coming in. The PCT stated that the disinfection should include the whole dialysis machine, the chair, and controls or appendages on the machine such as the blood pressure cuff, sharps containers, trash can, and the counter behind the treatment chair. The PCT confirmed that they failed to disinfect the counter behind the treatment chair but did not provide a reason why that was not done. Interview with PCT #1, on 08/28/2025 at 3:58 PM, reveaked that when cleaning the treatment station, staff should clean the chair and the machine to include the top, screen, and keyboard, intravenous (IV) pole, wall box, and counter behind the station. The PCT confirmed that they did not clean the counter behind the treatment chair but did not provide a reason why that was not done. During interview on 08/29/2025 at 3:27 PM, the Clinic Manager confirmed the expectation that the counters behind the treatment chair would be considered part of the dialysis station and should be cleaned as part of station disinfection after each treatment. On 08/29/2025 at 4:06 PM, the Medical Director confirmed the facility expectation that the counters behind the treatment chairs be cleaned as part of the station disinfection.”

“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: 50873 Based on record review, staff interview, facility policy review, and facility document review, the facility failed to monitor the patient’s fluid status per policy for 5 of 7 patients (Patients #2, #3, #4, #6, and #7) in the record review sample. The findings included: Review of facility policy titled, “Patient Assessment and Monitoring,” with a publication date of 05/01/2023, indicated staff should, “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes” and “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury - unit of measurement for blood pressure readings], Diastolic blood pressure greater than 100 mm/Hg, Blood pressure less than or equal to 100 mm/Hg systolic” and “Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular.” 1. Review of a “Treatment Sheet” for Patient #2 on 08/12/2025 indicated Patient Care Technician (PCT) #2 took the patient’s heart rate of 51 at 11:41 AM, 54 at 12:33 PM, and 54 at 3:04 PM; PCT #6 took heart rate readings of 54 at 12:32 PM and 52 at 2:32 PM; and PCT #7 took a heart rate reading of 55 at 2:03 PM. There was no evidence of the PCTs’ notification to the registered nurse (RN) of the out-of-range vital signs. Review of a “Treatment Sheet” for Patient #2 on 08/14/2025 showed no evidence of monitoring the patient’s vital signs from 11:41 AM till 12:32 PM (51 minutes). The treatment sheet also showed that PCT #6 took heart rate readings of 52 at 1:34 PM, 53 at 2:02 PM, and 53 at 2:32 PM. There was no evidence of the PCT’s notification to the RN of the out-of-range vital signs. 2. Review of a “Treatment Sheet” for Patient #3 on 08/16/2025 indicated Patient Care Technician (PCT) #5 took blood pressure readings of 198/84 at 1:19 PM, 199/89 at 1:34 PM, and 224/102 at 3:00 PM. There was no evidence of the PCT’s notification to the registered nurse (RN) of the out-of-range vital signs. 3. Review of a “Treatment Sheet” for Patient #4 on 08/14/2025 indicated that Patient Care Technician (PCT) #2 took the patient’s heart rate of 51 at 8:37 AM, 58 at 9:02 AM, and 59 at 10:21 AM. There was no evidence of the PCT’s notification to the registered nurse (RN) of the out-of-range vital signs. Review of a “Treatment Sheet” for Patient #4 on 08/26/2025 indicated that PCT #3 took blood pressure readings of 187/100 at 7:37 AM, 135/101 at 10:03 AM, and 135/101 at 10:40 AM. There was no evidence of the PCT’s notification to the RN of the out-of-range vital signs. 4. Review of a “Treatment Sheet” for Patient #6 on 08/23/2025 indicated Patient Care Technician (PCT) #6 took the patient’s heart rate of 53 at 1:33 PM, and PCT #4 took a heart rate reading of 59 at 2:32 PM. There was no evidence of the PCTs’ notification to the registered nurse (RN) of the out-of-range vital signs. Review of a “Treatment Sheet” for Patient #6 on 08/26/2025 indicated that PCT #3 took the patient’s heart rate of 53 at 1:10 PM, 56 at 1:30 PM, and 55 at 3:00 PM. There was no evidence of the PCT’s notification to the RN of the out-of-range vital signs. 5. Review of a “Treatment Sheet” for Patient #7 on 08/14/2025 showed no evidence of monitoring the patient’s vital signs from 2:04 PM till 3:35 PM (1 hour and 21 minutes). Additionally, review of a “Treatment Sheet” for Patient #7 on 08/19/2025 showed no evidence of monitoring the patient’s vital signs from 12:03 PM till 1:05 PM (1 hour and 2 minutes). During interview on 08/29/2025 at 12:08 PM, Patient Care Technician (PCT) #3 stated the staff should check the patient’s blood pressure, heart rate, access, and if the patient had any complaints or problems. The PCT stated if the blood pressure was lower than 100/60 or higher than 140/90, and if the heart rate was lower than 60 or higher than 100, the registered nurse (RN) should be notified and the notification should be documented. During interview on 08/27/2025 at 4:20 PM, the Clinic Manager (CM) confirmed the facility expectation that patient monitoring occur at a minimum of every 30 minutes not to exceed 45 minutes and that any notification made by staff such as the RN to the physician or the PCT to the RN should be documented. The CM also stated the facility did not have facility-specific reporting parameters for staff, and the staff should follow the Patient Assessment and Monitoring Policy. On 08/29/2025 at 4:06 PM, the Medical Director confirmed the facility expectation that staff notify the RN of out-of-range vital signs per policy and document the notification.”

“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: 50873 Based on observation, staff interview, and facility policy review, the facility failed to assess patients’ accesses prior to cannulation per facility policy for 1 of 2 observations of access cannulation. The findings included: A facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, indicated that the pre-treatment access assessment included, “Look. Listen. Feel.” On 08/26/2025 at 11:49 AM, Patient Care Technician (PCT) #5 was observed at patient treatment station #13 initiating dialysis treatment for a patient with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). The PCT palpitated the access, applied alcohol to the access, changed gloves, applied a tourniquet, palpated the access, applied numbing spray, and cannulated the access. The PCT failed to auscultate the access prior to cannulation. During interview on 08/27/2025 at 1:35 PM, PCT #7 stated that AVF and AVG should be assessed prior to cannulating and that to assess an access, the PCT would look, listen, and feel. The PCT stated that should be done every time the access was cannulated. The PCT stated the staff should listen with a stethoscope and that the facility had provided stethoscopes for staff use. During interview on 08/29/2025 at 3:27 PM, the Clinic Manager confirmed that the staff should auscultate every AVF and AVG prior to cannulation. On 08/29/2025 at 4:06 PM, the Medical Director confirmed the facility expectation that auscultation be performed before every cannulation.”