Fmc - NA of Grayson

“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: 44000 Based on observation, interview, and facility policy review, the facility failed to ensure staff performed hand hygiene when indicated to prevent cross-contamination and the spread of pathogens in 1 of 15 hemodialysis treatment stations. Additionally, a staff member did not perform correct hand hygiene at a dirty sink. Failure to perform hand hygiene provided a mode of cross-contamination with the potential for spread of pathogens, which could negatively impact the health and well-being of the 30 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Hand Hygiene,” dated 11/06/2023, revealed hands would be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves. Further review revealed to turn off the water faucet by touching the sink wrist blades with a clean single use paper towel because avoiding direct contact with the contaminated sink handle prevented contamination of washed hands. Observation on 06/25/2025 at 9:38 AM revealed Registered Nurse (RN) 4 washed her hands at the dirty sink and turned off the faucet with her bare hands. During interview with RN4 at the time of the observation, she stated she was nervous and just forgot to use a paper towel to turn off the faucet. Observation on 06/25/2025 at 10:27 AM revealed Patient Care Technician (PCT) 1 removed her gloves and put on new gloves after removing dialysis tubing from Patient (P) 7’s dialysis machine. She then put on new gloves without performing hand hygiene. She then removed the dialysis needles from P7’s arteriovenous fistula. During interview with PCT1 on 06/25/2025 at 10:36 AM, she stated she was working with the same patient, so she did not think she needed to perform hand hygiene after removing her gloves. During interview with the Clinical Educator on 06/25/2025 at 1:36 PM, she stated staff was educated to perform hand hygiene every time they removed their gloves. During interview with the Charge Nurse on 06/25/2025 at 1:47 PM, she stated staff should use hand sanitizer or wash their hands after taking off gloves. She stated she expected staff to follow the facility’s policy. During interview with the Director of Operations on 06/25/2025 at 2:22 PM, she stated she expected staff to sanitize or wash hands after they removed their gloves.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 44000 Based on observation, interview, and facility policy review, the facility failed to dispose of 1 unlabeled medication and 1 expired medication of 4 medications found in the locked medication cabinet. The findings include: Review of the facility’s policy titled, “Medication Preparation and Administration,” dated 02/06/2023, revealed all medications in syringes not being administered immediately shall be labeled appropriately with the name of medication, route, dose, name of patient, date, time, and initials of the person who prepared the medication. Further review revealed expiration dates for all stored medications were to be monitored on a monthly basis, and expired medications were to be discarded. Observation on 06/24/2025 at 11:04 AM of the locked medication cabinet revealed there was a vial of Calcitriol (vitamin D), which had an expiration date of 05/2025 on the label. Also observed was a syringe with approximately two milliliters of liquid. The syringe did not have a label or any identifying information on it. During interview with Registered Nurse (RN) 2/Clinic Manager, at the time of the observation, she stated staff monitored for expired medications quarterly. She also stated medications might lose their effectiveness if expired, and there was a potential to cause harm to the patient. She stated normally the nurse drew up the medication and immediately administered it. She stated if a medication was not going to be used immediately, it should be labeled. During interview with RN3/Charge Nurse on 06/24/2025 at 11:35 AM, she stated the unlabeled syringe should not have been in the medication cabinet, and it should have been discarded. She stated she expected staff to look at the expiration date of a medication prior to use and not to use an expired medication. She further stated the medication cabinet was monitored monthly to remove expired medications. During interview with the Director of Operations on 06/25/2025 at 2:22 PM, she stated she expected staff not to put unlabeled medications in the medication cabinet. She also stated she expected staff to discard expired medications.”