Fmcna - Donaldsonville Dialysis

“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: 14442 Based on record review, observation and interview, the dialysis facility failed to display required signage to advise the public regarding workplace violence in accordance with R.S. 40:2199.11 through 2199.19 (Workplace Violence Prevention, Act 461 of the Louisiana Legislature). Findings: In accordance with Louisiana Revised Statutes R.S. 40:2199-2199.19, “A. Each regulated entity shall display at its premises at least one sign that conforms with the specifications of Subsection B of this Section and indicates that abuse of or workplace violence against healthcare staff will not be tolerated and could result in a felony conviction under R.S. 14:38 or other applicable criminal laws. B. Each sign displayed in accordance with the requirements of this Section shall conform with all of the following specifications: (1) The sign shall be posted in a conspicuous location in a publicly accessible area of the regulated entity’s facility. (2) The sign shall be at least eighteen inches tall by eighteen inches wide and written in the English language with letters not less than one square inch in size.” Observation of publicly accessible areas of the facility on 01/28/2026 at 8:25 AM failed to reveal the required workplace violence cautionary signage. In an interview on 01/28/2026 at 11:06 AM, S1RN confirmed the facility did not have workplace violence cautionary signage posted.”

“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: 14442 Based on observation, policy review, and interview, the dialysis facility failed to ensure patients’ (R1, R2) were provided gloves when holding access sites post treatment and performed hand hygiene after each dialysis treatment. This deficient infection control practice presented a risk for cross-contamination to the 45 in-center hemodialysis patients on census. Findings: 1. Observation of Patient R1 on 01/28/2026 at 10:29 AM revealed Patient R1 used a bare hand to hold access sites post treatment to achieve hemostasis (stop bleeding). Further observation revealed Patient R1 left treatment room without performing hand hygiene. 2. Observation of Patient R2 on 01/29/2026 at 9:44 AM revealed Patient R2 used a bare hand to hold access sites post treatment to achieve hemostasis. Further observation revealed Patient R2 left treatment room without performing hand hygiene. Review of the facility policy titled “Hand Hygiene, Published: 11/06/2023, Version: 8,” revealed, in part: “Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Policy: Hand Hygiene: Patients. Patients should perform hand hygiene if able, prior to and after each dialysis treatment. As needed, direct patient care staff will demonstrate how to operate the sinks, demonstrate hand washing to patients who are able to perform hand washing, and explain risk of contamination with regard to their vascular access and hands to all patients. Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.” In an interview on 01/29/2026 at 8:56 AM, S1RN confirmed patients should be provided and wear gloves when holding access sites post treatment. S1RN confirmed patients should perform hand hygiene after each dialysis treatment.”

“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: 14442 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff perform hand hygiene after glove removal, when entering and leaving the treatment area, and wear gloves when touching surfaces within the patient station. This deficient infection control practice presented a risk for cross-contamination to the 45 in-center hemodialysis patients on census. Findings: 1. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 9:34 AM revealed S1RN did not perform hand hygiene after glove removal. Further observation revealed S1RN did not perform hand hygiene when leaving the treatment area. 2. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 9:42 AM revealed S2PCT did not perform hand hygiene between three glove changes. 3. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 9:44 AM revealed S3PCT did not perform hand hygiene after glove removal. 4. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 9:49 AM revealed S2PCT touched hemodialysis machine and treatment chair in a patient station with a bare hand. S2PCT then donned clean gloves. 5. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 9:52 AM revealed S2PCT did not perform hand hygiene after glove removal. Further observation revealed S2PCT did not perform hand hygiene when leaving and entering the treatment area. 6. Observation of the in-center hemodialysis treatment room on 01/28/2026 at 10:16 AM revealed S4PCT touched hemodialysis machine in a patient station with a bare hand. Review of the facility policy titled “Hand Hygiene, Published: 11/06/2023, Version: 8,” revealed, in part: “Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Policy: Hands Will Be ...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water. When ...Entering and leaving the treatment area. Immediately after removing gloves.” Review of the facility policy titled “Personal Protective Equipment, Published: 11/06/2023, Version: 6,” revealed, in part: “Purpose: The purpose of this policy is to identify Personal Protective Equipment (PPE) and potential areas for use. Policy. Gloves: A supply of clean, non-sterile gloves and a waste container shall be placed near each dialysis station or treatment area. Staff must remove gloves and wash hands after: Touching any surfaces within the patient station. Always perform hand hygiene after glove removal.” In an interview on 01/29/2026 at 9:01 AM, S1RN confirmed staff should perform hand hygiene after glove removal, when entering and leaving the treatment area, and wear gloves when touching surfaces within the patient station.”

“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: 14442 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff disinfect the stethoscope after use on each patient (#1, R3, R4). This deficient infection control practice presented a risk for cross-contamination to the 45 in-center hemodialysis patients on census. Findings: 1. Observation of Patient R3 on 01/28/2026 at 10:22 AM revealed S5RN did not disinfect the stethoscope after assessing the patient. 2. Observation of Patient R4 on 01/28/2026 at 10:34 AM revealed S5RN did not disinfect the stethoscope after assessing the patient. Further observation revealed S5RN assessed Patient #1 and did not disinfect the stethoscope after assessing the patient. Review of the facility policy titled “Cleaning and Disinfection of the Dialysis Station, Published: 09/02/2025, Version: 15,” revealed, in part: “Purpose: The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. General Cleaning: After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with a 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station.” In an interview on 01/29/2026 at 9:01 AM, S1RN confirmed staff should disinfect the stethoscope after use on each patient.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 14442 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff immediately replaced and inspected external transducer protectors wet with blood for 3 (R5, R6, R7) of 3 patients observed with wet transducer protectors. This deficient infection control practice presented a risk for cross-contamination to the 45 in-center hemodialysis patients on census. Findings: 1. Observation of the of the in-center hemodialysis treatment room on 01/28/2026 from 9:02 AM until end of hemodialysis treatment at 9:48 AM revealed the external transducer protector on Patient R5’s hemodialysis machine was wet with blood. Further observation revealed staff performed patient monitoring and dialysis machine checks and did not replace and inspect the wet transducer protector. 2. Observation of the of the in-center hemodialysis treatment room on 01/28/2026 at 9:24 AM revealed the external transducer protector on Patient R6’s hemodialysis machine was wet with blood. Further observation revealed staff performed patient monitoring and dialysis machine checks and did not replace and inspect the wet transducer protector. 3. Observation of the of the in-center hemodialysis treatment room on 01/29/2026 at 9:42 AM revealed the external transducer protector on Patient R7’s hemodialysis machine was wet with blood. Further observation revealed staff performed patient monitoring and dialysis machine checks and did not replace and inspect the wet transducer protector. Review of the facility policy titled “Maintenance of Transducer Protectors Procedure, Published: 11/01/2021, Version: 2”, revealed, in part: “Purpose: The purpose of this policy is to ensure accurate measurement of arterial and venous pressures by maintaining clean, dry, transducer protectors and to prevent cross contamination of bloodborne pathogens due to a contaminated internal transducer protector. Policy: External transducer protectors must be changed immediately when they become wet with blood or other fluid. Wet external transducer protectors must be thoroughly examined to determine if any blood or other fluid contamination is visible on the machine side (back) of the transducer protector prior to replacement. If no evidence of blood or fluid contamination is evident, no further action is required other than replacing the wet transducer. If the machine side (back) of the external transducer protector shows evidence of contamination with blood or other fluid, the machine must NOT be used to dialyze another patient until it has been thoroughly examined for any internal evidence of blood or fluid contamination by Technical Services.” In an interview on 01/29/2026 at 9:03 AM, S1RN confirmed external transducer protectors must be changed immediately and examined when they become wet with blood or other fluid.”

“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: 14442 Based on observation and interview, the dialysis facility failed to maintain the hemodialysis treatment room by having clear liquid substance on the floor and treatment room floors with build-up of whitish colored substance. This deficient practice had the potential to negatively impact the 45 in-center hemodialysis patients on census. Findings: Observation of the in-center hemodialysis treatment room on 01/28/2026 from 9:16 AM to 10:02 AM revealed a clear liquid on the floor around hemodialysis treatment stations #6, #7, #8, #13, and #14. Clear liquid was seen under hemodialysis machines and a patient treatment chairs. Further observation of floors around hemodialysis treatment stations #1 - #16 revealed areas of a whitish colored crystal-like substance near the hemodialysis machines and treatment chairs. Interviews during the observation period with Patient #1 and Patient R5 revealed clear liquid on the floors was an ongoing issue and patients’ complained about the liquid on the floor and condition of treatment room floors. Interviews during the observation period with S2PCT, S3PCT, S4PCT, and S6PCT revealed the clear liquid was either water or bicarbonate that was leaking from the wall box that housed water, bicarbonate, and acid concentrate plumbing. In an interview on 01/29/2026 at 9:01 AM, S1RN confirmed that clear liquid leaked from underneath the wall box behind patient treatment stations. S1RN indicated this has been an ongoing issue for approximately one year. S1RN confirmed areas of treatment room floors had a build-up of whitish colored substance and some floor areas were in poor condition.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 14442 Based on observation and interview, the dialysis facility failed to maintain hemodialysis machines as evidenced by having to use tape to prevent keyboard buttons from falling off and potentially affecting machine functionality. This deficient practice had the potential to impact the 45 in-center hemodialysis patients on census. Findings: Observation on 01/29/2026 at 9:49 AM revealed hemodialysis machines #5, #7, #12, #13, #19, and #20 had tape covering the enter button on keyboards. In an interview on 01/29/2026 at 9:50 AM, S2PCT indicated tape was used to keep enter buttons in place on keyboards to prevent them from falling off. S2PCT indicated if the button fell off the keyboard would not work properly. S2PCT indicated the enter button was used to enter information and change screens on hemodialysis machines. In an interview on 01/29/2026 at 10:03 AM, S1RN confirmed hemodialysis machine keyboards had tape to hold enter buttons in place.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 14442 Based on record review and interview, the dialysis facility failed to ensure the patient’s dialysis prescription for dialysis flow rate was delivered as ordered by the physician for 1 (#2) of 3 sampled patients. Findings: Review of Patient #2’s “Hemodialysis Orders” revealed, in part: “DFR: Manual 800 mL/min.” Review of Patient #2’s “Treatment Sheet” dated 01/16/2026 revealed DFR 500 mL/min during entire hemodialysis treatment. Further review revealed staff did not document any findings or interventions for the prescribed DFR not delivered. Review of Patient #2’s “Treatment Sheet” dated 01/21/2026 revealed DFR 500 mL/min during entire hemodialysis treatment. Further review revealed staff did not document any findings or interventions for the prescribed DFR not delivered. Review of the facility policy titled “Pre-Treatment Safety Checks Procedure, Published: 02/06/2023, Version: 3” revealed, in part: “Pre-Dialysis Safety Checks. Verify the following elements by two direct patient care staff members prior to treatment initiation: Dialysate flow rate. After Patient is Seated: The clinician initiating treatment must verify the prescribed set up matches the patient: Prescription. Dialysate flow rate.” In an interview on 01/29/2026 at 12:24 PM, S1RN confirmed Patient #2’s prescribed dialysate flow rate was not delivered as ordered by the physician.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 14442 Based on observation, the dialysis facility failed to ensure that staff were competent in the skills needed to perform specific duties as evidenced by staff (S1RN, S2PCT, S3PCT, S4PCT, S5RN) failing to implement infection control policies and procedures. This deficient practice had the potential to negatively impact the 45 in-center hemodialysis patients on census. Findings: 1. Observation of the in-center hemodialysis treatment room on 01/28/2026 from 9:34 AM to 10:16 AM revealed staff (S1RN, S2PCT, S3PCT, S4PCT) failed to demonstrate competencies by failing to perform hand hygiene after glove removal, when entering and leaving the treatment area, and wear gloves when touching surfaces within the patient station. See V113 for additional information. 2. Observation of the in-center hemodialysis treatment room on 01/28/2026 from 10:22 AM to 10:34 AM revealed staff (S5RN) failed to demonstrate competencies by failing to disinfect the stethoscope after use on each patient (#1, R3, R4). See V116 for additional information. 3. Observation of the of the in-center hemodialysis treatment room on 01/28/2026 from 9:02 AM to 9:48 AM and on 01/29/2026 at 9:42 AM revealed staff failed to demonstrate competencies by failing to immediately replace and inspect external transducer protectors wet with blood for 3 (R5, R6, R7) of 3 patients observed with wet transducer protectors. See V120 for additional information.”