Fkc - New Orleans Uptown

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 14442 Based on observation, facility policy review, and interview, the facility failed to ensure staff demonstrate compliance with medication practices by having medications that were pre-drawn greater than 4 hours available for patient use. Findings: Observation of the facility medication storage area on 12/08/2025 at 12:26 PM revealed two pre-drawn syringes of Heparin labeled with a time of 8:15 AM. Review of the facility “Medication Preparation and Administration” policy, Published: 07/07/2025, Version: 10, revealed, in part: “Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control. Pre-drawing Medications: Medications may be pre-drawn up to 4 hours prior to administration.” In an interview on 12/08/2025 at 12:29 PM, S1Clinic Manger confirmed the two Heparin syringes were pre-drawn greater than 4 hours and should be removed from medication storage area and discarded.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 14442 Based on observation, facility policy review, and interview, the facility failed to ensure the face mask worn by staff during initiation of hemodialysis treatment via central venous catheter completely covered the nose for 1 (Patient #3) of 1 sampled patient with a central venous catheter. Findings: Observation on 12/08/2025 at 12:16 PM of Patient #3’s initiation of hemodialysis treatment via the patient’s central venous catheter revealed the face mask worn by S2CCHT positioned under the nares and did not cover the nose. Review of the facility “Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer” policy, Published: 05/05/2025. Version: 9, revealed, in part: “Supplies: Personal Protective Equipment (PPE) including mask. Prior to Initiation: Step 1. Perform hand hygiene and don full PPE.” In an interview on 12/09/2025 at 9:28 AM, S1Clinic Manager confirmed face mask worn by staff during central venous catheter care should completely cover the nose.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 14442 Based on observations, facility policy review, and interview, the facility failed to ensure a patient’s (Patient R2) vascular access sites and bloodline connections were uncovered and visible at all times when receiving hemodialysis treatment. This deficient practice presented a risk for undiscovered accidental separation or needle dislodgement with resultant blood loss to the 63 in-center hemodialysis patients on census. Findings: Observations of Patient R2 on 12/08/2025 from 12:06 PM to 12:56 PM revealed vascular access sites and bloodline connections completely covered by a blanket. Further observations revealed staff performed patient monitoring and did not check Patient R2’s access including visibility of the access and securement of blood line connections. Review of the facility “Blood Loss: Prevention and Management of Needle Dislodgement/System Separation” policy, Published: 07/01/2024, Version: 2, revealed, in part: “Policy: The possibility of needle dislodgment and blood loss is the primary reason the patient’s vascular access, needles, and needle-to-line connections must be always visible. Visibility must never be blocked by blankets, pillows, under pads, or clothing. Patient assessment and monitoring policy while on hemodialysis requires the access check to be performed every 30 minutes or more as needed that includes visibility of the access and securement of blood line connections.” In an interview on 12/09/2025 at 9:33 AM, S1Clinic Manager confirmed each patient’s vascular access sites and bloodline connections should always be visible during hemodialysis treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 14442 Based on observations, record reviews, and interview, the facility failed to ensure the hemodialysis prescription for bicarbonate was verified prior to treatment initiation for 1 (Patient R1) of 3 patients observed for prescription verification. Findings: Observation of Patient R1 on 12/08/2025 at 11:43 AM revealed Patient R1 receiving hemodialysis treatment. Review of Patient R1’s hemodialysis treatment prescription with S1Clinic Manager revealed an order for bicarbonate 34. Observation of Patient R1’s hemodialysis machine with S1Clinic Manager revealed the machine bicarbonate was set to 40. Review of the facility “Pre-Treatment Safety Checks Procedure” policy, 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: Prescribed dialysate composition: On the Verify Concentrate Screen verify the following: Proper Bicarbonate has been entered per prescription.” In an interview on 12/09/2025 at 9:41 AM, S1Clinic Manager confirmed Patient R1’s hemodialysis prescription for bicarbonate was not verified and entered per prescription prior to treatment initiation.”