Fmc - Western Mass. Kidney Center (Bma Springfield)

“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: 37349 Based on observation, Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to consistently provide a sanitary environment to minimize the transmission of infectious agents within the patient treatment area. Findings Include: The CDC defines a “sanitary environment” as an environment that meets “Standard Precautions” for an in-patient hospital setting plus the more stringent precautions which are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. On 12/1/25 at 9:10 A.M., the surveyor observed a patient walking across the treatment floor. The patient had empty syringes attached to their Central Venous Catheter (CVC) limbs. The limbs were resting on a field that was contaminated with blood. The patient proceeded to walk past the nurses station and exited the treatment floor and into a common area bathroom. On 12/1/25 at 9:15 A.M., the surveyor observed the patient reenter the treatment area with the contaminated field, walk across the treatment floor to station 24 where Registered Nurse #4 restarted the patient’s hemodialysis treatment. During an interview on 12/1/25 at 2:20 P.M., the Clinic Manager said that the patient should not have left the treatment floor with blood on the field, staff who disconnected the patient should have put a clean field under the catheter limbs.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 37349 Based on observation, interview and policy review, the facility failed to ensure that 1 staff member (Registered Nurse [RN] #2) wore a face mask while examining a catheter exit site. Findings include: Review of the facility policy, titled, Changing the Catheter Dressing Procedure, published 5/2/25, included the following: * Catheter exit site disinfection and dressing change is to be completed prior to cap and hub connector disinfection. This provides an opportunity to view the exit site for infection or complications and if applicable, notify team leader charge nurse or home therapy nurse prior to initiating treatment. * Apply mask to patient and caregiver to help prevent contamination by airborne nasal bacteria. On 12/1/25 at 12:05 P.M., the surveyor observed Certified Clinical Hemodialysis Technician (CCHT) #6 provide exit site care for a patient with a Central Venous Catheter (CVC) in station 1. Prior to the procedure CCHT #6 placed a mask on himself and the patient. During the process, the patient said that the site was itchy and he/she thought he/she might have pulled a stitch that secures the catheter in place. CCHT #6 requested RN #2 to put a mask on and look at the exit site. RN #2 entered the station without a mask on and examined the exit site. During the examination, she was speaking to the patient while the exit site was exposed. During an interview on 12/1/25 at 12:31 P.M., RN #2 said that she should have worn a mask while examining an exposed CVC exit site.”

“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: 44223 Based on observation, interview, and policy review, the facility failed to ensure that 1 staff member, (Patient Care Technician [PCT] #4) identified, inspected, and changed a wet transducer protector for 1 station (#11). The transducer protectors must be dry in order to provide accurate venous and arterial pressures. Cross contamination can occur if the internal transducer becomes contaminated with blood and is not disinfected or changed before the machine is used on another patient. Findings include: Review of the Centers for Disease Control Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients, dated 4/27/01, included the following: *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. Review of the facility policy, titled Maintenance of Transducer Protectors Procedure, published 11/1/2021, indicated the following: *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. On 12/1/25 at 9:30 A.M., the surveyor observed the transducer protector on the dialysis machine in station 11 to be wet with blood. On 12/1/25 at 10:55 A.M., the surveyor observed PCT #4 remove the used supplies from station 11. She removed the wet transducer protector from the dialysis machine and without inspecting the back to determine if there had been any blood breakthrough, she threw the transducer protector away. During an interview on 12/1/25 at 11:05 A.M., PCT #4 said that she did not notice that the transducer was wet and she did not look at the back of it before she threw away the supplies. During an interview on 12/3/25 at 10:30 A.M., the Clinic Manager said she was aware of the wetted transducer and that the staff member did not check it before throwing away the supplies. The Clinic Manager said that it should have been checked for blood breakthrough.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 37349 Based on observation, interview and policy review, the medical director failed to ensure that 2 staff members, (Certified Clinical Hemodialysis Technician [CCHT] #1 and CCHT #2), adhered to the policy related to labeling of medication in syringes not being administered immediately. Findings include: The Medical Director failed to ensure that 2 staff members, CCHT #1 and CCHT #2, adhered to the policy related to labeling of medication in syringes not being administered immediately. Review of the facility policy, titled, Medication Preparation and Administration, published 7/7/25, included the following: *All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication. A. On 12/1/25 at 10:45 A.M., the surveyor observed CCHT #1 discontinue treatment for a patient with a Central Venous Catheter (CVC), in station 24. During the process, she administered heparin (a blood thinner) from a syringe into the arterial limb and from a second syringe into the venous limb. The labels on both heparin syringes failed to include the time and initials of the person who prepared the medication. During an interview on 12/1/25 at 10:50 A.M., CCHT #1 said that she drew up the heparin at around 9:30 A.M., but did not put her initials or time on the label.”