Fmc - Freedom Center of Worcester

“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: 27189 Based on observation, interview and policy review, the facility failed to ensure that staff members (Registered Nurse (RN) #5, Certified Clinical Hemodialysis Technician [CCHT] #3 and Certified Nursing Assistant (CNA) #1) working with the dialysis den (an area where home dialysis treatments are provided to multiple residents in a common area within the nursing home, more commonly referred to as a den setting) removed PPE (Personal Protective Equipment), such as a gown and implement contact precaution for 1 of 1 applicable patients (#9) with clostridioides difficile infection (CDI/C.difficile) out of a total sample of 11 patients, to protect against the potential spread of infection. Findings include: Review of the facility policy titled Management of Clostridioides Difficile Infection, dated 11/6/23, indicated but was not limited to the following: -C.difficile is shed in feces. Any surface, device or material that becomes contaminated with feces may serve as a reservoir for the C. difficile spores. C.difficile spores is transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface item. -C. difficile spores can persist for months in the healthcare environment and can be transmitted to patients during this time. -Fecal contamination of surfaces, devices and materials (e.g. dialysis chairs) with C. difficile spores may lead to transmission. -Reusable equipment must be cleaned and and disinfected between patients. -Personnel should be sure to clean and disinfect all patient care equipment that has been exposed to C. difficile contamination. -Contact precautions (in addition to dialysis precautions) are required for patients with confirmed CDI. -PPE used for patients with CDI must be dedicated to that patient. -PPE must be changed prior to caring for patients who are not infected with CDI. -Soap and water should be used for all hand hygiene practices by both staff and patients. Patient #9 was admitted to the dialysis facility in March 2025 with a diagnosis of End Stage Renal Disease and was receiving dialysis in the dialysis den five times a week. Patient #9 was hospitalized from 3/24/25-4/17/25. During the hospitalization, Patient #9 was diagnosed with C-Difficile. The patient returned to the dialysis den on 4/18/25 for his/her first treatment since his/her hospitalization. Review of the Dialysis Transition of Care Form/Communication Book (a written form of communication between the nursing facility and the dialysis den that includes but is not limited to, changes in resident condition and additional comments) from 4/18/2025 through 4/28/2025 indicated that Patient #9 was on contact precautions for C-Difficile. During an observation on 4/28/25 at 11:11 A.M., CNA #1 transported Patient #9 into the dialysis den from the nursing facility. CNA #1 donned her PPE and obtained a walker from a storage area. With the assistance of CCHT #3 and RN # 5 the patient was transferred, using the walker, into the dialysis chair in station # 6. CNA #1 then returned the walker to the storage area (did not disinfect the walker), doffed her gown, and placed it on 1 of the 2 hooks, located along the wall, outside of the storage room and left the den to retrieve another patient. CCHT #3 then initiated treatment for Patient #9 at 11:14 A.M., who received dialysis treatment via an Arteriovenous Fistula (AVF) and RN #5 performed his assessment on the patient at this time. CCHT #3 and RN #5 initiated treatment for Patient #9 and did not change their gowns prior to initiating treatment for other patients within the den ( a total of 4 patients). CCHT #3, RN #5 and CNA #1 performed hand hygiene after the removal of their gloves, however they did not wash their hands with soap and water after contact with Patient #9. CNA #1 used the same gown each time she entered the dialysis den treatment area. CNA #1 did not disinfect the walker after each time it was used for Patient #9. During an interview on 4/28/25 at 2:40 P.M., RN #5 and CCHT #3 that they had not noticed that the Dialysis Transition of Care Form/Communication Book from the nursing facility indicated that Patient #9 was on contact precautions for C-diff. They both said that they should have changed their gowns before caring for the other patients and should have used soap and water for hand hygiene. RN #5 said that CNA#1 should have discarded her gown after caring for Patient #9, using soap and water for hand hygiene and that the walker should be disinfected after patient use.”

“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: 44223 Based on observation and staff interview, the facility failed to ensure that proper infection control practices were followed when personal protective equipment (PPE) came in contact with both clean and dirty areas on the dialysis treatment floor at the dialysis den. Findings include: During an observation of the treatment floor at the dialysis den on 4/28/25 at 12:00 P.M., the surveyor observed 2 hooks, along the wall, outside of the storage room. There were 3 gowns, 1 faceshield, and 1 mask hanging on the hooks. The mask was overlapping one of the gowns on one hook, causing concern for potential cross contamination. The other 2 gowns, which had been worn by staff on the treatment floor, were overlapping each other and the facemask was sitting on top of both the gowns, causing concern for potential cross contamination. During an interview on 4/28/25 at 2:35 P.M., Registered Nurse #5 said that staff should not overlap their gowns or shields on the hooks and that the mask should have bee thrown away.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 31240 Based on record review, interview, facility report review and policy review, the facility failed to ensure an unstable comprehensive re-assessment and revision of the plan of care was conducted after an extended hospitalization stay greater than 15 days, for 1 of 7 applicable patients (#2), out of a total sample of 11 patients. Findings Include: Review of the facility policy titled, Comprehensive Interdisciplinary Assessment and Plan of Care, revised 7/3/23, indicated the following: * Unstable patients must be reassessed by the Interdisciplinary Team (IDT) monthly. Monthly reassessment and any plan of care (POC) updates related to the reason the patient is considered “unstable” must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the conditions is chronic. * The following are unstable criteria: -Extended or frequent hospitalizations: Hospitalization of more that 15 days with discharge occurring within the last 30 days, or more than 3 admissions in the past 30 days. Patient #2 was admitted in November 2023 with a diagnosis of End Stage Renal Disease, requiring dialysis three times a week. Review of the clinical record indicated Patient #2’s last Comprehensive Assessment was completed in May 2024, with a plan of care developed based on that assessment. Further review of the clinical record, and the facility’s Absence and Hospitalization report, indicated that Patient #2 had been hospitalized from 11/27/24 through 12/22/24, for a total of 26 days, with a diagnosis of adult failure to thrive. During an interview on 4/30/25 at 10:15 A.M., Registered Nurse #4 said when Patient #2 returned to the clinic after the hospitalization, she/he should have been made unstable. She said a Comprehensive Assessment of the patient and POC updates should have been completed. During an interview on 4/30/25 at 11:30 A.M., the Facility Administrator and Clinical Director of Operations said the facility should have completed a Comprehensive Assessment and POC update on Patient #2 because of his/her extended hospitalization, but it was missed.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 31240 Based on record review, interview and policy review, the facility failed to ensure the care plan was signed by the patient or the patient’s designee, or if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided, to ensure the patient had involvement with his/her plan of care for 1 patient (#3) of 7 applicable patients reviewed, out a total sample of 11 patients. Findings Include: Review of the facility policy, titled Comprehensive Interdisciplinary Assessment and Plan of care, published 7/3/23, indicated the following: *The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician (or physician extender where allowed by State regulations), qualified master’s degree social worker and qualified registered dietitian. *Comprehensive Assessment and Plan of Care (adult patient) must be completed electronically in the patient’s medical record. The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDT member within 30 days of the interdisciplinary team meeting. Patient #3 was admitted to the facility in October 2022 with a diagnosis of End Stage Renal Disease, requiring hemodialysis. Review of the clinical record indicated an unstable Comprehensive Assessment and Plan of Care was developed in September 2024 and an annual Comprehensive Assessment and Plan of Care was developed in October 2024. Review of the IDT signature sections of both care plans included the electronic signatures of the nurse, dietitian, social worker, and physician. Patient #3’s signature was not on the document, nor was there any documented reason why Patient #3 did not provide a signature. During an interview on 4/29/25 at 2:30 P.M., the Facility Administrator said she was unsure why the care plans had not been signed by Patient #3. She said Patient #3 was not always compliant with his/her monthly clinic visits at which time care plans would be reviewed. She said that there should have been documentation to indicate why the care plan was not reviewed with the patient or why the patient did not sign it.”