Fresenius Kidney Care Fairmount Heights

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 44367 Based on inspection of the emergency evacuation box and binder, the facility’s administrative staff failed to maintain a current list of all of the facility’s patients for the purpose of tracking in the event of an emergency evacuation. The failure to provide an updated patient list could potentially result in a patient’s injury or harm in the event of an evacuation. Patients: #6, #7 and #8 Findings include: Review on 11/28/2023 of the facility’s policy entitled “Emergency Equipment and Supplies” revealed that the “emergency evacuation box must: Contain all patient and staff emergency contact information; An itemized log must be kept indicating the contents and expiration dates of contents...” An inspection of the facility’s emergency evacuation box and binder on 11/28/2023 revealed the emergency evacuation box contained a list of patients and their contact information; However, the patient list was last updated 9/28/2023. A total of 3 out of 53 patients were not on the patient list in the emergency evacuation box. The Clinical Manager was informed of the findings on 11/28/2023.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 44367 Based on observations and interviews with facility staff, the governing body, the facility’s administration failed to ensure that all required emergency supplies were readily available in the event of an emergency. This failure placed patients at potential risk of harm and danger during a life threatening situation. Finding includes: Review on 11/28/2023 of the facility’s policy FMC-CS-IC-II-130-007A entitled “Emergency Medications, Equipment and Supplies” revealed that “An itemized log must be kept indicating the contents and expiration date of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.” Inspection of the facility’s crash cart on 11/28/2023 at 1:00 p.m. revealed the crash cart contained the following expired supplies: 1. One (1) Red Rubber 10 french (size) Urethral Catheter, lot number 8161RO4QX, expired 9/29/2023. 2. One pack of 17 gauge Safety Fistula Needles, lot number 17147, expired 10/31/2022. 3. Two packs of 16 gauge Safety Needles, lot number 18H29, expired 7/31/2023. The Charge Nurse observed the findings on 11/28/2023 at 1:15 p.m. The Charge Nurse and the Clinical Manager were informed of the findings on 11/28/2023.”

“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: 44367 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene and glove use requirements were complied by all staff who come in contact with the dialysis patients in the facility. This failure placed the patients and staff at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Staff: #3 and #7 Findings include: The Center for Disease Control (CDC) recommends that hand washing incorporate rubbing hands together “vigorously” for 15 seconds, and that the use of alcohol-based rubs incorporate covering all surfaces of hands and fingers, until hands are dry; “Even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.” 1. Observation of the clinical treatment area on 11/27/2023 at 11:04 a.m. at station 18, the surveyor observed that Staff #3 removed gloves after completing the patient’s treatment initiation and did not perform hand hygiene before gathering clean supplies. 2. Observation of the clinical treatment area on 11/29/2023 at 11:07 a.m. at station 55, the surveyor observed that Staff #7 removed gloves after completing the patient’s treatment termination and did not perform hand hygiene and then walked the patient to the scale. The Clinical Manager was informed of the findings on 11/27/2023 and 11/29/2023.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 44367 Based on infection control observations, the Clinical Manager and Medical Director failed to ensure that the clinical staff followed safe practices when handling infectious waste. This failure created a potential risk of blood exposure and risk of harm to patients and staff in the unit. Staff: #7 Findings include: The Occupational Health and Safety Administration (OSHA): 29CFR1910.1030(d)(2)(xi)states: “All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances. Carrying contaminated blood tubing, used needles, syringes and dialyzer from the patient’s station across the treatment floor to a biohazard box, or sharps container could result in unknown spattering of blood. Review on 11/29/2023 of the facility’s policy “Cleaning and Disinfection of the Dialysis Station” revealed that “For patients dialyzing in a treatment area where multiple patients dialyze, the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and setup for the next treatment.” 1. On 11/29/2023 at 11:00 a.m., observations on the clinical treatment area revealed that after terminating a patient’s treatment at station 11, Staff #7 removed the dirty bloodlines and dialyzer from the dialysis machine. Staff #7 then carried the bloodlines and dialyzer across occupied stations 9 and 10, to dispose in the biohazardous waste bin. The Clinical Manager was informed of the findings on 11/29/2023.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 44367 Based on clinical observations, the governing body failed to ensure that the clinical staff followed the standard regulations in the cleaning and disinfection of contaminated equipment being used in the facility.This failure put patients at risk for possible cross-contamination. Findings included: Review on 11/29/2023 of the facility’s policy ventilated “Cleaning and Disinfection of the Dialysis Station” revealed that the “Dialysis wall boxes and the area/wall around the wall box must be routinely cleaned at the end of each treatment day or immediately is splattered with blood.” On 11/29/2023 at 11:00 a.m., inspection of the isolation room revealed the wall box had a white and brown colored build up at the base of the box. The Clinical Manager was informed of the findings on 11/29/2023.”

“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: 44367 Based on clinical observations and interviews with the administrative staff, the facility’s governing body and the Medical Director failed to ensure that expired medications are removed from the available medication supply.This failure placed the patients at potential risk of harm of receiving expired medication. Findings include: Review on 11/28/2023 of the facility’s policy entitled “Medication Preparation and Administration” revealed that “Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via fresenius Kidney Care off-site return program or in accordance with local and/or state law...CDC immunizations program states vaccines are to be discarded per manufacturers expiration date.” Inspection of the facility’s medication area on 11/28/2023 at 1:30 p.m. revealed the following: 1. One box of Korsuva Injection 0.5 mg/1.3 ml, lot number AP16923, expired 10/2023. 2. Twelve pre filled-syringes of Micera 150 mcg/0.3 ml, lot number B00091405, expired 11/2022. 3. Fifteen single-dose syringes of Heplisav-B Hepatitis B vaccine, lot number 938794, expired 10/9/2023. The Charge Nurse and the Clinical Manager were informed and observed the findings on 11/28/2023.”

“BACT OF H20-MEDICAL DIRECTOR RESPONSIBLE CFR(s): 494.40(a) 4.1.2 Bacteriology of water: med dir resp The facility medical director is responsible to ensure the manufacturer or supplier of a complete water treatment and distribution system demonstrates that the complete water treatment, storage, and distribution system is capable of meeting these requirements at the time of installation Following installation of a water treatment, storage, and distribution system, the user is responsible for continued monitoring of the water bacteriology of the system and for complying with the requirements of this standard, including those requirements related to action levels. This Standard is not met as evidenced by: 44367 Based on review of the Reverse Osmosis (RO) water, dialysate and Hemodialysis (HD) machine culture logs and interviews with the biomedical technician, the governing body and medical director failed to ensure that systems were continually monitored for bacteria colony forming units and endotoxins.This failure to provide oversight by the Medical Director for the RO water, dialysate and HD machine cultures placed the facility’s patients at risk of harm and potential exposure to infection. Findings included: Review on 11/27/2023 of the facility’s policy entitled “AAMI Chemical Analysis of Water and Dialysis” revealed that the “Medical Director must review and sign each chemical analysis report obtained during the review period.” On 11/27/2023, review of the facility’s monthly RO water, dialysate, HD machine culture reports, and an interview with the Biomedical staff and the Clinical Manager revealed culture reports from August 2023 and September 2023 were both signed by the Medical Director (proof of reviewing the culture collection results) on 9/27/2023. The Clinical Manager provided culture reports from May 2023, June 2023, July 2023, October 20023 and November 2023 were all signed by the Medical Director on 11/28/2023. The culture reports were signed one day after they were requested by the surveyor. On 11/28/2023, the Clinical Manager corroborated the information that the cultures were signed the day after the surveyor requested the documents.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 44367 Based on observations of the facility’s bicarbonate tank and a review of the facility’s policies and procedure, the facility’s administration and the medical director failed to ensure that all mixing and holding tanks’ content were labeled correctly for identification. This failure placed the patients at potential risk for harm. Findings include: The contents of all mixing tanks, bulk storage/dispensing tanks, and small containers should be identifiable. The Bicarbonate tanks must be labeled with date, time and initials of the individual who made the mixture. 1. Inspection of the water treatment room on 11/28/2023 revealed that a large mixing tank used to mix bicarbonate had 105 gallons of clear liquid: however, the tank did not have a label identifying the liquid, who made the liquid, and what time the liquid would have expired. The Clinical Manager was informed of the findings on 11/28/2023.”

“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: 44367 Based on observation and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the facility provided and maintained a safe treatment environment for it’s patients by ensuring the facility conducted fire drills as required. This failure placed the patients and visitors at potential risk of harm during a potential fire. Findings include: On 11/28/2023, review of the facility’s policy entitled “Comprehensive Emergency/Fire Drill and Evaluation” revealed that “A fire drill is required to be conducted quarterly. Fire drills are conducted to ensure that the facility’s staff and patients are prepared in the event of a fire.” During review of the emergency preparedness binder on 11/28/2023, the surveyor noted that the facility conducted a fire drill on 9/3/2023. Additional fire drills were requested however, no additional fire drills were provided. On 11/28/2023 during an interview with the Clinical Manager, the surveyor was informed that he/she thought fire drills were conducted once a year. The Clinical Manager corroborated the findings that facility did not conduct fire drills quarterly per facility’s policy.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44367 Based on observations and interviews with the facility’s administration, the governing body failed to ensure that the water room and the surrounding area were free from defects or hazards and kept clean at all times. This failure placed the patients, staff, and visitors at potential risk of harm including exposure to hazardous or infectious material from a potentially contaminated water system. Findings included: All buildings and building systems must be maintained free from defects and/or hazards to ensure safety and functionality. Integrity of all surfaces, (e.g., countertops, floors, walls) must be intact, clean and free from damage. Intact surface integrity allows for effective cleaning and limits the potential for microbial growth on a porous surface. On 11/28/2023 at 11:30 a.m., inspection of the water treatment room and the surrounding areas revealed the following: 1. A gross amount of black stains around the drain and a gross amount of black and orange stains inside of the drain located under gauge P16. 2. A build up of white crystallization under the spout and on the entire surface of the 2.0 Ca 2.5 K+ acid holding tank. 3. A gross amount of white crystallization around valve marked V70. 4. Gross amount of black stains around the drain placed under the M-500 Pro Central Pre-Treatment Management System. 5. Gross amount of black stains in and around the drain next to the Booster Pump. 6. Three large steel colored racks and eight steel colored poles were placed inside of yellow line barrier ( used to keep area clear) under electrical boxes, which were labeled “High Voltage Danger.” The findings were presented to the Biomedical Technician and the Clinical Manager on 11/28/2023.”

“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: 44367 Based on observation and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the facility was free of expired supplies and ensure ancillary equipment maintenance is done as required. This failure placed the patients at potential risk of harm. Findings include: When medications and supplies are no longer needed, they should be disposed of promptly. Healthcare providers should remove expired medications and supplies as quickly as possible to help reduce the chances that others accidentally receive or intentionally misuse them. Observation of the facility’s lab area on 11/27/2023 at 1:00 p.m. revealed the following: 1. Fifty (50) Blood Glucose Strips, lot number A20L17271, expired 12/17/2022. 2. Fifty (50) 20g (gauge) Blood collection Set, lot number 9A1591, expired 1/31/2022. 3. Ninety-eight (98) Red Top Vacutainer Collection Blood Tubes, lot number 2098310, expired 8/3/2023. 4. Seven (7) Yellow Top UA Preservation Tube, lot number 1098417, expired 10/31/2022. Inspection of the facility’s water room on 11/27/2023 revealed the following: 1. One bottle of EZ Check Blood Leak Test Strips, lot number 101050, expired 8/31/2023. 2. Two bottles of Ez Check Blood Leak Test Strips, lot number 101049, expired 6/30/2023. 3. One bottle of Conductivity Solution 14.0 ms/cm, lot number MC-C141711, expired 7/11/2023. 4. One (1) bottle of Conductivity Solution 14.0 ms/cm, lot number ML-C141704, expired 5/29/2023. 5. One (1) bottle of Standard Buffer Solution 4.00 ph, lot number NK-P41698, expired 5/5/2023. 6. One (1) bottle of Standard Buffer Solution 7.00 ph, lot number ML-P71727, expired 10/4/2023. 7. One (1) bottle of Standard Buffer Solution 10.00 ph, lot number ML-P101708, expired 5/5/2023. 8. Six (6) bottles of Water Check Residual Chlorine Test Strips, lot number TJ355021, expired 4/2023. 9. Six (6) bottles of Water Check Residual Chlorine Test Strips, lot number TF350021, expired 12/2022. According to the Occupational Safety and Health Administration (OSHA), “Visually inspect portable extinguishers and hoses monthly. [29 CFR 1910.157(e)(2)] Perform an annual maintenance check on portable fire extinguishers.” Review on 11/28/2023 of the facility’s policy entitled “Health and Safety policy and Procedure” revealed that the “Fire extinguishers shall be checked monthly ...” 1. Observation of the facility’s fire extinguishers on 11/28/2023 revealed that all of the fire extinguishers had a annual inspection conducted on April 2023 and was visually inspected on 10/26/2023. The extinguishers were not visually inspected for May, June, July, September and November of 2023. The Clinical Manager and the Biomedical Technician were given the opportunity to provide proof of inspection for the missing dates; however, no proof of inspection was provided. On 11/28/2023, the Clinical Manager corroborated the findings that the fire extinguishers were not inspected monthly.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 44367 Based on review of medical records and interviews with the facility’s administrative staff, the governing body failed to ensure that initial nursing assessments were performed by the assigned registered nurse (RN) prior to the patients’ initial dialysis treatment when being admitted to the facility. This failure placed the affected patients at risk for receiving insufficient and ineffective care, and denied the patients their rights. Patients: #1, #2 and #3 Findings included: Review on 11/29/2023 of the facility’s policy entitled “Comprehensive Interdisciplinary Assessment and Plan of Care” revealed that “A registered nurse must perform an assessment on patient new to dialysis before initiation of their first treatment to determine immediate needs.” During a review of selected patients’ medical records on 11/29/2023, it was noted that three (3) out of the eight (8) selected patients’ charts did not contain an initial nursing assessment. The assessment should have been completed prior to the patient being placed on the dialysis machine on the day of admission. The Clinical Manager was given the opportunity to provide the missing initial nursing assessments; However, the Clinical Manager corroborated that the initial nursing assessments were not completed.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 44367 Based on the patient record review and interviews with the facility’s administration, the governing body and interdisciplinary team (IDT) failed to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days, or 13 treatments beginning with the first outpatient dialysis session. This failure placed the affected patient at potential risk of harm and denied the patients their rights. Patients: #1, #2, #3, and #4 Findings included: Review on 11/29/2023 of the facility’s policy entitled “Comprehensive Assessment and Plan of Care” revealed that “An initial comprehensive assessment (CIA) and plan of care (POC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session.” On 11/29/2023, review of the five (5) selected patients’ charts revealed either the initial Comprehensive Assessment was either not completed or was completed late. The charts revealed the following: 1. Patient #1 was admitted to the facility on 10/18/2021; However, there was no initial Comprehensive Assessment found in the Patient #1’s paper or electronic chart. 2. Patient #2 was admitted to the facility on 10/11/2021; However, there was no initial Comprehensive Assessment found in the Patient #1’s paper or electronic chart. 3. Patient #3 was admitted to the facility on 8/23/2021. An initial Comprehensive Assessment was found in the Patient #3’s electronic; However, the assessment was completed 1/26/2022, 6 months after Patient #3 was admitted. 4. Patient #5 was admitted to the facility on 7/21/2023. An initial Comprehensive Assessment was found in the Patient #5’s electronic. The assessment was completed 8/25/2023; However, the assessment was not signed by the Social Worker or the Physician. The Clinical Manager was given the opportunity to provide the missing initial comprehensive assessments; However, the Clinical Manager corroborated that the comprehensive assessments were not completed.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 44367 Based on observations and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the clinical staff complied with the appropriate procedures when assessing the patients’ vascular access prior to and during the cannulation process. This failure placed the safety and well being of the patients at potential risk of harm in maintaining their vascular access and/or infection. Staff: #2, #3 and #7 Findings included: Review on 11/27/2023 of the facility’s policy entitled “Access Assessment and Cannulation” revealed that the staff must clean their “stethoscope with alcohol. Listen: Bruit high pitch/whistle; Do not touch cannulation sites after skin disinfection.” 1. Observation of the clinical treatment area on 11/27/2023 at 10:56 a.m. revealed that during treatment initiation at station 5, Staff #2 did not listen to patient’s access prior to cannulation. Staff #2 did not use a tourniquet on the patient’s access. 2. Observation of the clinical treatment area on 11/29/2023 at 10:52 a.m. revealed that during treatment initiation at station 14, Staff #3 did not listen to patient’s access prior to cannulation. Staff #3 touched the arterial portion of the access after the disinfection process and did not disinfect the access again prior to cannulation. 3. Observation of the clinical treatment area on 11/29/2023 at 11:15 a.m. revealed that during treatment initiation at station 2, Staff #7 did not listen to patient’s access prior to cannulation. Staff #7 touched the arterial and venous portion of the access after the disinfection process and did not disinfect the access again prior to cannulation. The Clinical Manager was made aware of the findings on 11/27/2023 and 11/29/2023.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 44367 Based on review of the facility’s personnel files and interviews with the facility’s administration, the governing body, medical director, and facility’s administration failed to ensure that the facility’s clinical staff were trained properly for CPR (Cardiopulmonary Resuscitation). This failure posed a potential risk of harm in the event a patient experience cardiac arrest. Staff: #5 Findings include: Staff must maintain current CPR (Cardiopulmonary Resuscitation) certification for healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable. Occupational Safety and Health Agency (OSHA), institutions and States, have determined that online-only certification is not acceptable. Review of the facility’s personnel files on 11/30/2023 revealed Registered Nurse #5 did have a current CPR card. Registered Nurse #5 works as a Charge Nurse. Charge Nurse provided an online 10/31/2025. Charge Nurse has worked on the treatment floor every Monday, Wednesday, and Friday since receiving the online CPR card. On 11/30/2023, the Clinical Manager informed the surveyor that Registered Nurse #5 was pulled off the treatment floor on 11/30/2023 to complete the CPR training provided by the facility.”