Fmc - Chesterfield

“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: 50585 Based on observation, interview, and record review, the facility failed to ensure clean areas were separated from used equipment resulting in the increased likelihood of transmitting infectious agents to all patients. Findings include: On 6/3/2025 at 0930, Technician Staff L was observed at station #7 obtaining a patient’s body temperature with a handheld thermometer. After obtaining the temperature, Staff L walked away from station 7 and placed the thermometer (dirty) on a common cart (clean) without disinfecting the thermometer. When queried immediately after, Staff L confirmed they did not disinfect the thermometer. According to the facility’s policy and procedures, “Dialysis Precautions,” dated, 2020, “Clean area: An area designated for clean and unused equipment, supplies and medications. Dirty area: An area where this is a potential for contamination with blood or body fluids and areas where contaminated or used supplies, equipment, blood supplies or biohazard containers are stored or handled. Clean areas should be clearly designated for the preparation and handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from dirty areas where used supplies, equipment or blood samples are handled or stored.” On 6/4/2025 at 1200, Medical Director Staff M was asked if they expected staff to follow the facility’s policies and procedures, and they said “yes, I do.””

“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: 38269 Based on observation, interview and record review, the facility failed to ensure staff took measures to reduce the risk for central venous catheter (CVC) bloodstream infections for 1 ( P-7) of 2 patients observed for CVC exit site care during the initiation of dialysis treatment, resulting in the increased risk for bloodstream infections for patients with CVC’s currently serviced by this facility. Findings include: On 06/03/2025 at 1315, Staff L was observed performing a CVC dressing change and catheter care at station #7, on patient #7’s (right subclavian CVC site). After removing the old dressing, Staff L proceeded to clean the catheter exit site with an antiseptic swab. Staff L used the antiseptic swab in a back-and-forth motion (2-3 inches) repeatedly to and from the CVC exit site, potentially moving organisms from a contaminated area into the catheter exit site, thereby risking contamination of the catheter leading into a large central vein. On 06/03/2025 Staff L was queried regarding CVC cleaning. Staff L, confirmed that the motion of moving the antiseptic swab back and forth from the catheter site was not best practice and would increase the risk of introducing infectious organisms. During an interview with Staff A on 06/03/2025 at 1540, it was confirmed that catheter care should never involve moving the antiseptic cleaning swab toward the catheter site, increasing the risk of contamination. Findings were reviewed with and acknowledged by both the Facility Administrator (Staff A) and the Director of Operation (Staff B) during an interview on 06/04//2025 at 1100. On 06/04/2025 at 0940 policy specific to CVC catheter care and dressing change was requested and not received prior to exit.”

“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: 43001 Based upon observation and interview, the facility failed to maintain the walls and plumbing at patient treatment station 11 and near the water room resulting in potential growth of mold and spread of infectious agents to all patients served by the facility. Findings include: On June 3, 2025 at 0945 during a tour of the treatment floor, it was observed that there was water damage at treatment station 11 near the patient, as well as water damage extending beyond the treatment area into the staff only corridor behind the door swing. There was also water damage observed by the water room entrance door. Staff J was asked when this started and they stated not long ago. Staff J said there are quotes to have the damage repaired but at the time of the survey there were no purchase orders completed.”

“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: 43001 Based on observation and interview, the facility failed to maintain the emergency electrical generator resulting in the potential loss of power in the facility during treatments for all patients. Findings include: At 0950 on June 3, 2025 during a tour of the treatment floor, the generator annunciator panel was observed with three flashing lights, indicating common fault, low coolant level and system ready. Staff J was asked when this panel started indicating potential issues and they stated it was “recently” and that someone has been contacted to look at the generator. Documentation of this communication was not provided to the surveyor. The generator was observed at 1050 by the surveyor and the indicator panel on the generator stated there was an auxiliary fault as well.”