Fresenius Medical Care - Jackson Oaks

“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: 29955 Based on observation and interview, the facility failed to maintain an environment free of high dust and free of cardboard boxes in the facility treatment area resulting in the potential of the spread of infectious disease amongst the 9 patients dialyzing at the time of the findings. Findings include: On 2/24/2025 at 1040 during initial tour of the dialysis treatment area, a computer keyboard was observed on top of a cardboard box on the counter adjacent to the medication refrigerator. On 2/24/2025 at 1045 an interview with staff J, registered nurse, was queried why a cardboard box was supporting the computer keyboard. Staff J stated, “It is probably being used to give height to the keyboard for the computer users...I will get rid of the box.” On 2/24/2025 at 1055 during initial tour of the dialysis treatment area it was observed on the top of the hand towel dispenser near the medication preparation station a high amount of dust. High dust was also observed on top of the medication refrigerator and on top of the cabinets located between the isolation station and station 10. Staff B, the clinic manager was queried about the dust. Staff B stated she would address dusting with the cleaning company.”

“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: 36887 Based on interview and record review, the facility failed to complete a comprehensive interdisciplinary assessment and plan of care for 1 (P-3) of 3 unstable patients and failed to identify 1 (P-4) of 3 unstable patients resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: P-3 Review of the medical record for P-3 revealed he had missed multiple days of treatment in January due to hospitalization. On 2/25/2025 at 1010, review of the hospitalization log revealed P-3 had been hospitalized from 12/27/2024-1/2/2025 for hyperkalemia, 1/6/2025-1/21/2025 for encephalopathy, and 1/27/2025-2/13/2025 for acute respiratory failure with hypoxia. On 2/25/2025 at 1012, review of the unstable patient log revealed P-3 had been identified as being unstable. Further review of the medical record revealed the most recent plan of care (POC) was conducted on 5/13/2024. On 2/25/2025 at 1116, Staff A confirmed there had been no POC done since 5/13/2024. Staff A stated P-3 had been identified as unstable in a POC review. A POC meeting had been scheduled for 3/3/2025. On 2/25/2025 at 1350, Staff A stated P-3’s first day back in the clinic was 2/14/2025. The quality meeting was held on 2/19/2025 in which the POC review was done and P-3 “was made unstable.” She explained the POC meeting was scheduled for 3/3/2025 so the interdisciplinary team (IDT) had time to do a comprehensive assessment for the plan of care. The POC meeting was scheduled around the availability of the provider to start the comprehensive assessment. On 2/25/2025 at 1403, Social Worker Staff G stated the IDT had 30 days to complete an unstable care plan once the patient was back in the clinic, but they tried to get them done sooner. “If (Charge Nurse Staff D) says they’re due, they’re due.” On 2/25/2025 at 1420, Dietician Staff H stated the IDT met weekly; however, stability review was done monthly at the quality meeting. She stated POC meetings were scheduled around provider availability. She further stated, “When (Charge Nurse Staff D) recognizes (a patient) is unstable, we have 30 days to get the POC meeting done.” On 2/25/2025 at 1437, Charge Nurse Staff D stated there was a program in their electronic charting system that would trigger patients as being unstable for certain labs, hospitalizations and AKI and will provide a date the POC meeting is due. When a patient was out of the hospital, the IDT attempted to get a POC meeting within 2 weeks; however, he stated it was difficult to get all of the labs resulted in that short time frame. He also stated the team met to determine if the patient needed to be unstable, but once that determination was made, there was “no specific process for scheduling.” P-4 Review of the medical record for P-4 revealed he had missed several treatments in January. On 2/25/2025 at 1145, the hospitalization log was reviewed. It was discovered P-4 had been hospitalized 12/23-24/2024, 1/7-10/2025, and 1/23-24/2025 making three hospitalizations in a one month period. On 2/25/2025 at 1148, review of the unstable patient log revealed P-4’s name was not present. On 2/25/2025 at 1437, Charge Nurse Staff D stated the stability review was for a one month period and that the program “sometimes misses” discovery of 3 hospitalizations within a month, especially if the time frame overlapped two separate months. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “Unstable patients must be reassessed by the IDT monthly... The following are unstable criteria: Extended or Frequent hospitalizations: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days, or b. More than 3 admissions in the last 30 days...””