Fresenius Medical Care West Michigan Home

“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: 36887 Based on observation, interview, and record review, the facility failed to properly store all oral and intravenous medications in the crash cart resulting in the potential for inadvertent medication administration errors for all patients requiring emergent medication administration. Findings include: On 5/28/2025 at 1050, the top drawer of the crash cart was opened and a padded manilla envelope was found to be present which contained a tube of oral glucose, a card of oral Benadryl (anti-histamine), several vials of intravenous (IV) Benadryl, several vials of IV Adrenaline (adrenergic receptor agonist), and a few vials of IV Solu-Medrol (steroid). It was noted that the IV Benadryl and the IV Adrenaline were in the same sized vials with different colored caps. On 5/28/2025 at 1052, Staff E was queried as to why all of the medications were all in the same envelope together to which he replied there weren’t many medications in the crash cart and it was their way of keeping them together instead of rolling around inside the drawer. Facility policy #46865 titled “Emergency Medications, Equipment, and Supplies” published 2/3/2025 states, “Medications should be organized to meet the needs for specific emergency situations. For example: Cardiac arrest medications should be grouped together in emergency cart...” Facility policy #47544 titled “Receiving and Stocking Medications” published 11/7/2022 states, “Many medications come in similar sized vials, with similar packaging and coloring and may have similar sounding names. It is imperative that these medications be correctly identified by licensed nurses when they are received and then properly stored to reduce the risk of inadvertent medication administration errors...When putting away or stocking newly received medications, the Licensed Nurse shall: 1. Ensure that all medications are secured in a lockable cabinet or medication refrigerator. Note: It is recommended that medication storage areas or bins be labeled with the name of the medication that will be placed in a specific location. Labeling should include the complete name of each medication... 2. Place new stock in the same areas with remaining stock: Medication supplied in bulk packaging or medication s in individual containers that are similar in size, coloring or packaging or medications with similar sounding names must have a “Look Alike-Sound Alike” sticker applied to the flat or the container...Medications vials or containers that are similar in size, coloring or packaging must be stored/stocked in separate locations to prevent accidental misuse...””

“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: 36887 Based on observation, interview, and record review, the facility failed to 1) secure 1 of 2 oxygen tanks that were visualized and failed to 2) maintain cabinetry and a sink in the medication room resulting in the increased potential for hazardous and unsafe conditions in the facility. Findings include: 1) On 5/28/2025 at 1046, the medication room was entered and an oxygen tank was observed standing on end with no chain or cart to secure it from falling to the floor. This finding was confirmed by Staff A at the time of discovery. Facility policy #47557 titled “Emergency Administration of Oxygen” published 11/1/2021 states, “Oxygen cylinders must be secured in an area where they will not fall...Unless in use, secondary (reserve) cylinders/tanks must be: Secured to racks or rolling stands in a storage area or dedicated area for oxygen...” 2) On 5/28/2025 at 1046, the medication room was entered. Visualization of the sink area revealed the drain was rusted and unable to be properly cleaned. This finding was confirmed by Staff A at the time of discovery. Additionally, the far, upper, left cabinet was opened and immediately sagged as the bottom hinge was no longer attached to the cabinet. This finding was also confirmed by Staff A at the time of discovery. Facility policy version 2 titled “Storage of Supplies” published 4/5/2021 states, “Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged... Supplies must be stored in a manner that does not present a safety hazard to staff...””

“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 identify 1 (P-4) of 2 unstable patients resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: On 5/28/2025 at 1245, review of the Unstable Log for the past six months was reviewed and found that only P-3 was listed. On 5/28/2025 at 1300 while selecting patients for review, the hospitalization log was reviewed and it was noted P-4 had been in the hospital from 3/26/2025-4/22/2025 for a partial traumatic amputation of the right foot. Review of the medical record revealed the most recent plan of care meeting was conducted 3/14/2025 in which the patient was considered stable. Further review of the medical record revealed there was no discharge summary from the hospital present. Nursing notes dated 4/29/2025 indicate the patient was hospitalized 3/26/2025 and the discharge diagnosis was “partial traumatic amputation of right foot.” Social work notes from 4/29/2025 identified issues with “Emotional/Mental Health, Coping/Adjusting to Dialysis, Health-Related Social Needs.” Further notation from the social worker on 4/29/2025 indicated there were “barriers with patient’s insurance to receiving equipment and services needed.” Specific needs of a bed scale, a wheelchair that would lock into a wheelchair van, bipap, and need for aide to assist with patient bathing were also mentioned. On 5/29/2025 at 1052, Facility Administrator Staff B was queried as to why P-4 was not made unstable to which she replied, “He wasn’t unstable? I’ll have to ask (Staff E). He should’ve been because he was in the hospital so long.” On 5/29/2025 at 1056, Charge Nurse Staff E stated the hospital’s discharge plan for P-4 had “all fallen apart after discharge” and they (primary physician, dialysis clinic, and home health agency) were “scrambling” trying to help him out with his needs. Staff E agreed P-4 should have been made unstable because of the lengthy hospitalization and all of the issues that were present following his hospital discharge. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “Unstable patients must be reassessed by the IDT {interdisciplinary team} monthly. Monthly reassessment and any POC {plan of care} 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 condition is chronic. The following are unstable criteria: Extended or Frequent hospitalizations: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days...””

“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: 36887 Based on observation, interview, and record review, the medical director failed to ensure the medication room was secured resulting in the potential for medication tampering and/or theft and poor patient outcomes for all patients who might require medications from the facility. Findings include: On 5/28/2025 at 1046 during the initial tour of the facility with Administrative Assistant Staff A, the medication room was approached and an electronic lock was noted to be on the outside. Staff A accessed the room. Upon entry, it was discovered all of the cupboard doors and drawers were unlocked and the medication refrigerator was also unlocked. Dried streaks were visualized on one of the cupboard doors and Staff A was queried as to who was responsible to clean in the medication room. Staff A left the medication room to go inquire with the Facility Administrator (FA). On 5/28/2025 at 1052, Charge Nurse Staff E stated the cupboard/drawers and refrigerators were not ever locked. Only the outside door to the medication room. He was then queried as to who had access to the medication room to which he stated, “No one comes in but nurses.” On 5/28/2025 at 1054, Staff A returned to the medication room and stated the FA had told her housekeeping had access to the medication room to clean the floors and dust. On 5/29/2025 at 0930, BioMed Staff F opened the medication room door for the sanitarian inspection. On 5/29/2025 at 1140, Certified Clinical Hemodialysis Technician (CCHT) Staff H opened the medication room at surveyor’s request. Facility policy #47544 titled “Receiving and Stocking Medications” published 11/7/2022 states, “Ensure that medication cabinet and medication refrigerator are properly locked for security of medications, and that the medication keys are kept in the care of the Responsible Nurse.” Facility policy #47488 titled “Medication Preparation and Administration” published 2/6/2023 states, “The following steps must be taken for the securement: All medications will be kept in a locked cabinet except when in use. One key to the medication cabinet will be kept by the charge nurse/team leader. The Clinical Manager will retain a spare key, kept in a secure location... The medication refrigerator should be locked when not in use.””