Oaklawn Dialysis Center of Albion, LLC

“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 facility policies were adhered to concerning 1) oral medication administration and 2) removal of personal protective equipment when leaving the treatment floor resulting in the potential for adverse patient outcomes. Findings include: 1) On 1/13/2025 at 1036, Registered Nurse (RN) Staff I was observed taking a dixie cup and a medication cup into Station #10 and set them on the chairside table. No patient was in the chair; however, the station was patient ready. On closer inspection, there was a clear fluid in the dixie cup and 2 orange pills in the medication cup. Neither cup was labeled with patient name, contents, date, time, or Staff I’s initials. On 1/13/2025 at 1047, P-4 was observed entering the treatment floor via wheelchair from the main lobby. After weighing in, he went immediately to Station #10 and proceeded to take the contents of the medication cup and the dixie cup. No staff member was present to verify the patient was the correct patient or inform him of the medications he was taking. On 1/13/2025 at 1049, Charge Nurse Staff K stated it was common practice to take medications into the patient station and leave them prior to patient arrival. Staff K stated, “It should not happen that way. We will work to address that.” Facility policy #47488 titled “Medication Preparation and Administration” published 2/6/2023 states, “All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time, and intials of the person who prepared the medication...Oral mediations not being administered immediately must also be labeled as indicated above... Follow the prinicples below for medication preparation and administration. Right Drug, Right Dose, Right Route, Right Time, Right Patient, Right Documentation... Prior to administration of the medication: The patient receiving the medication shall be identified by visual and verbal confirmation, Verify there is a physician order. Ensure the patient does not have an allergy to the medication...” 2) On 1/13/2025 at 1022, RN Staff I was observed leaving the treatment floor and entering the main lobby wearing her gown, face shield, and gloves. On 1/13/2025 at 1024, RN Staff I was observed coming back onto the treatment floor still wearing all personal protective equipment (PPE) listed above and pushing P-5 in his wheelchair to Station #13. On 1/13/2025 at 1044, RN Staff I was observed returning to the lobby wearing her gown and gloves. On 1/13/2025 at 1049, Charge Nurse Staff K was queried if it were acceptable to wear PPE into the lobby to which she stated it was okay to do so since the beginning of the COVID pandemic. On 1/13/2025 at 1144, Director of Operations Staff E was queried if were acceptable to wear PPE into the lobby to which he stated, “No, it is not.” Review of facility policy #47663 titled “Personal Protective Equipment” published 11/6/2023 states, “All personal protective equipment shall be removed prior to leaving the treatment area.” On 1/15/2025 at 1034 Medical Director Staff H stated regarding putting medications at an empty station, “That is a major opportunity for major harm. We can’t do that.” Staff H agreed PPE should no longer be worn into the lobby.”