Fmc - St Louis Northeast

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to provide a sanitary environment to help prevent cross contamination by not maintaining the door frame to the exterior in the biohazard room, not properly storing wet mops to allow sufficient drying, and not ensuring staff don’t potentially cross contaminate the dialysis machine during one observation. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 52. Findings included: 1. Observation on 6/23/25 at 11:26 AM of the biohazard room showed the bottom of the door frame for the door to the exterior had rusted areas and an approximately two inch by four inch hole through the door frame. 2. Observation on 6/24/25 at 1:09 PM showed staff (G) had the bottom of her shoe propped up on the base of the dialysis machine at station # 11 while she adjusted the dialysis machine for the patient. 3. Observation on 6/24/25 at 1:21 PM of the janitor closet showed a wet mop in a mop bucket and another mop on the floor behind the door. Staff did not hang the mops to allow for proper drying and reduce the potential for mold and bacterial growth. 4. During an interview on 6/24/25 at 1:51 PM, the director of operations said staff need to repair the door frame in the biohazard room and staff should not prop their shoe on the base of the dialysis machine when adjusting the machine.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to check the chlorine level in the water at least every four hours during three dialysis treatment days. A high chlorine level in the water can cause complications for dialysis patients. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 52. Findings included: 1. Review of the facility chlorine check log dated 4/3/25 showed staff checked the chlorine level in the water at 4:55 AM but did not check the chlorine level in the water again until 10:30 AM. 2. Review of the facility chlorine check log dated 5/10/25 showed staff checked the chlorine level in the water at 7:15 AM but did not check the chlorine level in the water again until 1:00 PM. 3. Review of the facility chlorine check log dated 5/14/25 showed staff checked the chlorine level in the water at 7:02 AM but did not check the chlorine level in the water again until 12:30 PM. 4. During an interview on 6/24/25 at 10:20 AM, the biomedical technician said staff should check the chlorine level in the water at least every four hours.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for the blood flow rate or the dialysate flow rate for three (Patient # 7, # 22, and # 36) patients out of five clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 52. Findings included: 1. Review of the treatment flow sheet dated 6/19/25 for Patient # 7 showed the physician directed staff to set the dialysate flow rate at 600 during the patient’s dialysis treatment, but staff set the dialysate flow rate at 800. 2. Review of the treatment flow sheets dated 6/18/25 and 6/23/25 for Patient # 22 showed the physician directed staff to set the blood flow rate at 450 during the patient’s dialysis treatment, but staff set the blood flow rate at 400. 3. Review of the treatment flow sheet dated 5/6/25 for Patient # 36 showed the physician directed staff to set the blood flow rate at 300 during the patient’s dialysis treatment, but staff set the blood flow rate at 400. 4. During an interview on 6/24/25 at 1:51 PM, the director of operations said staff should follow the physician order for the blood flow rate and dialysate flow rate.”

“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: 17026 Based on record review and staff interview, the facility staff failed to complete the care plan within 30 days of a patient starting on dialysis treatment for three (Patient # 19, # 45, and # 52) patients. A total of five clinical records were reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 52. Findings included: 1. Review of the clinical record for Patient # 52 showed the patient started dialysis treatment on 3/3/25 but staff did not complete the 30 day care plan for the patient until 4/30/25. 2. Review of the clinical record for Patient # 45 showed the patient started dialysis treatment on 10/3/24 but staff did not complete the 30 day care plan for the patient until 11/27/24. 3. Review of the clinical record for Patient # 19 showed the patient started dialysis treatment on 5/13/25 but staff did not have the 30 day care plan scheduled to be completed until 6/26/25. 4. During an interview on 6/24/25 at 9:15 AM, the social worker said staff were behind on completing some of the care plans within 30 days of a patient starting dialysis treatment.”