Fmc - Fayetteville Kidney Center

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 51294 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to monitor a patient at a minimum of every 30-45 minutes during hemodialysis treatments for 4 of 6 sampled in-center hemodialysis records reviewed (Patients #3, #4, #5 and #6). Findings included: Review on 10/29/2025 of the facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, revealed, “...During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” 1. Open medical record review on 10/29/2025 for Patient #3 revealed a 40-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 06/30/2010. Review of the treatment sheet dated 10/08/2025 revealed the treatment started at 0722 and ended at 1205 for a duration of 283 minutes. Review of the monitoring documentation dated 10/08/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0932 and monitored next by staff at 1028 (56 minutes later). Review of the treatment sheet dated 10/17/2025 revealed the treatment started at 0725 and ended at 1103 for a duration of 218 minutes. Review of the monitoring documentation dated 10/17/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1009 and monitored next by staff at 1103 (54 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 10/08/2025 and 10/17/2025. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 10/08/2025 and 10/17/2025 for Patient #3. 2. Open medical record review on 10/29/2025 for Patient #4 revealed a 56-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 11/23/2022. Review of the treatment sheet dated 10/14/2025 revealed the treatment started at 1032 and ended at 1437 for a duration of 245 minutes. Review of the monitoring documentation dated 10/14/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1046 and monitored next by staff at 1134 (48 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 10/14/2025. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 10/14/2025 for Patient #4. 3. Open medical record review on 10/29/2025 for Patient #5 revealed a 60-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 04/07/2010. Review of the treatment sheet dated 07/03/2025 revealed the treatment started at 1136 and ended at 1538 for a duration of 242 minutes. Review of the monitoring documentation dated 07/03/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1400 and monitored next by staff at 1502 (62 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 07/03/2025. A review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 400 with a Dialysate Flow Rate (DFR) at 1.5 times the BFR. A review of the Treatment Flowsheet dated 10/09/2025 revealed that Patient #5’s hemodialysis treatment was initiated at 1138 and ended at 1541. Review of the Flowsheet revealed Patient #5’s BFR/DFR was not documented until 1259 (81 minutes after the treatment started). Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 07/03/2025 for Patient #5. Interview revealed the staff were expected to document BFR/ DFR with vital signs as part of patient monitoring. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 10/09/2025 for Patient #5. The interview confirmed that there was no documentation in the treatment record of the BFR/DFR for the first 81 minutes of treatment. 4. Open medical record review on 10/29/2025 for Patient #6 revealed a 75-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 02/27/2025. A review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 400 with a Dialysate Flow Rate (DFR) at 1.5 times the BFR. A review of the Treatment Flowsheet dated 10/07/2025 revealed that Patient #6’s hemodialysis treatment was initiated at 1158 and ended at 1558. Review of the Flowsheet revealed Patient #6’s BFR/DFR was not documented until 1223, 25 minutes after the treatment started. A review of the Treatment Flowsheet dated 10/09/2025 revealed that Patient #6’s hemodialysis treatment was initiated at 1204 and ended at 1614. Review of the Flowsheet revealed Patient #6’s BFR/DFR was not documented until 1256 (52 minutes after the treatment started). Review of the treatment sheet dated 10/18/2025 revealed the treatment started at 1201 and ended at 1606 for a duration of 245 minutes. Review of the monitoring documentation dated 10/18/2025 revealed Patient #6’s blood pressure, pulse and machine parameters were monitored by staff at 1230 and monitored next by staff at 1351 (81 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 10/18/2025. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to document BFR/ DFR with vital signs as part of patient monitoring. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 10/07/2025 and 10/09/2025 for Patient #5. The interview confirmed that there was no documentation in the treatment record of the BFR/DFR for the first 25 and 52 minutes of treatment. Interview revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 10/18/2025 for Patient #6.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51294 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis (The process of applying antiseptic agents to the skin to inhibit the growth of microorganisms) per policy before cannulation of 3 of 3 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #41; PCT (Patient Care Technician) #1; Station #37; PCT #2; Station #14; PCT #3). Findings included: Review on 10/29/2025 of the facility policy titled “Access Assessment and Cannulation” revised May 5, 2025 revealed “Skin disinfection, Step 1- Disinfect cannulation site as follows using any of the disinfectants below: 70 % isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating.” 1. Observation on 10/28/2025 at 1125 in the patient treatment area revealed PCT #1 entered Station #41 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #1 performed hand hygiene and donned clean gloves. PCT #1 cleansed the arterial and venous access sites with 70 % isopropyl alcohol pad for 13 seconds at the first site and 8 seconds on the second site. Observation revealed PCT #1 failed to disinfect each access site with 70 % isopropyl alcohol for 30 seconds per the facility policy. Interview on 10/29/2025 at 1553 with PCT #1 revealed when asked how long the access site was disinfected, they stated “15 seconds”. Interview revealed that PCT #2 failed to disinfect the access sites per facility policy. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to disinfect each access site for 30 seconds when using 70 % isopropyl alcohol pads and allow each site to dry prior to cannulating. Interview revealed the staff failed to follow the facility policy. 2. Observation on 10/28/2025 at 1227 in the patient treatment area revealed PCT #2 entered Station #37 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and donned clean gloves. PCT #2 cleansed the arterial and venous access sites with 70 % isopropyl alcohol pad for 14 seconds at the first site and 17 seconds on the second site. Observation revealed PCT #2 failed to disinfect each access site with 70 % isopropyl alcohol for 30 seconds per the facility policy. Interview on 10/28/2025 at 1248 with PCT #2 revealed when asked how long the access site was disinfected, they stated “15-20 seconds”. Interview revealed that PCT #2 failed to disinfect the access sites per facility policy. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to disinfect each access site for 30 seconds when using 70 % isopropyl alcohol pads and allow each site to dry prior to cannulating. Interview revealed the staff failed to follow the facility policy. 3. Observation on 10/29/2025 at 1100 in the patient treatment area revealed PCT #3 entered Station #14 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #3 performed hand hygiene and donned clean gloves. PCT #3 cleansed the arterial and venous access sites with 70 % isopropyl alcohol pad for 16 seconds at the first site and 8 seconds on the second site. Observation revealed PCT #3 failed to disinfect each access site with 70 % isopropyl alcohol for 30 seconds per the facility policy. Interview on 10/28/2025 at 1248 with PCT #3 revealed when asked how long the access site was disinfected, they stated “15-20 seconds.” Interview revealed that PCT #3 failed to disinfect the access sites per facility policy. Interview on 10/30/2025 at 1150 with the Clinical Manager revealed the staff were expected to disinfect each access site for 30 seconds when using 70 % isopropyl alcohol pads and allow each site to dry prior to cannulating. Interview revealed the staff failed to follow the facility policy.”