Fmc of Kinston Dialysis Unit

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 26622 Based on facility policy and procedure reviews, observations, and staff interview, the facility staff failed to prevent cross contamination by not performing hand hygiene after removing dirty gloves and prior to obtaining medication from the medication cabinet for 1 of 2 observations (Sta. #6, PCT #4). Findings included: Review on 12/05/2024 of the facility policy titled “Medication Preparation and Administration” published 02/26/2023, revealed “ ... Infection Control ... Perform hand hygiene prior to accessing supplies, handling vials ...and preparing or administering .medications.” Observation on 12/05/2024 1440 on the treatment floor revealed PCT #4 walked into Station #6, donned clean gloves and prepared to discontinue a Central Venous Catheter (CVC). Observation revealed during arrangement of supplies on chairside table PCT #4 knocked the syringe of Heparin onto the floor. Observation revealed PCT #4 walked to the medication cabinet located at the nurses’ station without removing the dirty gloves or performing hand hygiene. Observation revealed PCT #4 removed the dirty gloves at the medication cabinet and removed the multidose vial of Heparin from the medication cabinet without performing hand hygiene. Observation revealed PCT #4 failed to remove gloves and perform hand hygiene between dirty and clean tasks per facility policy. Interview on 12/05/2024 at 1445 with PCT #4 revealed PCT #4 should have removed her gloves and performed hand hygiene prior to leaving the dialysis station. The interview revealed that the PCT should have performed hand hygiene after removing the dirty gloves and prior to accessing the medication from the cabinet. Interview revealed PCT #4 failed to follow the facility policy.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 26622 Based on policy review, observations, and staff interview, the facility staff failed to prevent cross contamination by failing to store cleaned and disinfected non-disposable equipment (oxygen concentrators) in a clean common area for 2 of 2 observed oxygen concentrators being stored beside the hemodialysis stations in the treatment area (Station #5 and Station #37). Findings included: Review on 12/06/2024 of the facility policy, “Cleaning and Disinfection of the Dialysis Station” Published: 09/05/2023 revealed “...General Cleaning ...After use, any non-disposable equipment and supplies brought into the dialysis station ... must be disinfected with 1:100 bleach...” 1. Observation on 12/04/2024 from 1020 to 1214 in the patient treatment area revealed the facility discontinuing patients’ hemodialysis treatments, removing patients from hemodialysis machines and cleaning and disinfecting the machine and non-disposable equipment (oxygen concentrators) with 1:100 bleach solution. Observation revealed the facility staff failed to remove the cleaned and disinfected oxygen concentrator from the patient station to a clean common storage area. Observation revealed a cleaned and disinfected oxygen concentrator was stored beside Station 5 while patients were being dialyzed. Observation revealed the cleaned and disinfected oxygen concentrator was not returned to the common clean storage area after being cleaned and disinfected. Interview on 12/04/2024 at 1100 during the observation with the PCT revealed the staff were expected to clean and disinfect any non-disposable items brought into the dialysis station. Interview revealed the staff should have cleaned, disinfected and moved the oxygen concentrator to a clean common area prior to bringing another patient to the dialysis station. Interview revealed the facility policy was not followed. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the oxygen concentrators should be cleaned between every patient use and moved to a clean common storage area after disinfection. Interview revealed the oxygen concentrators should not be stored at the hemodialysis stations. 2. Observation on 12/05/2024 from 1410 to 1530 in the patient treatment area revealed the facility discontinuing patients’ hemodialysis treatments, removing patients from hemodialysis machines and cleaning and disinfecting the machine and non-disposable equipment (oxygen concentrators) with 1:100 bleach solution. Observation revealed the facility staff failed to remove the cleaned and disinfected oxygen concentrator from the patient station to a clean common storage area. Observation revealed a cleaned and disinfected oxygen concentrator was stored beside Station 37 while patients were being dialyzed. Observation revealed the cleaned and disinfected oxygen concentrator was not returned to the common clean storage area after being cleaned and disinfected. Interview on 12/05/2024 at 1450 during the observation with the PCT revealed the staff were expected to clean and disinfect any non-disposable items brought into the dialysis station. Interview revealed the staff should have cleaned, disinfected and moved the oxygen concentrator to a clean common area prior to bringing another patient to the dialysis station. Interview revealed the facility policy was not followed. Interview on 12/06/2024 at 1530 with the Clinical Manager revealed the oxygen concentrators should be cleaned between every patient use and moved to a clean common storage area after disinfection. Interview revealed the oxygen concentrators should not be stored at the hemodialysis stations.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 26622 Based on facility policy and procedure review, observation, and staff interviews, the facility staff failed to use aseptic technique when accessing a multidose medication vial for 1 of 2 staff observed preparing medication syringes (PCT #4). Findings included: Review on 12/05/2024 of the facility’s policy “Medication Preparation and Administration,” revised 02/06/2023, revealed “Infection Control ...Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with a new alcohol pad each time the vial is accessed with a needle using friction and 70% alcohol. Allow to dry before inserting a device into the vial.” Observation on 12/05/2024 1440 on the treatment floor revealed PCT #4 walked into Station #6, donned clean gloves and prepared to discontinue a Central Venous Catheter (CVC). Observation revealed during arrangement of supplies on chairside table PCT #4 knocked the syringe of Heparin onto the floor. Observation revealed PCT #4 walked to the medication cabinet located at the nurses’ station without removing the dirty gloves or performing hand hygiene. Observation revealed PCT #4 removed the dirty gloves at the medication cabinet and removed the multidose vial of Heparin from the medication cabinet without performing hand hygiene. The observation revealed PCT #4 then accessed the multidose vial with a syringe/needle without cleansing the rubber diaphragm of the vial. Observation revealed PCT #4 failed to disinfect the rubber diaphragm of the vial per facility policy. Interview on 12/05/2024 at 1445 with PCT #4 revealed PCT #4 should have cleaned the rubber diaphragm on the medication vial prior to accessing with the needle/syringe. Interview revealed PCT #4 failed to follow the facility policy. Interview on 12/05/2024 at 1430 with the Clinical Manager revealed the staff were expected to wipe the rubber diaphragm on the multi-dose vials with every needle insertion and prior to drawing up medications.”

“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: 26622 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 5 of 10 sampled in-center hemodialysis records reviewed (Patient #2, #3, #7, #1 and #9). Findings included: Review on 12/06/2024 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 12/05/2024 for Patient #2 revealed a 69-year-old female admitted to the facility for ICHD treatments on 08/15/2022. Review of the treatment sheet dated 11/26/2024 revealed the treatment started at 1121 and ended at 1506 for a duration of 225 minutes. Review of the monitoring documentation dated 11/26/2024 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1259 and monitored next by staff at 1352 (53 minutes later). Review of the treatment sheet dated 11/24/2024 revealed the treatment started at 1024 and ended at 1357 for a duration of 213 minutes. Review of the monitoring documentation dated 11/24/2024 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1151 and monitored next by staff at 1326 (95 minutes later). Review of the treatment sheet dated 11/22/2024 revealed the treatment started at 1017 and ended at 1403 for a duration of 226 minutes. Review of the monitoring documentation dated 11/22/2024 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1125 and monitored next by staff at 1229 (64 minutes later). Review of the treatment sheet dated 11/20/2024 revealed the treatment started at 1057 and ended at 1442 for a duration of 225 minutes. Review of the monitoring documentation dated 11/20/2024 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1400 and monitored next by staff at 1449 (49 minutes later). Review of the treatment sheet dated 11/18/2024 revealed the treatment started at 1101 and ended at 1446 for a duration of 225 minutes. Review of the monitoring documentation dated 11/18/2024 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1400 and monitored next by staff at 1451 (51 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 treatment on 11/26/2024, 11/24/2024, 11/22/2024, 11/20/2024 and 11/18/2024. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. 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. 2. Open medical record review on 12/05/2024 for Patient #3 revealed a 34-year-old female admitted to the facility for ICHD treatments on 08/09/2016. Review of the treatment sheet dated 11/29/2024 revealed the treatment started at 0746 and ended at 1210 for a duration of 264 minutes. Review of the monitoring documentation dated 11/29/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0827 and monitored next by staff at 0925 (58 minutes later). Further review of the monitoring documentation for 11/29/2024 revealed the vital signs and machine parameters were monitored by staff at 1005 and monitored next by staff at 1107 (62 minutes later). Review of the treatment sheet dated 11/26/2024 revealed the treatment started at 0737 and ended at 1155 for a duration of 258 minutes. Review of the monitoring documentation dated 11/26/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0738 and monitored next by staff at 0826 (48 minutes later). Further review of the monitoring documentation for 11/26/2024 revealed the vital signs and machine parameters were monitored by staff at 0919 and monitored next by staff at 1008 (49 minutes later). Review of the treatment sheet dated 11/22/2024 revealed the treatment started at 0743 and ended at 1157 for a duration of 254 minutes. Review of the monitoring documentation dated 11/22/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1020 and monitored next by staff at 1119 (59 minutes later). Review of the treatment sheet dated 11/18/2024 revealed the treatment started at 0743 and ended at 1204 for a duration of 261 minutes. Review of the monitoring documentation dated 11/18/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0739 and monitored next by staff at 0835 (56 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 treatment on 11/29/2024, 11/26/2024, 11/22/2024, and 11/18/2024. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. 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. 3. Open medical record review on 12/05/2024 for Patient #7 revealed a 76-year-old female admitted to the facility for ICHD treatments on 03/29/2024. Review of the treatment sheet dated 11/29/2024 revealed the treatment started at 0926 and ended at 1257 for a duration of 211 minutes. Review of the monitoring documentation dated 11/29/2024 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 1034 and monitored next by staff at 1133 (59 minutes later). Review of the treatment sheet dated 11/26/2024 revealed the treatment started at 0814 and ended at 1141 for a duration of 207 minutes. Review of the monitoring documentation dated 11/26/2024 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 0924 and monitored next by staff at 1016 (52 minutes later). Review of the treatment sheet dated 11/22/2024 revealed the treatment started at 1120 and ended at 1449 for a duration of 209 minutes. Review of the monitoring documentation dated 11/22/2024 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 1149 and monitored next by staff at 1239 (50 minutes later). Review of the treatment sheet dated 11/20/2024 revealed the treatment started at 1147 and ended at 1516 for a duration of 209 minutes. Review of the monitoring documentation dated 11/20/2024 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 1253 and monitored next by staff at 1340 (47 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 treatment on 11/29/2024, 11/26/2024, 11/22/2024, and 11/20/2024. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. 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. 4. Open medical record review on 12/05/2024 for Patient #1 revealed a 65-year-old male admitted to the facility for ICHD treatments on 10/31/2024. Review of the treatment sheet dated 11/21/2024 revealed the treatment started at 1012 and ended at 1413 for a duration of 241 minutes. Review of the monitoring documentation dated 11/21/2024 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 1120 and monitored next by staff at 1213 (53 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 treatment on 11/21/2024. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. 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. 5. Open medical record review on 12/05/2024 for Patient #9 revealed a 37-year-old male admitted to the facility for ICHD treatments on 07/26/2021. Review of the treatment sheet dated 11/26/2024 revealed the treatment started at 0629 and ended at 1024 for a duration of 235 minutes. Review of the monitoring documentation dated 11/26/2024 revealed Patient #9’s blood pressure, pulse and machine parameters were monitored by staff at 0924 and monitored next by staff at 1014 (50 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 treatment on 11/26/2024. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. 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.”

“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: 26622 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis per policy before cannulation of 2 of 2 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #22, PCT #1; Station #15, PCT #8). Findings included: Review on 12/04/2024 of the facility policy “Access Assessment and Cannulation,” Published: 05/06/2024, revealed “... Assessment of Vascular Access ... Skin Disinfection Step 1 Disinfect cannulation site as follows using any of the disinfectants below: ... Povidone Iodine pad: Work outward 2 inches in a concentric circle using gentile friction for a minimum 30 seconds and allow to dry for 3 minutes before cannulating. ...” 1. Observation on 12/04/2024 at 1110 in the patient treatment area, revealed PCT #1 entered Station #22 and prepared to access the patient’s AVF/AVG. Observation revealed PCT #1 donned clean gloves and applied antiseptic (Povidone Iodine) to each access site over the skin in a concentric circle for 5 seconds. The observation revealed the PCT failed to allow each access site to dry for 3 minutes prior to cannulation. Observation revealed PCT #1 failed to clean each access site for 30 seconds and allow each site to dry for 3 minutes per facility policy. Interview on 12/04/2024 at 1120 PCT #1 revealed PCT #1 verbalized the appropriate cleaning time for the cannulation of access sites. Interview revealed PCT #1 did not use the second hand on the available treatment floor clocks. Interview revealed PCT #1 failed to clean/disinfect each of the access sites for 30 seconds and allow to dry for 3 minutes, prior to cannulation and securing the needles. Interview revealed PCT #1 failed to follow the facility policy. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to disinfect each access site for 30 seconds when using Povidone Iodine and to allow each site to dry for 3 minutes prior to cannulation. Interview revealed the PCT did not follow the facility policy. 2. Observation on 12/04/2024 at 1140 in the patient treatment area, revealed PCT #8 entered Station #15 and prepared to access the patient’s AVF/AVG. Observation revealed PCT #8 donned clean gloves and applied antiseptic (Povidone Iodine) to each access site over the skin in a concentric circle for 5 seconds. The observation revealed the PCT failed to allow each access site to dry for 3 minutes prior to cannulation. Observation revealed PCT #8 failed to clean each access site for 30 seconds and allow each site to dry for 3 minutes per facility policy. Interview on 12/04/2024 at 1120 PCT #1 revealed PCT #8 verbalized the appropriate cleaning time for the cannulation of access sites. Interview revealed PCT #8 did not use the second hand on the available treatment floor clocks. Interview revealed PCT #8 failed to clean/disinfect each of the access sites for 30 seconds and allow to dry for 3 minutes, prior to cannulation and securing the needles. Interview revealed PCT #8 failed to follow the facility policy. Interview on 12/06/2024 at 1430 with the Clinical Manager revealed the staff were expected to disinfect each access site for 30 seconds when using Povidone Iodine and to allow each site to dry for 3 minutes prior to cannulation. Interview revealed the PCT did not follow the facility policy. NC00208522”