Fmc Bma of Asheboro

“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: 32003 Based on policy review, observations and staff interview, the facility staff failed to ensure patients performed hand hygiene for 4 of 4 AVF/G discontinuations (Patients #1, #5, #7 and #11). The findings include: Review on October 31, 2025 of the facility’s policy, “Hand Hygiene” published November 6, 2023 revealed, “Purpose ...Responsibility ...Policy [space] Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. ...Soap and Soap Dispensers ...Alcohol Based Hand Rubs ...Additional Guidelines for Home Therapies ...Hand Hygiene: Patients [space] Patients should perform hand hygiene if able, prior to and after each dialysis treatment. ...” 1. Observation on October 28, 2025 at 12:15 PM revealed, Patient #1 held manual pressure to a right AVF/G access site with a gloved hand. Hemostasis was achieved and the technician finished taping the access site. The patient removed the glove, escorted to the weight-scale area, a post-treatment weight was obtained and the patient exited the in-center treatment area. Observation revealed the patient failed to perform post-treatment hand hygiene. Interview on October 28, 2025 at 1:15 PM with the Clinical Manager revealed, patients should perform hand hygiene after treatment. 2. Observation on October 28, 2025 at 1:15 PM revealed, Patient #5 held manual pressure to a left AVF/G access site with a gloved hand. Hemostasis was achieved and the technician finished taping the access site. The patient removed the glove, transported to the weight-scale via wheelchair, a post-treatment weight was obtained, and the patient exited the in-center treatment area. Observation revealed the patient failed to perform post-treatment hand hygiene. Interview on October 28, 2025 at 1:15 PM with the Clinical Manager revealed, patients should perform hand hygiene after treatment. 3. Observation on October 28, 2025 at 2:00 PM revealed, Patient #7 held manual pressure to a right AVF/G access site with a gloved hand. Hemostasis was achieved and the technician finished taping the access site. The patient removed the glove, escorted to the weight-scale area, a post-treatment weight was obtained and the patient exited the in-center treatment area. Observation revealed the patient failed to perform post-treatment hand hygiene. Interview on October 28, 2025 at 1:15 PM with the Clinical Manager revealed, patients should perform hand hygiene after treatment. 4. Observation on October 29, 2025 at 9:30 AM revealed, Patient #11 held manual pressure to a left AVF/G access site with a gloved hand. Hemostasis was achieved and the technician finished taping the access site. The patient removed the glove, transported to the weight-scale via wheelchair, a post-treatment weight was obtained, and the patient exited the in-center treatment area. Observation revealed the patient failed to perform post-treatment hand hygiene. Interview on October 28, 2025 at 1:15 PM with the Clinical Manager revealed, patients should perform hand hygiene after treatment.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 32003 Based on policy review, observations and staff interview, the facility staff failed to remove PPE (gown and face shield) prior to leaving the in-center treatment area for 1 of 1 observation for 1 of 1 staff (CCHT #1). The findings include: Review on October 29, 2025 of the facility’s policy, “Personal Protective Equipment” published November 6, 2023 revealed, “Purpose ...Responsibility ...Background ...Definitions ...Policy ...All personal protection equipment shall be removed prior to leaving the treatment area. ...” 1. Observation on October 28, 2025 at 12:15 PM of the in-center treatment area entrance/exit doors revealed, both doors had signage that displayed no PPE should be worn beyond the in-center treatment area. 2. Observation on October 29, 2025 at 9:30 AM revealed, CCHT #1 assisted a patient into the care while still wearing PPE (face shield and gown) from the in-center treatment area. Once the patient was in the vehicle, the technician returned to the treatment area wearing the same PPE. Observation revealed, the staff failed to remove PPE prior to leaving the treatment area. Interview on October 29, 2025 at 1:15 PM with the Clinical Manager revealed, staff should not wear PPE beyond the in-center treatment area and staff should not be assisting patients into vehicles.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 32003 Based on policy review, observations and staff interview, the facility staff failed to ensure the Hansen connectors were cleaned and disinfected for 1 of 3 observations (Station #37). The findings include: Review on October 29, 2025 of the facility’s policy, “Cleaning and Disinfecting the Dialysis Station” published September 2, 2025 revealed, “Purpose ...Responsibility ...Background [space] ...The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses. ...Definition [space] Dialysis Station [ space] ...Equipment in the dialysis station may include (but is not limited to) the following: Dialysis machine/cycler and attachments such as IV pole, BP cuff and hand sanitizer holder, sharps container mounted to the machine. ...Cleaning of the Dialysis Machine [space] Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment. ...” Observation on October 28, 2025 at 12:30 PM revealed, a technician obtained 1:100 bleach cloth, cleaned and disinfected equipment associated with dialysis station #37 except for the Hansen connectors. Interview on October 29, 2025 at about 2:00 PM with Nurse #1 revealed, staff received video training on how to clean and disinfect the dialysis machine which included the Hansen connectors.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 32003 Based on policy review, medical record reviews and staff interviews, the facility staff failed to follow 2 of 2 patients’ plan of care by not dialyzing 1 of 4 patients (#25) at the prescribed DFR and by not dialyzing 1 of 4 patients (#21) at the prescribed BFR. The findings include: Review on October 29, 2025 of the facility’s policy, “Patient Assessment and Monitoring” published May 1, 2023 revealed, “Purpose ...Responsibility ...Definitions ...Delegation ...Data Collection ...Pre-Treatment ...During Treatment ...Step 1 [space] Blood Pressure ...3 [space] Machine Parameters and Extracorporeal Circuit [space] Check machine settings and measurements: Check prescribed blood flow is being achieved or reason documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. ...” 1. Open medical record review on October 31, 2025 revealed, Patient #25 was admitted to the in-center facility March 2025 and had a physician order for a DFR of 800 ml/min for 240-minutes. Treatment sheet review from October 13, 2025 through October 25, 2025 (six consecutive treatments) revealed October 24, 2025, the patient dialyzed at a DFR of 500 for 234-minutes. Review revealed the patient dialyzed at the incorrect DFR for treatment duration without a documented reason. Interview on October 31, 2025 at 10:31 AM with the Charge Nurse revealed there was no documentation for the DFR change for the patient and the plan was to audit three medical records per month. 2. Open medical record review on October 31, 2025 revealed, Patient #21 was admitted to the in-center facility February 2020 and had a physician order for a BFR of 450 for 225-minutes. Treatment sheet review from October 13, 2025 through October 25, 2025 (six consecutive treatments) revealed October 13, 2025 and October 24, 2025, the dialyzed at a BFR of 400 for 227-minutes and 161-minutes. Review revealed the patient dialyzed at the incorrect BFR for treatment duration without a documented reason. Interview on October 31, 2025 at 10:31 AM with the Charge Nurse revealed there was no documentation for the BFR change for the patient and the plan was to audit three medical records per month.”

“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: 32003 Based on policy review, observation, medical record review and interviews, the facility staff failed to ensure a visitor wore PPE (gown and face shield) while at the chairside during treatment initiation for 1 of 1 patient (Patient #21). The findings include: Review on October 29, 2025 of the facility’s policy, “Visitor Policy” published February 6, 2023 revealed, “Purpose ...Responsibility ...Background ...Visitors in the Patient Care Area [space] ...No visitors permitted during the initiation and discontinuation of dialysis unless they are assisting with the patient care. ...Visitors Assisting with Care [space] Visitors will be given appropriate infection control training and orientation to the clinic as well as a brief review of the dialysis procedure to assure that the visitor has at least a minimal understanding of what will be observed. ...” Observation on October 29, 2025 at 9:56 AM revealed, Patient #21 was located at Station #18 for treatment initiation by CCHT #2. Shortly thereafter, a visitor arrived, sat at the chairside as the technician cannulated the patient and remained at the chairside during treatment without PPE. Interview on October 29, 2025 at 12:40 PM with the family member of Patient #21 revealed, facility staff had not educated the family on use of PPE at the chairside. Interview on October 29, 2025 at 4:15 PM with the Clinical Manager revealed, the manager failed to have oversight and PPE education was offered to the visitor in real-time at the chair side, as the plan was to schedule a meeting with the family on next week. Open medical record review on October 31, 2025 revealed Patient #21 was admitted to the in-center treatment facility in 2020. The patient had as order for a sitter at the chairside because the patient was pulling needles. Review revealed, there was no documentation that the family received education regarding PPE while at the chairside. NC00233819”