Fmc Four Oaks

“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: 38766 Based on policy and procedure review, observations, and staff interviews, the facility staff failed to maintain bleach solution in a labeled and covered opaque container in 1 (one) of 2 (two) observations.. Findings included: Review on 08/12/2025 of the facility procedure “Mixing Bleach” published 02/03/2025, revealed “Procedure Follow the steps below for mixing bleach: ...4. Label opaque container with ‘Bleach Solution’, strength of solution, date and time prepared, and your initials. 5. Cover opaque container with lid...” Observation on 08/12/2025 between 0915 and 1205 of the patient treatment area revealed a clear container holding a clear solution located on a cart in front of the nursing station. The container was found to be unlabeled and uncovered. An interview on 08/12/2025 at 1125 with PCT #1 revealed that the solution in the container was a 1:100 bleach solution (cleaning solution consisting of one part bleach to 99 parts water) made in the morning by the opening PCT. The interview revealed that the container was to be labeled and kept covered. PCT #1 added, “I don’t know why it was not labeled. An interview on 08/12/2025 at 1145 with PCT #2 confirmed that he was the opening PCT. During the interview, it was revealed that the solution in the container was a 1:100 bleach solution. PCT #2 confirmed that the container should be labeled with the type of solution, the date and time of its preparation, and the initials of the staff member who prepared it. An interview on 08/14/2025 at 1320 with Staff #3 revealed that the container of bleach solution should be labeled with the concentration, date, time, and the initials of the preparer. Staff #3 added that the container should have a lid. The interview confirmed the findings.”

“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: 38766 Based on facility policy review, medical record reviews, and staff interviews, the facility staff failed to monitor a patient at least every 30-45 minutes during hemodialysis treatments for 4 (four) of 10 (ten) sampled in-center hemodialysis records reviewed (Patient #8, #5, #3, and #4). Findings included: A review on 08/12/2025 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 08/14/2025 for Patient #8 revealed a 85-year-old female admitted to the facility for ICHD treatments on 08/01/2023. A review of the treatment sheet dated 07/23/2025 revealed the treatment started at 1216 and ended at 1603 for 227 minutes. The review of the monitoring documentation dated 07/23/2025 revealed that Patient #8’s blood pressure, pulse, and machine parameters were monitored by staff at 1403 and monitored next by staff at 1501 (58 minutes later). A review of the treatment sheet dated 07/25/2025 revealed the treatment started at 1220 and ended at 1618 for 238 minutes. The review of the monitoring documentation dated 07/25/2025 revealed that Patient #8’s blood pressure, pulse, and machine parameters were monitored by staff at 1503 and monitored next by staff at 1629 (83 minutes later). The 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 07/23/2025 and 07/25/2025. An interview on 08/14/2025 at 1320 with PCT #3 revealed that vital signs and safety checks should be conducted and documented every 30 minutes. The safety check should include any changes in the patient’s condition, and interventions needed, the patient’s goals, conditions of the access site, and visualizing the patient’s face. An interview on 08/14/2025 at 1400 with the Clinical Manager revealed that the policy required patients to be monitored every 30-45 minutes. However, staff were expected to monitor patients every 30 minutes during treatments. The interview revealed that the staff failed to follow the facility policy. 2. Open medical record review on 08/14/2025 for Patient #5 revealed a 25-year-old male admitted to the facility for ICHD treatments on 06/18/2021. A review of the treatment sheet dated 07/26/2025 revealed the treatment started at 1044 and ended at 1421 for 217 minutes. The review of the monitoring documentation dated 07/26/2025 revealed that Patient #5’s blood pressure, pulse, and machine parameters were monitored by staff at 1104 and monitored next by staff at 1201 (57 minutes later). A review of the treatment sheet dated 07/29/2025 revealed the treatment started at 1043 and ended at 1447 for 244 minutes. The review of the monitoring documentation dated 07/29/2025 revealed that Patient #5’s blood pressure, pulse, and machine parameters were monitored by staff at 1106 and monitored next by staff at 1208 (62 minutes later). A review of the treatment sheet dated 07/31/2025 revealed the treatment started at 1028 and ended at 1429 for 241 minutes. The review of the monitoring documentation dated 07/31/2025 revealed that Patient #5’s blood pressure, pulse, and machine parameters were monitored by staff at 1031 and monitored next by staff at 1130 (59 minutes later). The 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 07/26/2025, 07/29/2025, and 07/3/2025. An interview on 08/14/2025 at 1320 with PCT #3 revealed that vital signs and safety checks should be conducted and documented every 30 minutes. The safety check should include any changes in the patient’s condition, and interventions needed, the patient’s goals, conditions of the access site, and visualizing the patient’s face. An interview on 08/14/2025 at 1400 with the Clinical Manager revealed that the policy required patients to be monitored every 30-45 minutes. However, staff were expected to monitor patients every 30 minutes during treatments. The interview revealed that the staff failed to follow the facility policy. 3. Open medical record review on 08/13/2025 for Patient #3 revealed a 61-year-old female admitted to the facility for ICHD treatments on 01/15/2024. A review of the treatment sheet dated 07/21/2025 revealed the treatment started at 1036 and ended at 1439 for 243 minutes. The review of the monitoring documentation dated 07/21/2025 revealed that Patient #3’s blood pressure, pulse, and machine parameters were monitored by staff at 1209 and monitored next by staff at 1302 (53 minutes later). A review of the treatment sheet dated 07/23/2025 revealed the treatment started at 1036 and ended at 1449 for 253 minutes. The review of the monitoring documentation dated 07/23/2025 revealed that Patient #3’s blood pressure, pulse, and machine parameters were monitored by staff at 1400 and then by staff at 1501 (61 minutes later). A review of the treatment sheet dated 07/30/2025 revealed the treatment started at 1038 and ended at 1446 for 248 minutes. The review of the monitoring documentation dated 07/21/2025 revealed that Patient #3’s blood pressure, pulse, and machine parameters were monitored by staff at 1038 and monitored next by staff at 1132 (54 minutes later). The 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 07/21/2025, 07/23/2025, and 07/30/2025. An interview on 08/14/2025 at 1320 with PCT #3 revealed that vital signs and safety checks should be conducted and documented every 30 minutes. The safety check should include any changes in the patient’s condition, and interventions needed, the patient’s goals, conditions of the access site, and visualizing the patient’s face. An interview on 08/14/2025 at 1400 with the Clinical Manager revealed that the policy required patients to be monitored every 30-45 minutes. However, staff were expected to monitor patients every 30 minutes during treatments. The interview revealed that the staff failed to follow the facility policy. 4. Open medical record review on 08/13/2025 for Patient #4 revealed a 36-year-old female admitted to the facility for ICHD treatments on 06/13/2023. A review of the treatment sheet dated 07/26/2025 revealed the treatment started at 0605 and ended at 1005 for 240 minutes. The review of the monitoring documentation dated 07/26/2025 revealed that Patient #4’s blood pressure, pulse, and machine parameters were monitored by staff at 0608 and monitored next by staff at 0710 (62 minutes later). The 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 07/26/2025. An interview on 08/14/2025 at 1320 with PCT #3 revealed that vital signs and safety checks should be conducted and documented every 30 minutes. The safety check should include any changes in the patient’s condition, and interventions needed, the patient’s goals, conditions of the access site, and visualizing the patient’s face. An interview on 08/14/2025 at 1400 with the Clinical Manager revealed that the policy required patients to be monitored every 30-45 minutes. However, staff were expected to monitor patients every 30 minutes during treatments. The interview revealed that the staff failed to follow the facility policy.”

“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: 38766 Based on policy review, medical records review, and staff interview, the facility staff failed to follow the adequacy plan of care by failing to dialyze 2 of 10 (Patient #5 and #3) in-center hemodialysis patients at the prescribed BFR/DFR. Findings included: A review on 08/13/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “Purpose ...Responsibility ...Definitions ...Delegation ...Data Collection ...Pre-Treatment ...During Treatment ...Step 1 ...Step 3 [space] Machine Parameters and Extracorporeal Circuit [space] Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. ...” 1. Review of the medical record for Patient #5 revealed a 25-year-old male admitted for In-Center Hemodialysis treatments on 06/18/2021. Review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 1.5 times the BFR rate (600). Review of the Treatment Flowsheet dated 07/26/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1044 and ended at 1421 (217 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 350 and DFR average was 600, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 07/31/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1028 and ended at 1429 (241 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 350 and DFR average was 600, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/02/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1039 and ended at 1440 (241 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 380 and DFR average was 580, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. An interview on 08/14/2025 at 1320 with Patient Care Technician #3 revealed that the patient’s BFR and DFR were part of the treatment order. The PCT added that the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview confirmed the findings. 2. Review of the medical record for Patient #3 revealed a 61-year-old female admitted for In-Center Hemodialysis treatments on 01/15/2024. Review of the Physician orders revealed Patient #3’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 1.5 times the BFR rate (600). Review of the Treatment Flowsheet dated 07/30/2025 revealed Patient #3’s hemodialysis treatment was initiated at 1038 and ended at 1446 (248 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 350 and DFR average was 560, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/01/2025 revealed Patient #3’s hemodialysis treatment was initiated at 1037 and ended at 1437 (240 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 370 and DFR average was 600, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. An interview on 08/14/2025 at 1320 with Patient Care Technician #3 revealed that the patient’s BFR and DFR were part of the treatment order. The PCT added that the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview confirmed the findings.”

“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: 38766 Based on review of the facility’s policy and procedure, observation, and staff interviews, the facility staff failed to ensure a patient’s vascular access site was washed with soap and water or antibacterial scrub upon entering the facility for 2 of 2 patients’ AVF/G access observations (Patient #5 and #3). Findings include: Review of the facility’s policy “Access Assessment and Cannulation” published 05/05/2025 revealed “...Assessment of Vascular Access: Follow the steps below to access the vascular access: 1. Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient’s access with soap and water. Note: If unable to was with soap and water, staff may use hand sanitizer with 60-70 percent alcohol to clean access arm ...” 1. Observation on 08/12/2025 at 1045 revealed Patient #5 entered the treatment area, his weight was obtained, and he was escorted to Station #2. Continued observation revealed PCT #2 evaluated Patient #5’s access, applied antiseptic, and proceeded with cannulation. The observation revealed PCT #2 did not instruct Patient #5 to wash his access site with soap and water, nor did PCT #2 verbally confirm the access site had been washed. An interview with PCT #2 on 08/12/2025 at 1145 confirmed that he did not instruct Patient #5 to wash his access site, although he should have done so. An interview conducted on 08/12/2025 at 1220 with the Clinical Manager indicated that patients were expected to wash their access sites upon entering the treatment floor. The interview confirmed these findings. 2. Observation on 08/12/2025 at 1140 revealed Patient #3 entered the treatment area, her weight was obtained, and she was escorted to Station #1. Continued observation revealed PCT #2 evaluated Patient #3’s access, applied antiseptic, and proceeded with cannulation. The observation revealed PCT #2 did not instruct Patient #3 to wash her access site with soap and water, nor did PCT #2 verbally confirm the access site had been washed. An interview with PCT #2 on 08/12/2025 at 1145 confirmed that he did not instruct Patient #5 to wash his access site, although he should have done so. An interview on 08/12/2025 at 1150 with Patient #3 revealed that she should have washed her access site when she entered the treatment area. An interview conducted on 08/12/2025 at 1220 with the Clinical Manager indicated that patients were expected to wash their access sites upon entering the treatment floor. The interview confirmed these findings.”