Fmc Bma Albemarle

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 32003 Based on NCBON position statement review, policy review, observation, and staff interview, the facility staff failed to observe heparin drawn up by a technician for 1 of 2 patients (Patient #5). The findings include: Review on July 11, 2025 of the position statement from the NCBON revised September 2021 revealed, “ ... 2. May assist the licensed nurse with the administration of heparin, lidocaine, and normal saline, provided there is an established written protocol which limits the delegation to the competent UAP (dialysis technician). ...” Review on July 11, 2025 of the facility’s policy, “North Carolina State Specific: Heparin Administration by Patient Care Technicians” published February 25, 2025 revealed, “ ...Validation Process [space] To validate heparin dose: The Licensed Nurse will watch the PCT draw up heparin into the syringe based on the information on the medication label. ...” Observation on July 9, 2025 at 12:25 PM revealed, CCHT #5 went to the medication area and drew up two syringes of heparin without the nurse being present. The technician then went to the nurse station and nurse #1 observed the patient label and volume located on the outside of the syringe. Observation revealed, the nurse and the technician did not validate the solution and dosage at the same time. Interview on July 11, 2025 at 9:30 AM with the Clinical Nurse Manager revealed, the nurse and the technician should be present at the same time when the heparin is drawn up.”

“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 prevent cross-contamination by failing to ensure patients performed hand hygiene for 3 of 3 AVF/G discontinuation. (Patients #3, #4 and #19). The findings include: Review on July 9, 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. ...” 1. Observation on July 9, 2025 at 11:55 AM revealed, Patient #3 applied manual pressure with a gloved hand to a left AVF/G access site. Hemostasis was achieved and CCHT #1 applied tape to finish securing the access site. Once tape was applied, the patient went to the scale for a post-treatment weight and exited the in-center treatment area without performing hand hygiene. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed patients should perform hand hygiene [soap and water] or be offered hand sanitizer before leaving the in-center treatment area. 2. Observation on July 9, 2025 at 12:00 PM revealed, Patient #4 applied manual pressure with a gloved hand to a left AVF/G access site. Hemostasis was achieved and CCHT #2 applied tape to finish securing the access site. Once tape was applied, the patient went to the scale for a post-treatment weight and exited the in-center treatment area without performing hand hygiene. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed patients should perform hand hygiene [soap and water] or be offered hand sanitizer before leaving the in-center treatment area. 3. Observation on July 10, 2025 at 2:45 PM revealed, Patient #19 applied manual pressure with a gloved hand to a left AVF/G access site. Hemostasis was achieved and CCHT #2 applied tape to finish securing the access site. Once tape was applied, the patient went to the scale for a post-treatment weight and exited the in-center treatment area without performing hand hygiene. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed patients should perform hand hygiene [soap and water] or be offered hand sanitizer before leaving the in-center treatment area.”

“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, staff interview and ICHD clinic audit checklist review, the facility staff failed to clean and disinfect the and Hansen connectors for 3 of 3 HDM and station disinfections (Station #5, HDM #22; Station #15, HDM #15 and Station #25, HDM #25). The findings include: Review on July 11, 2025 of the facility’s policy, “Cleaning and Disinfecting the Dialysis Station” published September 5, 2023 revealed, “Purpose ... Responsibility ...Background ...Definition ...General Cleaning ...Cleaning of the Dialysis Machine [space] Externally disinfect the dialysis machine with 1:100 bleach solution after each dialysis treatment. ...” 1. Observation on July 9, 2025 at 12:10 PM revealed, CCHT #1 and #3 both obtained 1:100 bleach cloths to clean and disinfect Station #5, HDM #22. The observation revealed, all non-disposable equipment was cleaned and disinfected except for the Hansen connectors. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed the Hansen connectors should be disinfected between patient use. Interview on July 11, 2025 of the ICHD clinic audit checklist revealed from August 2024 through June 2025, the audits of the cleaning and disinfection of the Dialysis Station ranged from 90% to 100%. 2. Observation on July 9, 2025 at 12:50 PM revealed, a facility staff member obtained 1:100 bleach cloths to clean and disinfect Station #15, HDM #16. The observation revealed, all non-disposable equipment was cleaned and disposed except for the Hansen connectors. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed the Hansen connectors should be disinfected between patient use. Interview on July 11, 2025 of the ICHD clinic audit checklist revealed from August 2024 through June 2025, the audits of the cleaning and disinfection of the Dialysis Station ranged from 90% to 100%. 3. Observation on July 10, 2025 at about 1:50 PM revealed, CCHT #4 obtained 1:100 bleach cloths to clean and disinfect Station #25,, HDM #25. The observation revealed, all non-disposable equipment was cleaned and disposed except for the Hansen connectors. Interview on July 11, 2025 at 9:30 AM with the Clinical Manager revealed the Hansen connectors should be disinfected between patient use. Interview on July 11, 2025 of the ICHD clinic audit checklist revealed from August 2024 through June 2025, the audits of the cleaning and disinfection of the Dialysis Station ranged from 90% to 100%.”