Fmc Johnston Dialysis Center Inc.

“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 facility policy review, observation, and interview, the patient care staff failed to prevent cross-contamination by failing to clean and disinfect the Hoyer lift per the facility policy for one of one observation of staff using the Hoyer lift (RN #1) Findings include: Review on 12/30/2025 of the facility’s policy, “Cleaning and Disinfecting the Dialysis Station” published 09/02/2025, revealed, “... General Cleaning... After use, any non-disposable equipment and supplies brought into the dialysis station (ex. stetoscope) must be disinfected with 1:100 bleach, or EPA-registered disinfectant before being removed from the dialysis station...” Observation on 01/20/2026 at 1120 revealed that RN #1 obtained a Hoyer Lift from a holding area to Bay #2. RN #1 and PCT #2 assisted a patient from a wheelchair into the treatment chair via the Hoyer Lift. The observation revealed that RN #1 returned the Hoyer Lift to the holding area near the dialysis machine in station #1. The observation failed to show the staff cleaning and disinfecting the non-disposable equipment before returning to the holding area. An interview on 01/20/2026 at 1130 with RN #1 revealed that the area where the Hoyer Lift was placed, near the dialysis machine in station #1, was clean. The RN reported that the staff planned to disinfect the Hoyer Lift after the patient left for the day, as the patient was the only one using it that day. The RN acknowledged that the Hoyer Lift needed disinfection before being returned to the clean area. The interview confirmed that the cleaning and disinfecting policy was not adhered to.”

“RO-MONITOR/ALARM/PREVENT UNSAFE H20 USE CFR(s): 494.40(a) 5.2.7 Reverse osmosis: alarm/prevent use of unsafe water Refer to RD62:2001, 4.3.7 Reverse osmosis: Reverse osmosis devices shall be equipped with on-line monitors that allow determination of rejection rates and product water conductivity. The product water conductivity monitor should activate audible and visual alarms when the product water conductivity exceeds the preset alarm limit. The audible alarm must be audible in the patient care area when reverse osmosis is the last chemical purification process in the water treatment system. Monitors that measure resistivity or TDS may be used in place of conductivity monitors. 6.2.7 Reverse osmosis: Reverse osmosis systems should be monitored daily using continuous-reading monitors that measure product water conductivity (or total dissolved solids (TDS)). 5.2.7 Reverse osmosis: Refer to RD62:2001, 4.3.7 Reverse osmosis: When a reverse osmosis system is the last chemical purification process in the water treatment system, it [should] include a means to prevent patient exposure to unsafe product water, such as diversion of the product water to drain, in the event of a product water conductivity or rejection alarm. This Standard is not met as evidenced by: 38766 Based on the facility policy review, the facility’s “RO (Reverse Osmosis) Machine Log” review, and staff interviews, the facility staff failed to maintain a daily RO waterlog for two of the two RO waterlogs reviewed. Findings include: Review on 12/30/2025 of the facility’s policy, “Central Reverse Osmosis Water Purification, Operation and Maintenance Policy” published 02/03/2025, revealed “... Policy: Daily Performance Documentation... For RO machines that are not equipped with automated data recording, monitoring of the RO machine’s performance will be completed, documented, and found to be within established operational parameters prior to use of water for dialysis purposes each treatment day...” Review of the daily RO waterlog from 11/01/2025 to 12/31/2025 revealed no documented data on 12/10/2025 for both RO #1 and RO #2 logs. The review indicated that the ROs were not monitored for performance and were not documented as being within operational parameters before patient treatments on 12/10/2025. An interview on 01/21/2026 at 1225 with the Biomedical Technician revealed that the staff should monitor the RO daily before any water usage. The reading of the RO’s performance was to ensure the clinic had safe water for the patients’ safety. The interview also revealed that the Biomedical Technician audited the RO logs monthly, including the log for December 2025. The Technician did not recall noticing the missing data for December 10. The Technician reported that if he had recognized the missing data, he would have emailed the clinic manager immediately about the findings. An interview on 01/21/2026 at 1225 with the ATOM, along with the Biomedical Technician, revealed that the ROs did not have automated data recording, and a daily monitoring documentation was required. The interview confirmed that the policy was not adhered to.”

“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: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to comply with policies and procedures by not ensuring the patient’s medication syringe was not left unattended in one of two observations (RN #3). Findings included: A review on 01/21/2026 of the facility’s policy, “Medication Preparation and Administration” published 07/07/2025, revealed “...Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control... Pre-drawing Medications... The pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration...” An observation on 01/21/2026 from 1035 to 1130 of the treatment area revealed that staff attended to the patients during treatments. At or around 1050, RN #3 went to the medication preparation area and removed a kidney basin with multiple pre-drawn syringes from a locked cabinet. The observation revealed that RN #3 placed the basin with the medication syringes on a table in the center of the treatment area. RN #3 obtained two pre-filled syringes from a patient’s station and proceeded with discontinuation of the patient’s treatment. Further observation revealed that RN #3 returned to the table, retrieved two additional syringes from the basin, and proceeded to another patient’s station. The observation revealed that the pre-filled medication syringes were left on the table in the middle of the treatment area unattended while RN #3 provided patient care. An interview on 1105 with RN #3 revealed that the nurse had removed the basin from the medication cabinet to the table because RN #3 needed Heparin (an injectable anticoagulant {blood thinner} used to prevent and treat blood clots in veins, arteries, and lungs, or during medical procedures like dialysis) for two patients. RN #3 acknowledged that she should have removed the patient’s medication from the cabinet one at a time. The interview indicated that RN #3 did not follow the proper process.”