Fmc Dare County Dialysis

“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: 38766 Based on facility policy and procedure review, observation, and staff interviews, the facility staff failed to use an aseptic technique when accessing a multidose medication vial for 1 of 2 staff observed preparing heparin syringes (PCT #2). Findings included: The facility’s policy “Medication Preparation and Administration,” revised 02/06/2023, was reviewed on 04/02/2025 and 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.” An observation on 04/02/2025 at 1100 on the treatment floor revealed PCT #2 walked to the medication cabinet located at the nurses’ station to prepare a heparin syringe for a patient cannulation. The observation revealed PCT #2 accessed the multidose vial with a syringe/needle without cleansing the rubber diaphragm of the vial. The observation revealed PCT #2 failed to disinfect the rubber diaphragm of the vial per facility policy. An interview on 04/02/2025 at 1105 with PCT #2 revealed, “I did not know that the rubber diaphragm should be cleaned each time it was accessed. I thought it was only when the bottle was first opened.” An interview on 04/02/2025 at 1115 with RN #1 revealed that the process for using a multidose vial was to clean the top of the vial before each use, allow it to dry, and then draw up the medication. An interview on 04/02/2025 at 1415 with the Clinical Manager revealed that the multidose vials should be wiped after the cap was popped and each time the vial was accessed. The interview confirmed that PCT #2 did not follow the facility’s policy regarding this procedure.”

“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 policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis per policy before cannulation of 1 of 2 patients Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #7, PCT #2). Findings included: A review on 04/02/2025 of the facility policy titled “Access Assessment and Cannulation” published 05/06/2024 revealed, “Skin Disinfection Step 2 Perform skin antisepsis on one site at a time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection. Note: This method minimizes the risk of contaminating the second site while cannulating the first site...” An observation on 04/02/2025 at 1102 in the patient treatment area revealed PCT #2 entered Station #7 and initiated access to an Arterial-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and applied clean gloves. PCT #2 cleansed both cannulation sites with one 70% isopropyl alcohol pad. The observation revealed PCT #2 failed to apply skin antisepsis on one site at a time per the facility policy. An interview on 04/02/2025 with PCT #2 confirmed that the access sites were cleaned with one alcohol pad. The PCT added, “I think I could use two alcohol pads and clean the sites one at a time. I did not think of it.” The interview revealed that the staff had failed to follow the facility policy. An interview with RN #1 on 04/02/2025 at 1115 revealed that the staff were expected to apply skin antiseptic to one site at a time and use a different pad for each access site. The Interview revealed that the staff failed to follow the policy.”