Fmc Bma of Southwest Greensboro

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 32003 Based on policy review, observation, and staff interview, the facility staff failed to prevent the potential spread of infectious disease by not removing their gowns when going from the treatment area to the warehouse for 1 of 1 observation. Findings included: Review on March 1, 2024 of the facility’s policy, “Personal Protective Equipment” published November 6, 2023 revealed, “Purpose...Policy...All person protective equipment shall be removed prior to leaving the treatment area. ...” Observation on February 28, 2024 in the warehouse revealed, CCHT #2 and PCT #3 entered the warehouse from the treatment area without removing their gowns thereby, not preventing the potential spread of infectious disease. Interview on February 29, 2024 at 10:40 AM with the Clinical Manager revealed, staff should not wear their gowns from the treatment area into the warehouse.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 32003 Based on policy review, personnel worksheet review, and staff interview, the facility staff failed to prevent the potential spread of infectious diseases by not having a Hepatitis B vaccination validation process for 6 of 6 employees employed at the facility as transfers from other facilities within the organization. Findings included. Review on March 1, 2024 of the facility’s policy, “Employee Requirements for Testing and Vaccination for Hepatitis B” published April 5, 2021 revealed, “Purpose...Documentation...Hepatitis B vaccinations status shall be documented in the employees’ vaccination record...” Review on March 1, 2024 of the personnel worksheet revealed, six employees (CCHT #4, Nurse #5, CCHT #6, CCHT #7, CCHT #8, and Biomed Technician #9) had no documentation related to their Hepatitis B vaccination status. Review on March 1, 2024 of personnel files revealed: 1.) on February 19, 2023, CCHT #4 was employed at the facility as a transfer from another facility within the [organization], 2.) on October 30, 2022, Nurse #5 was employed at the facility as a transfer from another facility within the [organization], 3.) on August 6, 2023, CCHT #6 was employed at the facility as a transfer from another facility within the [organization], 4.) on October 1, 2023, CCHT #7 was employed at the facility as a transfer from another facility within the [organization], 5.) on May 28, 2023, CCHT #8 was employed at the facility as a transfer as a transfer from another facility within the [organization], and 6.) on October 16, 2022, Biomed Technician #9 was employed at the facility as a transfer from another facility within the [organization]. Review revealed no documentation related to the Hepatitis B vaccination status for the six transfer-in employees. Interview on March 1, 2024 at 3:30 PM with the Clinical Manager revealed, an inability of obtaining the Hepatitis B vaccination status for the six employees that were employed at the facility as a transfer from other facilities within the [organization].”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 32003 Based on policy review, consent for treatment review, observations, and staff interviews, the facility staff failed to promote patient safety by not ensuring access sites were visible during dialysis treatment and failed to update patient educational information related to visibility of access site during dialysis treatment for 3 of 3 patients with access sites covered (Patient #5, #15, and #19) for 2 of 3 survey days. Findings included: Review on March 1, 2024 of the facility’s policy, “Patient Rights and Responsibilities List “ published June 28, 2018 revealed, “[organization] PATIENT RESPONSIBILITIES...You have the responsibility to:...Chose Healthy Behaviors...For your safety, make sure your face and dialysis access are uncovered and visible for staff at all times during your treatment. ...” Review on March 1, 2024 of the facility’s, “Confirmation of Consent for in-center Hemodialysis Treatment” published November 1, 2021 revealed, “1. ...10...1. ...2. I should keep my catheter, access needle sites, and bloodline connections uncovered and in plain view during dialysis...” 1. Observation on February 28, 2024 at 10:00 AM - 10:30 AM (30-minutes) revealed, Patient #5 was located at Station #25 and asleep as dialysis treatment was underway. Observation revealed, the access site was not visible for 30-minutes consecutively. Open medical record review on March 1, 2024 revealed on February 23, 2018, Patient #5 signed the acknowledgement of receipt form for [organization] patient rights and responsibilities before the reference policy was published. Review revealed, the facility staff failed to obtain the patient signature for the updated educational information related to visibility of access sites during dialysis treatment. Interview on February 29, 2024 at 10:09 AM with CCHT #1 revealed, patients were going to do what they wanted to regardless of how many times patients were reminded to keep their access uncovered. Interview on February 29, 2024 at 2:25 PM with the Clinical Manager revealed, it was a constant battle with patients to keep their access sited uncovered. Interview revealed, patients were educated and signed a form acknowledging to keep their access sites visible during dialysis treatment. 2. Observation on February 29, 2024 from 9:30 AM to 10:00 AM (30-minutes) revealed, Patient #19 was located at Station #3 and asleep as dialysis treatment was underway. Observation revealed, the access site was not visible for 30-minutes consecutively. Open medical record review on March 1, 2024 revealed on February 1, 2018, Patient #19 signed the acknowledgement of receipt form for [organization] patient rights and responsibilities before the referenced policy was published. Review revealed, the facility staff failed to obtain the patient signature for the updated educational information related to visibility of access sites during dialysis treatment. 3. Observation on February 29, 2024 from 10:15 AM to 10:45 AM (30-minutes) revealed, Patient #15 was located at Station #16 and asleep as dialysis treatment was underway. Observation revealed, the access site was not visible for 30-minutes consecutively. Open medical record review on March 1, 2024 revealed on September 19, 2023, Patient #15 signed the consent for in-center hemodialysis treatment which outlined the patient understood the keep access site and bloodlines uncovered and in plain view during dialysis treatment. Interview on February 29, 2024 at 10:09 AM with CCHT #1 revealed, patients were going to do what they wanted to regardless of how many times patients were reminded to keep their access uncovered. Interview on February 29, 2024 at with the Clinical Manager revealed, it was a constant battle with patients to keep their access sited uncovered. Interview revealed, patients were educated and signed a form acknowledging to keep their access sites visible during NC00204603”