Fmc Dialysis Services of Briggs Avenue

“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 observations and staff interview, the facility staff failed to clean and disinfect non-disposable equipment between patient use for 2 of 2 observations. The findings include: Review on January 24, 2025 of the facility’s policy, “Cleaning and Disinfection the Dialysis Station” published September 5, 2023 revealed, “Purpose...Responsibility...Background...Definition [space] Dialysis Station [ space] Area including the dialysis machine, chair/bed and other reusable equipment or supplies...General Cleaning [space] ...After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station. ...” 1. Observation conducted January 21, 2025 at 3:45 PM revealed, CCHT #1 disinfected dialysis station #14 but failed to disinfect the prime waste container and the laminate located on the HDM IV pole between patient use. Interview on January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, the manager had plans to change the culture at the facility. 2. Observation conducted January 24, 2025 at 9:50 AM revealed, CCHT #2 disinfected dialysis station #9 but failed to disinfect the prime waste container and the laminate located on the HDM IV pole between patient use. Interview on January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, the manager had plans to change the culture at the facility.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 32003 Based on medical record reviews and staff interview, the facility staff failed to obtain patients’ signatures from the plan of care meetings for 5 of 5 patients (Patients #4, #5, #8, #9, and #10). The findings include: Review on January 24, 2025 of the facility’s policy, “Comprehensive Interdisciplinary Assessment and Plan of Care” published July 3, 2023 revealed, “Plan of Care Requirements....Transplant Referral Tracking...Patient Participation in Plan of Care...Notify the patient in writing of the time and date of the Plan of Care review....Comprehensive Assessment Participation...The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record....” 1. Open medical record review conducted January 24, 2025 revealed, Patient #4 was admitted to the in-center facility in 2022 and the last plan of care meeting occurred in 2024. Review revealed the facility staff failed to obtain a patient’s signature from the plan of care meeting. Interview conducted January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, patients’ signatures from the plan of care meetings had not been obtained from patients in the last two years, which was during the timeframe that the manager was hired at the facility. 2. Open medical record review conducted January 24, 2025 revealed, Patient #5 was admitted to the in-center facility in 2021 and the last plan of care meeting occurred in 2024. Review revealed the facility staff failed to obtain a patient’s signature from the plan of care meeting. Interview conducted January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, patients’ signatures from the plan of care meetings had not been obtained from patients in the last two years, which was during the timeframe that the manager was hired at the facility. 3. Open medical record conducted January 24, 2025 revealed, Patient #8 was admitted to the in-center facility in 2019 and the last plan of care meeting occurred in 2024. Review revealed the facility staff failed to obtain the patient’s signature from the plan of care meeting. Interview conducted January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, patients’ signatures from the plan of care meetings had not been obtained from patients in the last two years, which was during the timeframe that the manager was hired at the facility. 4. Open medical record conducted January 24, 2025 revealed, Patient #9 was admitted to the in-center facility in 2019 and the last plan of care meeting occurred in 2024. Review revealed the facility staff failed to obtain the patient’s signature from the plan of care meeting. Interview conducted January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, patients’ signatures from the plan of care meetings had not been obtained from patients in the last two years, which was during the timeframe that the manager was hired at the facility. 5. Open medical record conducted January 24, 2025 revealed, Patient #10 was admitted to the in-center facility in 2020 and the last plan of care meeting occurred in 2024. Review revealed the facility staff failed to obtain the patient’s signature from the plan of care meeting. Interview conducted January 24, 2025 at about 12:00 PM with the Clinical Manager revealed, patients’ signatures from the plan of care meetings had not been obtained from patients in the last two years, which was during the timeframe that the manager was hired at the facility.”

“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: 32003 Based on chairside treatment observations, medical record reviews and staff interview, the facility staff failed to follow the adequacy plan of care by not dialyzing patients at the prescribed blood flow rate for 2 of 3 patients (Patients #2 and #3). The findings include: Review on January 24, 2025 of the facility’s policy, “Patient Assessment and Monitoring” published May 1, 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...Post-Treatment...” Review on January 24, 2025 of the facility’s policy, “Nursing Supervision and Delegation” published November 6, 2023 revealed, “Purpose...Responsibility...Definitions...Background...Determination of Task Appropriateness for Delegation...Non-Delegated Tasks...Policy...the registered nurse must evaluate each patient preferably within an hour or according to statement requirements...Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed....” 1. Observation at the chairside conducted January 21, 2025 at 12:00 PM revealed the blood flow rate for Patient #2 was set at 450 milliliters per hour. Open medical record review conducted January 24, 2025 revealed Patient #2 was admitted to the in-center facility in 2020. The last plan of care meeting occurred in 2024 and the blood flow rate was ordered at 450 milliliters per hour for 225 minutes each treatment for three days per week. Treatment sheet review from December 24, 2024 through January 4, 2025 (six consecutive treatments) revealed, the patient was not dialyzed at the prescribed blood flow rate for treatment duration for each treatment day. Interview conducted January 24, 2025 at about 12:00 noon with the Clinical Manager revealed, Patient #2 was not dialyzed at the prescribed blood flow rate. 2. Observation at the chairside conducted January 21, 2025 at 12:27 PM revealed the blood rate for Patient #3 was set at 500 milliliters per hour. Open medical record review conducted January 24, 2025 revealed Patient #3 was admitted to the in-center facility in 2017. The last plan of care meeting occurred in 2024 and the blood flow rate was ordered at 500 milliliters per hour for 225 minutes each treatment for three days per week. Treatment sheet review from December 23, 2024 through January 4, 2025 (six consecutive treatments) revealed, the patient was not dialyzed at the prescribed blood flow rate for treatment duration for each treatment day.”