Fmc Carolina Dialysis Siler City

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 38766 Based on policy and procedure review, observation, and interviews, the facility staff failed to ensure a visitor wore a gown while in the treatment area and during patient care for 1 of 1 observation. Findings included: A review on 03/25/2025 of the facility’s policy, “Visitor Policy,” published 02/06/2025, revealed that “... Visitors in the Patient Care Area... Visitors Assisting with Care... PPE will be provided along with instructions for proper use if there is a likelihood that the visitor may be exposed to bloodborne pathogens during the time that he/she is in the treatment area...” Observation on 03/25/2025 from 1145 and 1245 revealed a patient was located at Station #8/HDM #25. The observation revealed, a female visitor was sitting in a chair next to the patient. Observation revealed the female visitor was interacting with the patient during patient care and was not wearing a gown. Observation revealed the visitor was at increased risk for exposure to bloodborne pathogens during patient care. An interview on 03/25/2025 at 1200 with the patient’s daughter, who also served as a sitter. During the conversation, she mentioned, “My brother, mother, and I have been accompanying the patient for a year and a half for treatment.” She also noted, “I have never received a gown, nor have I been asked to wear one while on the treatment floor.” An interview conducted on 03/25/2025 at 1225 with RN #1 revealed that the nurse was uncertain whether visitors were required to wear gowns on the treatment floor. An interview on 03/25/2025 at 1325 with the Clinical Operations Manager revealed that she was unaware why the staff had not offered the visitor (sitter) a gown while on the treatment floor. The interview confirmed the findings.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38766 Based on a review of policies and procedures, medical records, and staff interviews, the facility’s interdisciplinary team (IDT) members failed to identify a patient as unstable and perform a monthly reassessment and a plan-of-care for one (1) of one (1) sampled patient with an extended hospitalization (Patient #4). Findings included A review on 01/16/2025 of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” revised 07/03/2023 revealed “...CIA/POC for Unstable Patients: Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered ‘unstable’ must be documented until the issues have been resolved or the IDT (including the patient, if possible) determines that the condition is chronic. The following are unstable criteria: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days. ... or Marked deterioration in health status ... or Significant change in psychosocial needs ...” A medical record review on 03/27/2025 of Patient #4 revealed the patient was admitted to the facility on 06/21/2024 for in-center hemodialysis treatment. A review of the record revealed the patient was admitted to the hospital on 12/30/2024 through 01/28/2025 (29 days hospital stay) with a Primary Discharge Diagnosis of “severe protein-calorie malnutrition. The patient was brought to the hospital emergency department after being found unresponsive at home with a blood glucose of 27. The review revealed the patient’s discharge disposition was to a Skilled Nursing Facility (SNF). The review revealed the patient’s last Plan of Care (POC) was on 09/23/2024, the patient’s status was stable and the next POC meeting was on 09/23/2025. The review revealed no documentation that a monthly reassessment or revisions of the plan of care were done to consider the patient as unstable by the IDT after a hospitalization a 29-day stay, and a transfer to an SNF. An interview on 03/27/2025 at 1020 with the Medical Director revealed that Patient #4 had a prolonged hospitalization for altered mental status and deconditioning during the hospitalization. The interview revealed that based on the length of the hospitalization and the family being unable to care for the patient at home, he was sent to an SNF. The interview revealed the patient should have been reassessed and be made unstable.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 38766 Based on facility policy and procedure review, medical record reviews, and staff interviews, the facility staff failed to complete a post-treatment assessment for 5 of 9 patients’ treatment records review (Pt. #2, #3, #1, #4, and #9). Findings included: A review on 03/26/2025 of the facility policy titled “Patient Assessment and Monitoring,” revised 05/01/2023, revealed, “Data Collection: Direct patient care staff may collect data such as weight, BP, pulse, respiration, temperature, general observations... The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed. Pre-Treatment ...During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters ...Assess the patient for symptoms... Lungs sound... Edema... Heart sounds... Post-Treatment 1. ... The registered nurse will assess/re-assess post-treatment as indicated. 2. Document findings in the patient’s record...” 1. A review on 03/26/2025 of the medical record for Patient #2 revealed a 72-year-old male admitted for In-Center Hemodialysis treatments on 01/25/2024. A review of a Treatment Flowsheet dated 03/11/2025 revealed Patient #2’s treatment started at 0919 and ended at 1250. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/1/2025 revealed Patient #2’s treatment started at 0939 and ended at 1309. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/15/2025 revealed Patient #2’s treatment started at 0949 and ended at 1319. The Flowsheet revealed no documentation of a post-treatment nursing assessment. An interview conducted on 03/27/2025 at 1020 with the Medical Director revealed that staff were expected to perform an RN assessment before and after each treatment. The interview confirmed the findings. 2. A review on 03/27/2025 of the medical record for Patient #3 revealed a 71-year-old female admitted for In-Center Hemodialysis treatments on 12/16/2024. A review of a Treatment Flowsheet dated 03/10/2025 revealed Patient #3’s treatment started at 1150 and ended at 1544. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/19/2025 revealed Patient #3’s treatment started at 1148 and ended at 1524. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/21/2025 revealed Patient #3’s treatment started at 1158 and ended at 1515. The Flowsheet revealed no documentation of a post-treatment nursing assessment. An interview conducted on 03/27/2025 at 1020 with the Medical Director revealed that staff were expected to perform an RN assessment before and after each treatment. The interview confirmed the findings. 3. A review on 03/27/2025 of the medical record for Patient #1 revealed a 38-year-old female admitted for In-Center Hemodialysis treatments on 02/11/2025. A review of a Treatment Flowsheet dated 03/11/2025 revealed Patient #1’s treatment started at 1044 and ended at 1445. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/13/2025 revealed Patient #1’s treatment started at 1030 and ended at 1443. The Flowsheet revealed no documentation of a post-treatment nursing assessment. An interview conducted on 03/27/2025 at 1020 with the Medical Director revealed that staff were expected to perform an RN assessment before and after each treatment. The interview confirmed the findings. 4. A review on 03/27/2025 of the medical record for Patient #4 revealed a 56-year-old male admitted for In-Center Hemodialysis treatments on 06/21/2024. A review of a Treatment Flowsheet dated 03/14/2025 revealed Patient #4’s treatment started at 1116 and ended at 1524. The Flowsheet revealed no documentation of a post-treatment nursing assessment. A review of a Treatment Flowsheet dated 03/19/2025 revealed Patient #4’s treatment started at 1121 and ended at 1529. The Flowsheet revealed no documentation of a post-treatment nursing assessment An interview conducted on 03/27/2025 at 1020 with the Medical Director revealed that staff were expected to perform an RN assessment before and after each treatment. The interview confirmed the findings. 5. A review on 03/26/2025 of the medical record for Patient #9 revealed a 58-year-old male admitted for In-Center Hemodialysis treatments on 04/18/2023. A review of a Treatment Flowsheet dated 03/11/2025 revealed Patient #9’s treatment started at 0920 and ended at 1357. The Flowsheet revealed no documentation of a post-treatment nursing assessment. An interview conducted on 03/27/2025 at 1020 with the Medical Director revealed that staff were expected to perform an RN assessment before and after each treatment. The interview confirmed the findings.”

“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: 38766 Based on policy review, medical record review, and staff interviews, the facility staff failed to follow the adequacy plan of care by failing to dialyze 4 of 9 (Patient #5, #1, #2, and #9) in-center hemodialysis patients at the prescribed BFR/DFR. Findings included: A review on 03/26/2025 of the facility’s policy, “Patient Assessment and Monitoring,” published 05/012023 revealed, “...During Treatment ...3. Machine Parameters and Extracorporeal Circuit Check prescribed blood flow is being achieved, or reason is documented in the medical record if unable to meet prescribed blood flow rate. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...” 1. An open medical record review on 03/27/2025 for Patient #5 revealed a 68-year-old female admitted to the facility for ICHD treatments on 05/10/2024. A review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. A review of the treatment flowsheet on 03/13/2025 revealed the treatment started at 0543 and ended at 0943 (240 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 340/620, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/15/2025 revealed the treatment started at 0542 and ended at 0950 (248 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 240/800, with no documentation for the decrease in the BFR. A review of the treatment flowsheet on 03/18/2025 revealed the treatment started at 0527 and ended at 0930 (243 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 390/770, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/20/2025 revealed the treatment started at 0539 and ended at 0955 (256 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 340/800, with no documentation for the decrease in the BFR. A review of the treatment flowsheet on 03/22/2025 revealed the treatment started at 0541 and ended at 0940 (239 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 350/790, with no documentation for the decrease in the BFR/DFR. An interview on 03/27/2025 at 1300 with the CM revealed that the facility’s PCTs should notify the nursing staff any time they decrease the patient’s BFR/DFR, or the patients are unable to achieve their ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decrease or the patient’s inability to obtain the prescribed BFR/DFR. The interview confirmed the medical record findings that patient #5 was not treated at the prescribed BFR/DFR. 2. An open medical record review on 03/27/2025 for Patient #1 revealed a 38-year-old female admitted to the facility for ICHD treatments on 02/11/2025. A review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. A review of the treatment flowsheet on 03/13/2025 revealed the treatment started at 1030 and ended at 1443 (233 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 370/580, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/15/2025 revealed the treatment started at 1031 and ended at 1446 (255 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 370/620, with no documentation for the decrease in the BFR. A review of the treatment flowsheet on 03/18/2025 revealed the treatment started at 1029 and ended at 1435 (246 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 360/800, with no documentation for the decrease in the BFR. A review of the treatment flowsheet on 03/20/2025 revealed the treatment started at 1023 and ended at 1427 (244 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 360/580, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/22/2025 revealed the treatment started at 1043 and ended at 1430 (227 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 380/800, with no documentation for the decrease in the BFR. An interview on 03/27/2025 at 1300 with the CM revealed that the facility’s PCTs should notify the nursing staff any time they decrease the patient’s BFR/DFR, or the patients are unable to achieve their ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decrease or the patient’s inability to obtain the prescribed BFR/DFR. The interview confirmed the medical record findings that patient #1 was not treated at the prescribed BFR/DFR. 3. An open medical record review on 03/27/2025 for Patient #2 revealed a 72-year-old male admitted to the facility for ICHD treatments on 01/25/2024. A review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 700. A review of the treatment flowsheet on 03/11/2025 revealed the treatment started at 0919 and ended at 1250 (211 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 300/580, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/13/2025 revealed the treatment started at 0939 and ended at 1309 (210 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 350/600, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/15/2025 revealed the treatment started at 0949 and ended at 1319 (210 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 310/500, with no documentation for the decrease in the BFR/DFR. An interview on 03/27/2025 at 1300 with the CM revealed that the facility’s PCTs should notify the nursing staff any time they decrease the patient’s BFR/DFR, or the patients are unable to achieve their ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decrease or the patient’s inability to obtain the prescribed BFR/DFR. The interview confirmed the medical record findings that patient #2 was not treated at the prescribed BFR/DFR. 4. An open medical record review on 03/26/2025 for Patient #9 revealed a 58-year-old male was admitted to the facility for ICHD treatments on 04/18/2023. A review of the Physician orders revealed Patient #9’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 800. A review of the treatment flowsheet on 03/11/2025 revealed the treatment started at 0920 and ended at 1357 (277 minutes). A review of the Flowsheet revealed Patient #9’s BFR/DFR averages were 440/650, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 03/18/2025 revealed the treatment started at 0930 and ended at 1419 (289 minutes). A review of the Flowsheet revealed Patient #9’s BFR/DFR averages were 360/730, with no documentation for the decrease in the BFR/DFR. An interview on 03/27/2025 at 1300 with the CM revealed that the facility’s PCTs should notify the nursing staff any time they decrease the patient’s BFR/DFR, or the patients are unable to achieve their ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decrease or the patient’s inability to obtain the prescribed BFR/DFR. The interview confirmed the medical record findings that patient #9 was not treated at the prescribed BFR/DFR.”

“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 3 patients Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #7, PCT #1). Findings included: A review on 03/26/2025 of the facility policy titled “Access Assessment and Cannulation” published 05/06/2024 revealed, “Skin Disinfection Step 1 Action Disinfect cannulation site as follows using any of the disinfectants below: *70% (percent) isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulation...” Observation on 03/26/2025 at 0945 in the patient treatment area revealed PCT #2 entered Station #16 and initiated access of an Arterial-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #1 performed hand hygiene and applied clean gloves. PCT #2 cleansed the cannulation sites with a 70% isopropyl alcohol pad for about 5 seconds (three concentric circles) per site. The observation revealed PCT #2 failed to disinfect the access site for 30 seconds per the facility policy. An interview on 03/26/2025 with PCT #2 revealed that the access site should be cleaned for 30 seconds for each site. The PCT added, “I don’t think I cleaned the sites for 30 seconds each today. I may have done them too fast.” The interview revealed that the staff had failed to follow the facility policy. An interview with the CM on 03/27/2025 at 1300 revealed that the staff were expected to adhere to the skin disinfection policy by cleaning each site for 30 seconds. The Interview revealed that the staff failed to follow the policy.”