Fmc Eastern Wake

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 38766 Based on policy review, observation, and interviews, the patient care staff failed to disinfect the Central Venous Catheter (CVC) hubs per facility policy in 1 of 2 observed initiation of hemodialysis treatments with a CVC. (PCT #3, Station #6). Findings include: A review on 02/25/2025 of the facility policy titled “Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer” published 05/06/2024 revealed “...Preparing the Catheter: Disinfection of the Catheter Connections... 3. Using a sterile alcohol pad (or other antiseptic such as chlorhexidine, povidone if required by the hospital) scrub the side (threads) and end of the hub thoroughly with friction, making sure to remove any residue. 4. Using the same sterile alcohol pad (or other antiseptic such as chlorhexidine, povidone if required by the hospital) applying friction to remove any blood or residue, move from the hub at least several centimeters towards the body of the catheter...” Observation on 02/25/2025 at 1125 in the patient treatment area revealed PCT #3 entered Station #6 and initiated access to a Central Venous Catheter (CVC). Observation revealed PCT #2 performed hand hygiene and applied clean gloves. Observation revealed PCT #3 cleansed the arterial and venous catheter limbs. Observation revealed the PCT failed to disinfect the catheter hubs. Observation revealed PCT #3 failed to cleanse each catheter hub per facility policy. An interview with PCT #3 on 02/25/2025 at 1130 revealed that the technician believed she had disinfected the catheter hubs. The technician confirmed that she should have cleaned the catheter hubs more thoroughly. The interview also revealed that PCT #3 did not disinfect the catheter hubs per facility policy. An Interview with the clinical manager on 02/25/2025 at 1630 revealed that the staff were expected to thoroughly scrub each catheter hub with an alcohol pad per facility policy. The interview revealed that the staff failed to follow the facility policy.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 38766 Based on the manufacturer instructions for use, a review of the dialysis machine preventive maintenance log, and staff interviews, the facility staff failed to ensure the dialysis machines were maintained in safe working conditions by not performing preventive maintenance for 1 of 3 dialysis machines maintenance reviews (Machine #10). Findings included: A review on 02/26/2025 of the “[Named] Medical Care 2008T Hemodialysis System Preventive Maintenance Procedure” with part number 508033 revealed, “Introduction ...Scheduled maintenance is performed based on a timed interval or number of hours a machine is operated, whichever comes first. The time and hour intervals are as follows: ...2008T BlueStar Premium Machines ...Six (6) months. Annually or after 4000 hours of operations...” A review of the facility’s equipment records for hemodialysis machine #10 with serial number 7T0S-211632 for the past 12 months revealed that the machine had an annual Preventive Maintenance (PM) on 03/13/2024 (11 months later). The review revealed no documentation of a six-month PM. The review revealed that the facility failed to perform preventive maintenance for machine #10 per facility policy. An Interview with the Area Technical Operations Manager (ATOM) on 02/26/2025 at 1530 showed no documentation indicating that machine #10 was out of service, as evidenced by consistent disinfection. The interview indicated that someone may have inadvertently flagged the machine as out of service, resulting in the missed six-month maintenance check. The ATOM noted that the six-month preventive maintenance (PM) was completed on 11/01/2024; however, the documentation was not entered into the computer system. The interview confirmed that the machine was not maintained according to the manufacturer’s instructions.”

“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: 38766 Based on policy review, record review, and staff interviews, the facility staff failed to ensure that a patient without documented photosensitivity to light did not wear sunglasses during dialysis per policy for 1 of 1 patient observed wearing sunglasses (Patient #1, Station #13) and failed to promote patient safety by not ensuring patients’ access sites were visible during treatment for 1 of 12 in-center patients observed (Patients #12). Findings included: a. A review on 02/25/2025 of the facility’s policy, “Patient Assessment and Monitoring,” published 05/012023 revealed, “...During Treatment ...General Observation/Mental Status ...Patients may not wear sunglasses or sleeping masks without medical documentation confirming a photosensitivity condition. These products may obscure the observation of the patient’s eyes. ...” Observation on 02/25/2025 from 1015 to 1140 (85 minutes) revealed Patient #1 dialyzing in Station #13 wearing dark sunglasses. The observation revealed that the patient did not remove the sunglasses and that the staff did not ask for them to be removed during the 85 minutes of observation. The observation revealed that the facility staff failed to ensure the patient did not wear sunglasses during treatment. A medical record review on 02/25/2025 revealed that Patient #1 was admitted for ICHD on 02/04/2020. The record review did not document any photosensitivity to light or provide an order for the patient to wear sunglasses during treatment. An interview with the Clinical Manager on 02/25/2025 at 1650 confirmed that the patient had been wearing sunglasses during his treatment since being admitted to the clinic. The patient did not have an order for face coverings during treatment. The interview also revealed that the clinic managers acknowledged that the policy was not followed. b. A review on 02/02/2025 of the facility’s policy titled “Patient Assessment and Monitoring, “ published on 05/01/2023, revealed “...During Treatment ...Follow the steps for monitoring patient and machine parameters during treatment: ...Access: Observe connections are secure and visible... Ensure access remains uncovered throughout the treatment...” An observation on 02/25/2025 between 1015 and 1140 revealed a patient was in Station 5, HDM 2, and had the access site covered with a blanket. Observation revealed that at 1105, PCT #1 entered the station for safety checks and documentation and left the station without visualizing the access site and the connections. The observation revealed the access site remained covered for 85 minutes during treatment. An interview on 02/27/2025 at 1410 with PCT #2 revealed that the patient’s access site should remain visible for safety reasons. The interview revealed the staff, including the nurse, should pull down the patient’s blanket so access could always be visible.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on a review of policy and procedures, medical records review, and staff interviews, the facility staff failed to perform and/or document patient monitoring every 30-45-minute during dialysis treatments for 10 of 10 in-patient records reviewed (Patient #1, #7, #2, #3, #10, #5, #4, #6, #9, and #8). Findings included: A review on 02/25/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring” published 05/01/2023, revealed “...During Treatment Obtaining blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes per state regulations...” 1. An open medical record review on 02/25/2025 for Patient #1 revealed a 72-year-old male admitted to the facility for ICHD treatments on 02/04/2025. A review of the treatment sheet dated 02/11/2025 revealed the treatment started at 0802 and ended at 1203 (241 minutes). The treatment flowsheet revealed no documented vital signs from 0907 through 1014 (57 minutes) and again from 1014 through 1206 (112 minutes). A review of the treatment flowsheet on 02/13/2025 revealed the treatment started at 0755 and ended at 1255 (240 minutes). The treatment flowsheet revealed no documented vital signs from 1055 through 1209 (74 minutes). A review of the treatment flowsheet on 02/15/2025 revealed the treatment started at 0752 and ended at 1159 (247 minutes). The treatment flowsheet revealed no documented vital signs from 1002 through 1109 (67 minutes). A review of the treatment flowsheet on 02/18/2025 revealed the treatment started at 0747 and ended at 1153 (246 minutes). The treatment flowsheet revealed no documented vital signs from 0749 through 0842 (53 minutes) and again from 0943 through 1155 (132 minutes). A review of the treatment flowsheet on 02/20/2025 revealed the treatment started at 1107 and ended at 1427 (210 minutes). The treatment flowsheet revealed no documented vital signs from 1302 through 1429 (87 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the facility policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 2. An open medical record review on 02/26/2025 for Patient #7 revealed a 68-year-old male was admitted to the facility for ICHD treatments on 11/19/2024. A review of the treatment sheet dated 02/14/2025 revealed the treatment started at 0739 and ended at 1149 (250 minutes). The treatment flowsheet revealed no documented vital signs from 0740 through 0837 (57 minutes). A review of the treatment sheet dated 02/19/2025 revealed the treatment started at 0614 and ended at 0916 (182 minutes). The treatment flowsheet revealed no documented vital signs from 0731 through 0916 (107 minutes). A review of the treatment sheet dated 02/21/2025 revealed the treatment started at 0836 and ended at 1122 (166 minutes). The treatment flowsheet revealed no documented vital signs from 0907 through 1019 (72 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 3. An open medical record review on 02/25/2025 for Patient #2 revealed a 49-year-old male was admitted to the facility for ICHD treatments on 06/07/2022. A review of the treatment sheet dated 02/13/2025 revealed the treatment started at 0750 and ended at 1222 (272 minutes). The treatment flowsheet revealed no documented vital signs from 0757 through 0936 (99 minutes). A review of the treatment sheet dated 02/15/2025 revealed the treatment started at 0744 and ended at 1227 (283 minutes). The treatment flowsheet revealed no documented vital signs from 1000 through 1112 (72 minutes). A review of the treatment sheet dated 02/18/2025 revealed the treatment started at 0748 and ended at 1227 (279 minutes). The treatment flowsheet revealed no documented vital signs from 1112 through 1232 (80 minutes). A review of the treatment sheet dated 02/22/2025 revealed the treatment started at 0738 and ended at 1219 (281 minutes). The treatment flowsheet revealed no documented vital signs from 1012 through 1122 (70 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 4. An open medical record review on 02/27/2025 for Patient #3 revealed a 59-year-old male was admitted to the facility for ICHD treatments on 12/23/24. A review of the treatment sheet dated 02/18/2025 revealed the treatment started at 0723 and ended at 1100 (217 minutes). The treatment flowsheet revealed no documented vital signs from 0924 through 1000 (96 minutes). A review of the treatment sheet dated 02/22/2025 revealed the treatment started at 0727 and ended at 1120 (233 minutes). The treatment flowsheet revealed no documented vital signs from 1018 through 1123 (65 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 5. An open medical record review on 02/27/2025 for Patient #10 revealed a 26-year-old female was admitted to the facility for ICHD treatments on 10/11/2022. A review of the treatment sheet dated 02/14/2025 revealed the treatment started at 1303 and ended at 1620 (197 minutes). The treatment flowsheet revealed no documented vital signs from 1530 through 1624 (54 minutes). A review of the treatment sheet dated 02/17/2025 revealed the treatment started at 1256 and ended at 1702 (246 minutes). The treatment flowsheet revealed no documented vital signs from 1500 through 1632 (92 minutes). A review of the treatment sheet dated 02/20/2025 revealed the treatment started at 1401 and ended at 1700 (179 minutes). The treatment flowsheet revealed no documented vital signs from 1540 through 1640 (60 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 6. An open medical record review on 02/26/2025 for Patient #5 revealed an 81-year-old male admitted to the facility for ICHD treatments on 11/09/2017. A review of the treatment sheet dated 02/10/2025 revealed the treatment started at 0700 and ended at 1110 (250 minutes). The treatment flowsheet revealed no documented vital signs from 1015 through 1110 (55 minutes). A review of the treatment sheet dated 02/17/2025 revealed the treatment started at 0701 and ended at 1105 (244 minutes). The treatment flowsheet revealed no documented vital signs from 1000 through 1109 (69 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 7. An open medical record review on 02/25/2025 for Patient #4 revealed a 64-year-old male was admitted to the facility for ICHD treatments on 05/11/2023. A review of the treatment sheet dated 02/14/2025 revealed the treatment started at 1224 and ended at 1621 (237 minutes). The treatment flowsheet revealed no documented vital signs from 1340 through 1440 (60 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 8. An open medical record review on 02/26/2025 for Patient #6 revealed a 36-year-old female admitted to the facility for ICHD treatments on 10/24/2024. A review of the treatment sheet dated 01/28/2025 revealed the treatment started at 1312 and ended at 1717 (245 minutes). The treatment flowsheet revealed no documented vital signs from 1332 through 1439 (67 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 9. An open medical record review on 02/27/2025 for Patient #9 revealed an 83-year-old male admitted to the facility for ICHD treatments on 01/06/2024. A review of the treatment sheet dated 02/15/2025 revealed the treatment started at 1120 and ended at 1508 (228 minutes). The treatment flowsheet revealed no documented vital signs from 1408 through 1508 (60 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy. 10. An open medical record review on 02/27/2025 for Patient #8 revealed a 59-year-old female was admitted to the facility for ICHD treatments on 09/07/2023. A review of the treatment sheet dated 02/22/2025 revealed the treatment started at 1158 and ended at 1530 (212 minutes). The treatment flowsheet revealed no documented vital signs from 1437 through 1534 (57 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment per the policy. An interview on 02/27/2025 at 1400 with the CM revealed that the PCTs should take the patient’s vital signs and safety checks every 30 to 45 minutes. The interview also revealed that the PCTs were expected to notify the nurse of any abnormal blood pressure and heart rate readings. The interview confirmed that the staff did not follow the policy.”

“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 3 of 10 (Patient #1, #10, and #6) in-center hemodialysis patients at the prescribed BFR/DFR and/or treatment duration. Findings included: a. A review on 02/25/2025 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 02/25/2025 for Patient #1 revealed a 72-year-old male admitted to the facility for ICHD treatments on 02/04/2025. A review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 800. A review of the treatment flowsheet on 02/18/2025 revealed the treatment started at 0747 and ended at 1153 (246 minutes). A review of the Flowsheet revealed Patient #1’s DFR average was 500, with no documentation for the decrease in the dialysate flow rate. An interview on 02/27/2025 at 1400 with the Clinical Manager revealed the facility’s PCTs should notify the nursing staff any time they increase or decrease the patient’s BFR/DFR, or the patients were 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 DFR. 2. An open medical record review on 02/27/2025 for Patient #10 revealed a 26-year-old male was admitted to the facility for ICHD treatments on 10/11/2022. A review of the Physician orders revealed Patient #10’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 500. A review of the treatment flowsheet on 02/13/2025 revealed the treatment started at 1255 and ended at 1547 (178 minutes). A review of the Flowsheet revealed Patient #10’s BFR average was 340 and the DFR average was 0, with no documentation for the decrease in the blood flow rate and the dialysate flow rate. An interview on 02/27/2025 at 1400 with the Clinical Manager revealed the facility’s PCTs should notify the nursing staff any time they increase or decrease the patient’s BFR/DFR, or the patients were 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 #10 was not treated at the prescribed BFR/DFR. 3. An open medical record review on 02/26/2025 for Patient #6 revealed a 36-year-old male was admitted to the facility for ICHD treatments on 10/24/2024. A review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 600. A review of the treatment flowsheet on 02/22/2025 revealed the treatment started at 1312 and ended at 1717 (245 minutes). A review of the Flowsheet revealed Patient #6’s BFR average was 400 and the DFR average was 450, with no documentation for the decrease in the dialysate flow rate. An interview on 02/27/2025 at 1400 with the Clinical Manager revealed the facility’s PCTs should notify the nursing staff any time they increase or decrease the patient’s BFR/DFR, or the patients were 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 #10 was not treated at the prescribed BFR/DFR.”