Fmc Roseboro Dialysis

“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: 51294 Based on policy review, observation and staff interviews, the facility staff failed to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one object to another to another) by failing to remove and wet wipe the internal and external surfaces of the prime waste container on the hemodialysis machine prior to bringing new supplies for the next patient for 2 of 2 observations of cleaning and disinfection of dialysis stations (Station #11, HDM (Hemodialysis Machine) #5 and Station #8 and HDM #7). Findings included: Review on 09/26/2025 of the facility policy, “Use of Priming Buckets”, revised May 6, 2024 revealed “...Step 4- At the completion of the patient treatment, remove the priming bucket or approved removable container, and dispose of the Normal Saline in the utility room hopper or dirty sink. Step 5- After routine surface disinfection with 1:100 bleach solution, replace on machine.” Review on 09/22/2025 of the facility policy, “Cleaning and Disinfection of the Dialysis Station”, revised September 2, 2025 revealed “...The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, an aesthetically pleasant environment for patients, staff and visitors...Definition - Dialysis Station - area, including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment ...General cleaning - the dialysis station could become contaminated with blood and or other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station ...Cleaning of the dialysis machine - externally disinfect the dialysis machine with 1:100 bleach solution after each dialysis treatment...Work surface cleaning and disinfection with and without visible blood using bleach solutions - all work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures.” 1. Observation on 09/22/2025 at 1112 revealed PCT (Patient Care Technician) #1 approached Station #11 and proceeded to clean and disinfect dialysis machine #5. PCT #1 was observed wiping down the dialysis machine with a paper cloth soaked in 1:100 bleach. Observation revealed PCT #1 failed to remove the prime waste container, empty the prime waste container and wet wipe the internal and external surfaces of the container. PCT #1 failed to disinfect the internal and external surfaces of the prime waste container per facility policy. Observation at 1118 revealed PCT #1 approached Station #11 with clean supplies to set up the hemodialysis machine for the next patient. The prime waste receptacle was cleaned prior to the next patient arriving at the dialysis. Interview on 09/22/2025 at 1118 with PCT #1 revealed PCT #1 did not remove and empty the prime waste container. PCT #1 stated they failed to clean and disinfect the prime waste container prior to initiating set up of the hemodialysis machine for another patient. Interview revealed the prime waste container should have been removed, emptied, disinfected and allowed to dry prior to placing back on the cleaned and disinfected hemodialysis machine. Interview on 09/23/2025 with the Manager of Clinical Services revealed if the prime waste container was not cleaned and disinfected during the cleaning and disinfection of the station, the cleaning and disinfection was not done according to policy. Interview revealed the entire hemodialysis delivery system should be cleaned and disinfected after each patient treatment, including the prime waste container. 2. Observation on 09/22/2025 at 1225 revealed PCT #2 approached Station #8 and proceeded to clean and disinfect dialysis machine #7. PCT #2 was observed wiping down the dialysis machine with a paper cloth soaked in 1:100 bleach. Observation revealed PCT #2 failed to remove the prime waste container, empty the prime waste container and wet wipe the internal and external surfaces of the container. PCT #2 failed to disinfect the internal and external surfaces of the prime waste container per facility policy. Observation at 1230 revealed PCT #2 approached Station #8 with clean supplies to set up hemodialysis machine for the next patient. The prime waste receptacle was cleaned prior to the next patient arriving at the dialysis. Interview on 09/22/2025 at 1230 with PCT #2 revealed PCT #2 did not remove and empty the prime waste container. PCT #2 stated they failed to clean and disinfect the prime waste container prior to initiating set up of the hemodialysis machine for another patient. Interview revealed the prime waste container should have been removed, emptied, disinfected and allowed to dry prior to placing back on the cleaned and disinfected hemodialysis machine. Interview on 09/23/2025 with the Manager of Clinical Services revealed if the prime waste container was not cleaned and disinfected during the cleaning and disinfection of the station, the cleaning and disinfection was not done according to policy. Interview revealed the entire hemodialysis delivery system should be cleaned and disinfected after each patient treatment, including the prime waste container to prevent cross contamination.”

“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: 51294 Based on policy review, observation and interviews, the patient care staff failed to disinfect the CVC (Central Venous Catheter) exit site with 2 % Chlorhexidine Gluconate/70 % Isopropyl alcohol (chemical combination used to clean and disinfect the dialysis catheter exit site) for 30 seconds per facility policy for 1 of 2 observed CVC exit sites disinfected with Chlorhexidine (PCT (Patient Care Technician) #2, Station #13). Findings include: Review on 09/23/2025 of the facility policy/procedure titled “Changing the Catheter Dressing Procedure” effective May 2, 2025 revealed “...2% Chlorhexidine Gluconate/70% Isopropyl Alcohol: Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds.” Observation on 09/22/2025 at 1217 in the patient treatment area revealed PCT #2 entered Station #13 and initiated CVC exit site care for dialysis treatment with a CVC. PCT #2 cleansed the CVC exit site and area around site with 2% Chlorhexidine for 13 seconds and allowed to dry for thirty (30) seconds. Observation revealed that the PCT failed to disinfect the CVC exit site for thirty (30) seconds per facility policy. Interview on 09/22/2025 at 1230 with PCT #2 revealed that the CVC exit site should be disinfected for 30 seconds. The interview confirmed that PCT #2 did not follow the facility policy. Interview on 09/23/2025 at 1449 with the Manager of Clinical Services revealed the staff were expected to disinfect the CVC catheter exit site with Chlorhexidine swabs for 30 seconds prior to applying a new dressing per facility policy. Interview revealed the staff failed to follow the facility policy.”

“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: 51294 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to monitor a patient at a minimum of every 30-45 minutes during hemodialysis treatments for 2 of 6 sampled in-center hemodialysis records reviewed (Patient #4 and #5). Findings included: Review on 09/22/2025 of the facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, revealed, “... During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” 1. Open medical record review on 09/23/2025 for Patient #4 revealed a 76-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 04/30/2024. Review of the treatment sheet dated 09/10/2025 revealed the treatment started at 1237 and ended at 1626 for a duration of 225 minutes. Review of the monitoring documentation dated 09/10/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1321 and monitored next by staff at 1413 (52 minutes later). Review of the treatment sheet dated 09/15/2025 revealed the treatment started at 1224 and ended at 1613 for a duration of 229 minutes. Review of the monitoring documentation dated 09/15/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1327 and monitored next by staff at 1418 (51 minutes later) and 1504 (46 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 09/10/2025 and 9/15/2025. Interview on 09/23/2025 at 1449 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 09/10/2025 and 09/15/2025 for Patient #4. 2. Open medical record review on 09/23/2025 for Patient #5 revealed a 60-year-old female admitted to the facility for ICHD treatments on 09/08/2022. Review of the treatment sheet dated 09/10/2025 revealed the treatment started at 1203 and ended at 1532 for a duration of 209 minutes. Review of the monitoring documentation dated 09/10/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1431 and monitored next by staff at 1531 (60 minutes later). Review of the treatment sheet dated 09/15/2025 revealed the treatment started at 1219 and ended at 1550 for a duration of 221 minutes. Review of the monitoring documentation dated 09/15/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1257 and monitored next by staff at 1359 (62 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatment on 09/10/2025 and 09/15/2025. Interview on 09/23/2025 at 1449 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 09/10/2025 and 09/15/2025 for Patient #5.”

“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: 51294 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis (The process of applying antiseptic agents to the skin to inhibit the growth of microorganisms) per policy before cannulation of 1 of 2 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #1; PCT (Patient Care Technician) #2). Findings included: Review on 09/22/2025 of the facility policy titled “Access Assessment and Cannulation” revised May 5, 2025 revealed “Skin disinfection, Step 1- Disinfect cannulation site as follows using any of the disinfectants below: 70 % 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 cannulating.” Observation on 09/22/2025 at 1049 in the patient treatment area revealed PCT #2 entered Station #1 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and donned clean gloves. PCT #2 cleansed the arterial and venous access sites with 70 % isopropyl alcohol pad for 5 seconds at the first site and 6 seconds on the second site. Observation revealed PCT #2 failed to disinfect each access site with 70 % isopropyl alcohol for 30 seconds per the facility policy. Interview on 09/22/2025 at 1230 with PCT #2 revealed “I thought it (the policy) was 15 seconds.” PCT #2 stated that they thought the policy was to disinfect the access site for 15 seconds which they stated they disinfected the site for 15 seconds. Interview revealed that PCT #2 failed to disinfect the access sites per facility policy. Interview on 09/23/2025 at 1449 with the Manager of Clinical Services revealed the staff were expected to disinfect each access site for 30 seconds when using 70 % isopropyl alcohol pads and allow each site to dry prior to cannulating. Interview revealed the staff failed to follow the facility policy.”