Fmc Brunswick County

“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: 35306 Based on policy review, observation, and staff interview, the facility staff failed to wear PPE in order to cover the arms and prevent potential blood exposure while performing exit site care and initiating dialysis via a central venous catheter in 1 of 2 observations (Station #6, RN #1, Patient #1). Findings include: Review on 07/15/2025 of the facility policy “Personal Protective Equipment” (Published Date: 11/06/2023), revealed “Personal protective equipment including ... fluid-resistant gowns ... must be worn to protect employees from blood or other potentially infectious materials (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis ...).” Observation on 07/14/2025 at 1209 at dialysis station #6 of the patient treatment area revealed RN #1 performing exit site care initiating hemodialysis treatment to Patient #1 via the patient’s CVC access and initiating treatment at 1217. The observation revealed that while RN #1 performed exit site care and subsequently initiated treatment, the staff member’s cover gown sleeves were pulled above her gloved hands, exposing the wrists. The observation revealed the staff member failed to ensure the forearms were covered during time of exposure risk. Interview on 07/14/2025 at 1230 with RN #1 revealed that the staff are educated by the facility to use PPE appropriately and that gown sleeves should be pulled down, covering all exposed skin during CVC care. Interview on 07/15/2025 at 1325 with the facility’s CM revealed that wrists should be covered and not exposed when staff are at risk for potential exposures.”

“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: 35306 Based on policy review, observation, and staff interview, the facility staff failed to prevent potential cross-contamination between patients by failing to ensure the hemodialysis station was completely vacated prior to cleaning the HDM at station #7 in 1 of 2 observations (Station #7, PCT #1, Patient #8 ). Findings include: Review on 07/15/2025 of the facility policy “Cleaning and Disinfecting the Dialysis Station” (Published Date: 09/05/2023), revealed “... Vacating the Machine To prevent cross-contamination between patients, it is important that the previous patient completely vacate the station before staff begin cleaning and disinfection of the station and set up for the next patient. For patients dialyzing in a treatment area where multiple patients dialyze, the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next treatment.” Observation on 07/14/2025 at 1059 at dialysis station #7 of the patient treatment area revealed that while Patient #8 applied pressure to the access sites post-treatment, PCT #1 turned the HDM away from the patient, cleaned and disinfected the machine and then re-strung the machine in preparation for the next scheduled patient. The observation revealed the PCT failed to wait until the hemodialysis station was completely vacated prior to cleaning and disinfecting the HDM. Interview on 07/14/2025 at 1430 with RN #1 revealed that the nurse spoke with PCT #1 following the observation and that the PCT stated that she had been told that if the HDM was turned away from the patient, it could be cleaned and disinfected. RN #1 stated that reeducation was provided and that the PCT assured her that it would never happen again. Interview on 07/14/2025 at 1715 with the facility’s CM revealed that the “patient has to be completly gone from the station area prior to cleaning and re-stringing” the HDM for the next scheduled patient.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 35306 Based on policy review, observation and staff interview, the facility’s nursing staff failed to ensure that expiration dates for stored medications were monitored and not available for use in 1 of 1 stored medication observations. Findings include: Review on 07/15/2025 of the facility policy “Medication Preparation and Administration” (Published Date: 07/07/2025), revealed “... Monitoring Expired Medications Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via (Organization name) off-site return program or in accordance with local and/or state law.” Observation on 07/14/2025 at 1101 of stored medications revealed a container of RPC E-Z Chek Blood Leak K100-0114 strips (Lot #101064) with an expiration date of 07/31/2024; a box with 3, 1.3 oz tubes of Glutose 15 Oral Glucose Gel (Lot # 2308625) with an expiration date of 06/30/2025; a box with 1, 1.3 oz tube of Glutose 15 Oral Glucose Gel (Lot # 2308625) with an expiration date of 06/30/2025; a bottle of Benadryl (Diphenhydramine HCI) 25mg capsules (Lot #112436) 1 capsule with an expiration date of 03/2024, a bottle of Benadryl (Diphenhydramine HCI) 25mg capsules (Lot # 129430) 65 capsules with an expiration date of 03/2025, and a box of Medi-First Triple Antibiotic Ointment with 41, 1/57 oz packets (Lot # A175) with an expiration date of 02/2025. Interview on 07/14/2025 at 1715 with the facility’s CM revealed monthly checks of the stored medications should be performed by the nursing staff to ensure expired medications are not available for use. The CM stated that the facility was currently being staffed by the agency’s float pool and that recruitment efforts have been ongoing for permanent staff for some time. Interview revealed the CM planned to develop a process to ensure practices are streamlined and consistent with float staff. “This is definitely an area of opportunity for us.””