Fmc Seacoast Dialysis Center

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 26364 Based on observation, interview, and record review, the dialysis facility failed to ensure staff removed gloves and performed hand hygiene between each patient and station for 1 of 10 patients observed for hemodialysis care and infection control practices (Patient Identifier #11). Findings include: Review of the facility’s policy titled, “Hand Hygiene”, with a published date of 11/6/23, revealed that hands will be decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water. Hands shall be washed “before and after direct contact with patients...after contact with inanimate objects near the patient...and after contact with other objects within the patient station or treatment space.” Observation on 8/27/24 at approximately 7:10 a.m. during initiation of Patient #11 revealed Staff A (Registered Nurse) located and palpated the cannulation site. Staff A cleansed the site with antiseptic and proceeded to input data at the dialysis machine. Staff A moved back to the patient and inserted the cannulation needles and initiated treatment without changing his/her gloves or performing hand hygiene.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 38218 Based on interview and record review it was determined that the facility failed to follow the hemodialysis prescriptions for 2 of 14 prescriptions reviewed (Patient Identifiers are #4 and #5). Findings include: Patient #4 Review on 8/28/24 of Patient #4’s dialysis prescription dated: 7/8/24-8/2/24 revealed the following: Blood Flow Rate (BFR) 350 and Dialysate Flow Rate (DFR) 700 milliliters per minute (ml/min). Review on 8/28/24 of Patients #4’s dialysis run sheets revealed the following: 7/17/24- 11:07 a.m. through 2:34 p.m. Patient #4’s BFR was run at 400. 7/22/24- 1:56 p.m. through 4:37 p.m. Patient #4’s BFR was run at 400. Patient #5 Review on 8/28/24 of Patient #5’s dialysis prescription dated: 8/16/24-8/23/24 revealed the following: BFR 425 and DFR 800 ml/min. Review on 8/28/24 of Patients #5’s dialysis run sheets revealed the following: 8/16/24 6:26 a.m. through 7:02 a.m. Patients #5’s BFR was run at 400 and the DFR was run at 600, and from 7:33 a.m. through 10:14 a.m. Patient #5’s BFR was run at 420 and the DFR was run at 700. Review on 8/29/24 of Patient #4 and Patient #5’s medical records with Staff B (Clinical Manager) revealed that there were no notes explaining the deviations and the physician was not notified. Interview on 8/29/24 at approximately 9:30 a.m. with Staff B confirmed the above findings. Review on 8/29/24 of the facility policy titled, “Unable to Achieve Prescribed Blood Flow Rate”, Dated 11/1/21 revealed: “...Notification: Notify physician/extender if unable to achieve prescribed blood flow rate. Documentation: Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physicians orders...””

“GOV-APPOINT CEO/ADMINISTRATOR CFR(s): 494.180(a) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, This Standard is not met as evidenced by: 38218 Based on interview and record review, it was determined that the governing body failed to appoint an individual as the Administrator who exercises responsibility for the management of the facility and the provision of all dialysis services for a current census of 100 patients. Findings include: Review on 8/27/24 of the facility’s End Stage Renal Disease (ESRD) facility state license revealed Staff B (Clinical Manager) as the Administrator. Interview on 8/27/24 at approximately 8:30 a.m. with Staff B revealed that they were the Clinical Manager at the facility. Review on 8/28/24 of the facility’s Resignation of Professional Staff Member Governing Body Minutes, Dated 8/23/23 revealed: “New Business...The Chairperson directed the attention of the members to the resignation of [pronoun omitted], Facility Administrator effective August 23, 2023. The Governing Body has appointed Staff C (Administrator) as the replacement Facility Administrator...” Interview on 8/28/24 at approximately 2:00 p.m. with Staff C confirmed that he/she has been the Administrator at the facility since 8/2023 and was not the Adminsitrator designated on the facility license.”