Fmc Fairview

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 49828 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1) a defect free environment is maintained at all times. (V-401); and 2) “Dummy” drip chambers (DDC’s) are not available for use in the hemodialysis treatment room. “Dummy” drip chambers (DDC) are fluid-filled chambers that are used to bypass the dialysis machine’s air detectors. (V-403) This failure resulted in an Immediate Jeopardy (IJ), posing serious risk of harm to the patients. Findings include: On 7/31/24 at 10:25 AM an IJ was identified for the facility’s failure to ensure that a DDC was not available for use in the hemodialysis treatment room (V-403). On 7/31/24 at 12:02 PM, the Clinic Manager and Director of Operations were informed of the IJ findings, and a copy of the IJ template was provided. An immediate Removal Plan was requested at that time. On 7/31/24 at 3:09 PM, an acceptable Removal Plan was received, and the facility implemented the following: the Medical Director was informed, a Governing Body meeting was held to execute a Removal Plan for the immediacy of the IJ, and staff re-education. On 8/1/24 at 10:27 AM, the surveyors were able to verify implementation of the Removal Plan through facility tour of the hemodialysis treatment room, facility document review, staff interviews, and review of the staff education documentation. The IJ was removed on 8/1/24 at 10:27 AM and Condition level non-compliance remains. Cross Reference: 494.60 - Physical Environment: Safe/Functional/Comfortable Environment 494.60(b) - Physical Environment: Equipment maintenance - manufacturer’s DFU (Directions for Use)”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 39228 3. On 7/31/24 at 11:33 AM, during a tour of the treatment floor, a pair of blue gloves, the type that are worn by staff members for patient care on the dialysis unit, were laying on a countertop area located between a designated clean handwashing sink and the patient scale. The gloves appeared to have been used and were turned inside out. There was no waste receptacle readily accessible in the area of the sink. At 11:34 AM, an interview was conducted with S2, the Charge Nurse, who confirmed that the gloves were dirty and stated, “We had a trash can here, but it has been gone for a couple of weeks and I’ll have to ask our cleaning company what happened to it.” N.J.A.C 8:43A-24.8(b)”

“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: 49828 Based on one of one observation of a “Dummy” drip chamber (DDC) on the treatment floor, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that DDCs are not available for use on the hemodialysis treatment floor. “Dummy” drip chambers (DDC) are fluid-filled chambers that are used to bypass the dialysis machine’s air detectors. The presence of a DDC in the hemodialysis treatment room is considered an immediate and serious threat to patient health and safety. Findings include: On 7/31/24 at 10:25 AM, during tour of the hemodialysis treatment floor, a DDC that contained a clear solution was present in the top right drawer of Clean Sink 19. During an interview at 11:02 AM, the Biomedical Technicians, Staff (S) 3, and S4, stated they were unsure why the DDC was present on the floor, that the staff does not use DDCs, and that it should not be present on the treatment floor. S3 further stated, “the DDCs are used only in the water room to test the dialysis machines”. Review of facility policy titled, “Use of “Dummy” Drip Chambers,” revised 3/28/18, stated “... Security of Dummy Drip Chambers: DDCs may never be stored in the dialysis treatment area ...””

“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: 49828 Based on review of one of three medical records (Patient (P) 5), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that staff followed the physician’s hemodialysis prescription orders for the dialysis machine temperature in six of nine hemodialysis treatments reviewed. Findings include: On 8/1/24, a review of P5’s medical record revealed the following: The “Current Orders” portion of the “Patient transfer” section of the medical record stated the hemodialysis prescription: “In Ctr HD [In-center hemodialysis], MonWedFri [Monday, Wednesday, Friday], 3 hrs [hours] and 30 min [minutes] ... Machine Temp [temperature]: 37 [Celsius]...”. A review of hemodialysis treatment sheets from 7/8/24 to 7/26/24 indicated that the prescribed temperature of 37 degrees Celsius (C) was not administered in accordance with the physician order above on the following treatment dates: On 7/8/24, the machine temp was documented as 36 C. On 7/17/24, the machine temp was documented as 36 C. On 7/19/24, the machine temp was documented as 36 C. On 7/22/24, the machine temp was documented as 36 C. On 7/24/24, the machine temp was documented as 36.5 C. On 7/26/24, the machine temp was documented as 36.5 C. On 8/2/14 at 9:58 AM, Staff (S) 2, Charge Nurse, stated, “The patient complains of being too hot and the staff adjusts the temperature to keep the patient comfortable.” S2 continued, “The staff should follow the machine temperature that is ordered.” S2 confirmed that if there is a variation between the order and delivered treatment, the physician should be made aware. The medical record did not contain documented evidence that the physician was aware of the changes in temperatures on the above dates. Review of facility policy titled, “Physician Order Documentation,” revised 7/3/23, stated the following: “ ... General Policy: Nurses practice acts requires nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders ...”. N.J.A.C. 8:43A-24.6(d)(4)”

“POC-PT/FAMILY EDUCATION & TRAINING CFR(s): 494.90(d) The patient care plan must include, as applicable, education and training for patients and family members or caregivers or both, in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types. This Standard is not met as evidenced by: 39228 Based on review of one of two medical records for a newly admitted patient, (Patient (P) 7), staff interview, and review of facility documents, it was determined that the facility failed to ensure that education and training for a newly admitted patient are provided within a specified time frame in accordance with the facility’s policy and procedure. Findings include: On 8/2/24, a review of P7’s medical record revealed the following: P7 was admitted to the facility on 5/23/24 for in-center hemodialysis. The patient’s plan of care (POC) was dated 6/24/24. The POC stated that the patient had a CVC (central venous catheter) and a maturing AV (arteriovenous) fistula. P7’s medical record did not contain documentation that he/she was educated within the first month of admission on fire/emergency evacuation and take off procedures. On 8/3/24 at 10:42 AM, an interview was conducted with Staff (S) 1, the Clinic Manager. S1 stated that P7’s education on fire/emergency evacuation and take off procedures had not been completed per the facility’s policy. Review of facility policy and procedure titled, “Patient Education,” published 2/6/23, stated, “... Policy Refer to the information below on the education topics and time frame specific to a new patient admission. Topic ...Fire/Emergency Evacuation and Take Off Procedures ... Time Frame ... Within the 1st month for new patients ... Document Patient Education, Patient Education must be documented in the patient’s medical record. This may occur through the use of: Patient education assessment, Other interdisciplinary specific assessments, Clinical/progress notes ...” N.J.A.C. 8.43A-24.14(a)(3)(iv)”

“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: 49828 3. On 7/21/24 at 10:10 AM, two medication storage cabinets located above the clean sink area across from Station 1 were unlocked and easily opened. Affixed to each medication storage cabinet was a number combination lock which was not utilized to prevent the storage cabinets from opening. Inspection of the two unlocked cabinets revealed the following contents: Cabinet 1, labeled “IV Medications” (Intravenous medications), contained the following IV medications: Heparin Sodium, Doxercalciferol, Venofer, and Cryodose Anesthetic Spray. Cabinet 2, labeled “Oral Medications,” contained the following oral medications: Cinacalcet, Clonidine, Tamiflu, Midodrine Hydrochloride, Loperamide, and Glucose 15 gel. During an interview at 10:15 AM, Staff (S) 2, the Charge Nurse, stated, “Yes, they [the medication cabinets] must be locked at all times. We use a lock number combination.” S2 stated, “I don’t know why it [the medication storage cabinets] was left unlocked, these are usually locked at all times.” S2 then locked medication storage Cabinet 1 and Cabinet 2 using the number combination lock affixed to each cabinet doors. Review of facility policy titled, “Medication Preparation and Administration,” revised 2/6/23, stated the following: “... Securement: The following steps must be taken for the securement: All medications will be kept in a locked cabinet except when in use...”. N.J.A.C. 8:43A-9.5(a)”