Fkc Liberty Hammonton

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 37656 Based on observation, review of facility documents, and staff interviews, it was determined that the facility failed to: 1. maintain designated hand washing sinks as clean areas (Cross refer, V114); 2. ensure that the transducer protector was replaced immediately when it became wetted with blood or other fluids, and inspected to prevent blood contamination of the dialysis machines’ pressure monitor (Cross refer, V120); and 3. ensure that six out of 18 blood pressure (BP) cuffs are maintained to allow for adequate cleaning and disinfection (Cross refer, V122).”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 37656 Based on one of one observation of a clean sink, review of facility documents, and staff interview, it was determined that the facility failed to ensure that designated hand washing sinks as clean areas are maintained. Findings include: On 10/29/24 at 10:48 AM, during tour of the Treatment Room, an open one liter bag of 0.9% Sodium Chloride solution was observed in the designated clean sink in the Isolation Room (Station #18). Upon interview at 10:52 AM, Staff (S) 9, a Registered Nurse, stated that the bag was used during dialysis and should be drained in the dirty sink. A review of the facility policy titled, “Hand Hygiene,” published 11/6/2023, states, “... Sink Policy ... Hand washing sinks should be dedicated for hand washing only and should remain clean. Used items should not be placed, cleaned or drained in the handwashing sink. ...” N.J.A.C 8:43A-24.4(b)”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 37656 Based on one of one observation of a wet external transducer protector, staff interview, and review of facility policy, it was determined that the facility failed to ensure that the transducer protector is replaced immediately when it becomes wetted with blood or other fluids, and is inspected to prevent blood contamination of the dialysis machines’ pressure monitor. Findings include: On 10/29/24 at 10:22 AM, a patient was dialyzing at Station #4. The venous and the arterial external transducer protector connected to the hemodialysis machine both contained a red substance. At 10:30 AM, Staff (S) 8, a Patient Care Technician (PCT), checked the machine due to arterial pressure alarm and exited the station. S8 did not check the arterial and venous transducer protectors at this time. At 11:10 AM, S10, a Registered Nurse (RN), checked the machine due to arterial alarms, but did not checked the transducer protectors. At 11:34 AM, the dialysis machine was alarming again due high arterial pressure and S10 checked the machine. At 11:35 AM, S10 inspected the venous external transducer protector and changed it. S10 placed the wet external transducer protector without inspecting the side facing the machine, and was about to discard it, when this surveyor asked S10 what he/she needed to do before discarding the wet transducer protector. S10 stated he/she will clean the dialysis connection with alcohol swab and after the patient’s dialysis, the machine will be removed and have biomed (biomedical) inspect internal circuit for blood contamination. This was not in accordance with facility policy. At 11:40 AM, the wet arterial external transducer was not changed and remained on the machine. At this time, the patient was experiencing cramping and was hypotensive (low blood pressure). S10 stopped the dialysis treatment and gave a normal saline bolus, then returned the blood. A review of the facility titled, “Maintenance of Transducer Protectors,” published 11/01/21, states, “... The transducer protector must be changed immediately when contaminated with saline or blood. ...” A review of the facility policy titled, “Patient Assessment and Monitoring,” published 5/1/23, states, “... 1. During Treatment ... Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations. ... 3. Machine Parameters and Extracorporeal Circuit ... Observe and ensure that: ... That the transducer protectors are dry, unclamped and pressure lines is free of fluid. ...” N.J.A.C. 8:43A-24.8(c)”

“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: 37656 Based on observations, staff interview, and a review of facility policy, it was determined that the facility failed to ensure that six out of 18 blood pressure (BP) cuffs are maintained to allow for adequate cleaning and disinfection. Findings include: On 10/28/24, during tour of the Hemodialysis Treatment Room, the BP cuffs at Station #’s: 1, 4, 5, 11, 12, and 15, were covered with white lint on the Velcro portion of the cuff, which rendered them uncleanable. On 10/30/24 at 1:30 PM, the above findings was discussed with Staff (S) 1, Clinic Manager, who stated that they will be changing the BP cuffs covered with lint.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 48966 Based on one of one observation of total chlorine testing, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure chlorine testing is performed in accordance with facility policy. Findings include: During an observation of total chlorine testing on 10/28/24 at 11:40 AM, Staff (S) 8, a Patient Care Technician (PCT), obtained a sample cup of water and after filling and dumping the cup with water three times, dipped a RPC Test Strip (strip use for chlorine testing) into the sample and set a timer for two minutes and gently moved the strip back and forth. After the two minutes, S8 removed the RPC strip and waited 20 seconds to read it. During an interview at 11:48 AM, when asked if another staff member should be present during chlorine testing, S8 explained in the morning when the unit opens up a Registered Nurse (RN) is present, but it is difficult to have a RN come back to the water treatment room during turnover, so S8 shows the RPC test strip to the RN out on the hemodialysis floor. S8 was not observed showing the RPC test strip to a RN on the hemodialysis floor. During an interview at 1:05 PM, S3, the Area Technical Operations Manager, was asked if a RN needs to be present when chlorine testing. S3 stated they had to check the policy. S3 provided the policy and confirmed that a RN needs to be present during chlorine testing. A review of S8’s Skills Validation In Center form indicated that he/she successfully completed training on total chlorine testing on 1/8/24. A review of facility policy titled, “Carbon Filtration Monitoring for Incenter Central Water Systems Policy,” published 11/07/2022, stated, “... Verification of Test Results: Two trained staff members, one of whom must be licensed RN, will perform and verify total chlorine testing. To verify: ... Both staff members must be present. One staff member will perform the test while the other staff member observes the test being performed. ... If both staff members are unable to be present at the time of testing, then each must perform the test individually, comparing results. In the case, verification will be determined by both staff members obtaining similar results ...” N.J.A.C. 8:43A-24.4(a)”

“DIST SYS-CULTURE/LAL/SITES/FREQ(NEW)/LOG CFR(s): 494.40(a) 6.3.3 Water distribution systems: culture/LAL sample sites/frequency (new)/log Water distribution piping systems should be monitored for bacteria and endotoxin levels. Bacteria and endotoxins shall not exceed the levels specified in [AAMI] 4.1.2. [(i.e., bacteria <200 CFU/mL and endotoxin <2 EU/mL] Bacteria and endotoxin testing should be conducted at least monthly. For a newly-installed water distribution piping system, or when a change has been made to an existing system, it is recommended that weekly testing be conducted for 1 month to verify that bacteria or endotoxin levels are consistently within the allowed limits. Monitoring should be accomplished by taking samples from the first and last outlets of the water distribution loop and the outlets supplying reuse equipment and bicarbonate concentrate mixing tanks. If the results of this testing are unsatisfactory, additional testing (e.g., ultrafilter inlet and outlet, RO product water, and storage tank outlet) should be undertaken as a troubleshooting strategy to identify the source of contamination, after which appropriate corrective actions can be taken. Bacteria and endotoxin levels shall be measured as specified in ANSI/AAMI RD62:2001 (see 2.3). All bacteria and endotoxin results should be recorded on a log sheet to identify trends that may indicate the need for corrective action. This Standard is not met as evidenced by: 48966 Based on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that microbiological testing of the Reverse Osmosis (RO) machine and water distribution system are completed monthly for one of six months reviewed. Findings include: The “water collection schedule” for the RO and water distribution system and the test results were provided for review for May 2024 through October 2024. The following was revealed: For the month of June 2024, the loop feed and loop return, and the RO permeate (product water) were to be completed for microbiological testing according to the “water collection schedule.” There was no documented evidence that the microbiological tests were completed nor documented for the month of June 2024. During an interview on 10/28/24 at 1:45 PM, Staff (S) 5, the Biomed Technician, stated, “I sent out the cultures to the lab [laboratory] for the June draw, but it came back that it was not received. I did not notice it until the following month.” S5 informed S1, the Facility Administrator, Medical Director and S3, Area Technical Operations Manager, about the missing results. S5 confirmed that repeat cultures were not drawn at the time results were found to be missing. When asked if the above missing results were noted in QAPI (Quality Assurance and Performance Improvement), S5 stated “yes it was.” On 10/28/24 at 1:47 PM, a review of the July 2024 QAPI documents lacked evidence that the June 2024 microbiological results were not resulted. During an interview on 10/28/24 at 1:48 PM, S3 confirmed that the missing June 2024 microbiological results should have been documented in the July 2024 QAPI, and it was not. S3 stated, “the missing cultures from June 2024 will be drawn tomorrow” (10/29/24). A review of the facility’s policy titled, “Microbiological Monitoring of Central Water and Concentrate Mixing and Delivery Systems,” stated “... Scheduled Sampling: After successful baseline sampling, microbiological samples will be collected no less than monthly ... Sample Locations ... Indirect Feed System Sampling: [bullet] RO Machine ... [bullet] The first sample point on the distribution loop after the storage tank distribution pump. [bullet] Last sample point of the distribution loop prior to water re-entering the storage tank ...” N.J.A.C. 8:43A-24.10(a)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 33557 Based on observations and staff interview, it was determined that the facility failed to ensure the areas under sinks are kept clean and in good condition. Findings include: On 10/28/24 at 10:45 AM, on the Treatment Floor, black colored spots were found on the floor of the cabinet directly under the sink drain for Clean Sink #7. Staff (S)1, Facility Administrator, confirmed this finding during the exit conference. On 10/28/24 at 11:00 AM, in the Soiled Utility Room, water was found leaking out of the drain located under the handwashing sink. Black spots were also located on the floor of the cabinet directly under the handwashing sink. S1 confirmed this finding during the exit conference.”

“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: 50912 Based on a review of one of one medical record of a patient receiving home peritoneal dialysis (Patient (P) 4), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that home peritoneal dialysis treatments are provided in accordance with a physician’s order. Findings include: A review of P4’s medical record revealed that the patient began home CCPD (Continuous Cyclic Peritoneal Dialysis) treatment (a type of renal dialysis that uses a machine to automatically perform exchanges on patient) on 12/13/23. Admission and standing peritoneal dialysis prescription orders, dated 12/18/23, included a “Peritoneal Dialysis Weight Change Guidelines at Home.” The guidelines were signed by the nephrologist and Registered Nurse (RN), and reviewed with P4 and his/her caregiver. P4 was hospitalized on 8/8/24 until 9/4/24, per a note from the nephrologist. On 10/29/24, S15, an RN stated that P4 had been discharged from the facility due to extended hospitalization. On 9/9/24, P4 was readmitted to the facility and had a Comprehensive RN Assessment completed by S15. On 9/10/24 and 9/11/24, S15 was able to obtain CCPD standing orders from P4s nephrologist. Nephrologist PD prescription orders states: “Special attention: Patient will follow weight change guideline per MD (Medical Doctor), Every treatment.” A review of P4’s medical record lacked evidence of Peritoneal Dialysis Weight Change Guidelines at Home after readmission to the facility on 9/9/24. During an interview on 10/29/24 at 1:00 PM, S15 and S16 stated there was no current Peritoneal Dialysis Weight Change Guidelines since P4 was readmitted on 9/9/24. The last PD Weight Change Guideline Form was signed and dated 12/18/23. At 1:30 PM, S15 presented a PD Weight Change Guideline at Home form that was dated 10/29/24 and signed by S15. The form lacked the nephrologist and the patient’s signature. A review of P4’s CCPD Daily Flowsheet dated from 9/10/24 to 10/14/24, revealed that P4 had been performing the CCPD treatments daily without the new PD Weight Change Guidelines at Home ordered by the nephrologist since 9/10/24. A review of facility policy titled “Physician Order Documentation,” published 07/03/23 states, “... It is the nurses’ responsibility to ensure that all treatments, medications ... or any care provided to the patient have an accurately documented physician order ...Nurse practice acts requires the nurse to carry out treatment care, medication ... procedures and other treatments, based on physicians’ orders ...” N.J.A.C. 8:43A-24.14(a)(5)(i)”

“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: 50912 Based on observation, staff interview and review of facility policy and procedure, it was determined that the facility failed to ensure that all the emergency medications and supplies are kept locked inside the Emergency Code Cart when not in use. Findings include: On 10/28/24 at 1:10 PM, an inspection of the Emergency Code Cart located within the Nurse’s Station that was across from the medication preparation area was conducted. The plastic sheet covering the Emergency Code Cart was lifted off and revealed that the breakaway lock bar was unsecured. A broken off red plastic breakaway lock seal was found on the floor beside the Emergency Code Cart. The red plastic breakaway seal number read “054664.” This finding was confirmed with Staff (S) 12, Charge Nurse, and Staff (S) 1, Facility Administrator, who were both present upon inspection of the emergency cart. Upon interview, S1 stated that, “The emergency cart must be kept locked at all times when not in use.” When questioned, S1 stated that the facility performs monthly update checks on the code cart and documents it on the FKC (Fresenius Kidney Care) Log Readings Grid Report in the computer. A review of the grid report log checklist from 4/24-10/24 revealed that the last time the code cart was checked was on 10/4/24. The lock number of the red plastic breakaway seal documented on the grid report lock checklist read “055664.” Inspection of the top-drawer of the unsecured emergency code cart revealed the following contents: Solumedrol IV (Intravenous) 125 mg (milligrams) per vial, two vials Calcium Chloride 1 gm (gram) per 10 ml (milliliter), two vials Epinephrine Injection USP (United States Pharmacopoeia) 1 mg per ml, four vials Sodium Bicarbonate Injection USP 50 MEq (milliequivalent) per 50 ml, one vial Benadryl IV 50 mg per 1 ml, four vials Naloxone HCL (hydrochloride) 1 mg USP, 0.4 mg per ml, two vials Glucose 37.5 gms per 13 oz (ounce) tube, three tubes 20 -18-gauge hypodermic needles 10 - 21-gauge hypodermic needles Five - 19-gauge hypodermic needles 10 -10 cc (cubic centimeter) prefilled syringes with NSS (normal saline solution) 10 - 3 ml syringes A review of facility policy titled, “Emergency Medications, Equipment and Supplies”, published 05/01/23, stated, “ ...Definitions ...Emergency Cart: An emergency cart, sometimes ‘called crash’ cart contains emergency equipment and medications for medical emergencies ...Emergency Cart: The emergency cart must be: Locked when not in use ...”. N.J.A.C. 8:43A-9.5(a)”