Fmc Edison

“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: 51227 Based on one of one observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that all surfaces of the plastic hemostat clamps are disinfected after use according to facility policy. Findings include: On 2/10/24 at 9:40 AM, during a tour of the Treatment Floor, a clear container that had a 1:100 bleach solution (one part bleach to 100 parts water) in it was observed on a countertop located across from Station 8. The container had six plastic hemostat clamps soaking in the bleach solution. Five of the six clamps were in the closed position. The soaking of the clamps in the closed position could potentially prevent the bleach solution from contacting and disinfecting all surfaces of the hemostat clamps. During an interview at 9:45 AM, Staff (S) 12, the Charge Nurse, stated that dirty clamps should be in an open position while soaking in the bleach. Facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 9/5/23, stated, “... Cleaning Clamps Place used plastic pressure clamps and plastic hemostat clamps in a labeled opaque plastic container filled with a 1:100 bleach solution per the Mixing Bleach policy. Make sure the items are completely submerged, unclamped, and in open position when placed in the solution ...” N.J.A.C. 8:43A-24.8(b)”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 51990 Based on one of one observation of patient monitoring during hemodialysis, staff interview and review of facility documents, it was determined that the facility failed to ensure all patient’s remain in view of staff to ensure patient safety. Findings include: On 2/10/25 at 9:57 AM, in Station 10, during an observation of Patient (P) 8’s hemodialysis through a right chest Central Venous Catheter (CVC, a type of access used for hemodialysis), the following was revealed: P8 had a blanket over top of them which covered from his/her neck down to his/her feet. The blanket did not allow for the CVC access to be visible to staff. At 10:28 AM, P8’s access continued to remain covered with the blanket. At 10:35 AM, Staff (S) 16, a Registered Nurse, entered Station 10, typed on the dialysis machine’s keyboard, did not uncover the access, then exited the station. P8’s access was not visible to staff from 9:57 AM to 10:35 AM, a length of 38 minutes. During an interview at 10:35 AM, S16 stated that a patient’s access should be checked and uncovered while on hemodialysis. S16 subsequently uncovered P8’s access to be visible by the staff. Facility policy titled, “Patient Assessments and Monitoring,” published 5/1/2023, stated, “... During Treatment ... Follow the steps below for monitoring patient and machine parameters during treatment: ... 6. Access .... Ensure access remains uncovered throughout the treatment ...” N.J.A.C. 8:43A-24.4(a)”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 51990 Based on one of one observation of the termination of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview and a review of facility documents, it was determined that the facility failed to ensure patient’s rights to privacy. Findings include: On 2/10/25 at 10:00 AM in Station 10, Staff (S) 12, the Charge Nurse, terminated hemodialysis on Patient (P) 9 through a right chest CVC. During the procedure, the curtains were fully drawn on both sides of Station 10 ensuring privacy to the left and the right side of P9. The curtains were not fully closed in front of the station leaving an approximate two feet opening. The patient’s chest was visible from the nurse’s station and to the patient in Station 2, which was located across from Station 10. During an interview at 10:35 AM, S12 confirmed that the curtains should be fully closed around the patient’s station when discontinuing hemodialysis. Facility policy titled, “Patient Rights and Responsibilities,” published 4/4/2012, stated, “... Policy: Privacy Rights ... Patients have the right to privacy during activities that may require the exposure of private body parts while in the dialysis facility. Privacy screens or curtains may be used to provide privacy ...” N.J.A.C. 8:43A-16.2(a)10”

“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: 50912 Based on one of five medical records reviewed (Patient (P) 2), staff interview, and review of facility documents, it was determined that the facility failed to ensure that post hemodialysis nursing assessments are completed according to facility policy. Findings include: A review of P2’s plan of care, dated 11/13/24, stated, “Area of Focus BP [blood pressure] and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ... Intervention (s): ... Educate patient/family/caregiver on fluid control In Progress ... Continue to monitor patient ... In Progress ... Monitor fluid gains ... In Progress ...” A review of the “Treatment Sheets For Facility” from 1/13/25 through 2/10/25 in P2’s medical record revealed the following: On 1/13/25 at 3:08 PM, the pre-treatment “Nursing Evaluation” indicated bilateral ankle edema, plus one: two mm (millimeters) or less, disappears rapidly. The post-treatment “Nursing Evaluation” at 6:40 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 1/17/25 at 3:25 PM, the pre-treatment “Nursing Evaluation” indicated bilateral ankle edema, one plus: two mm or less, disappears rapidly. The post-treatment “Nursing Evaluation” at 7:19 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 1/24/25 at 3:14 PM, the pre-treatment “Nursing Evaluation” indicated bilateral ankle edema, one plus: two mm or less, disappears rapidly. The post-treatment “Nursing Evaluation” at 6:49 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 2/10/25 at 3:23 PM, the pre-treatment “Nursing Evaluation” indicated bilateral ankle edema, one plus: two mm or less disappears rapidly. The post-treatment “Nursing Evaluation” at 7:05 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. During an interview on 2/11/25 at 12:42 PM, Staff (S) 1, the Clinical Manager, reviewed the above findings and confirmed that the post hemodialysis re-assessment of edema was not documented on the above-mentioned hemodialysis flowsheets. S1 stated that staff nurses should reassess and document post-treatment edema if abnormal findings were found pre-treatment. Facility policy and procedure titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “... Purpose ... provide guidance to (facility name) direct patient care staff on assessment and monitoring patients before, during and after treatment ... Edema (As indicated by patient condition): Assess the patient for edema ... Location ... Severity ... Post Treatment ... Follow the steps below for obtaining post-treatment assessment data ... Edema ...” N.J.A.C. 8:43A-24.4(a)”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 51990 Based on one of five medical records reviewed (Patient (P) 4), staff interviews, and review of facility documents, it was determined that the Registered Nurse (RN) failed to ensure that a comprehensive review of all Home Therapy patients flowsheets are performed monthly. Findings include: On 2/11/25, a review of P4’s medical record revealed the following: The “CCPD [continuous cycling peritoneal dialysis] Daily Flowsheets,” a paper PD (peritoneal dialysis) flowsheet completed by the patient or the care partner, and the “PatientHub Flowsheets,” an electronic transmitted treatment report from the PD Cycler (a machine used to perform PD treatments) also completed by the patient or care partner, from 11/20/24 to 1/1/25, indicated that there were 19 PD treatments that lacked documentation of either the patient’s weight, blood pressure, pulse, temperature, and the dextrose solutions used. A review of the “ESRD [end-stage renal disease] Comprehensive RN Assessment” dated 1/9/25, did not contain documentation by a RN that addressed the missing treatment information in the patient’s flowsheets. A review of the “Plan of Care” dated 1/9/25, stated, “... Area of Focus Dialysis Access (PD) ... Intervention(s) ... Educate on using Patient Portal to check access concerns Completed ... Patient unable to use patient hub for treatment data. Alternatively, patient enters data using CCPD flowsheet into cycler. Patient and wife educated on signs and symptoms of exit site/ tunnel infection and prompt reporting of symptoms ... Area of Focus Dialysis Adequacy (PD) Issues Open ... Intervention(s) ... Educate patient on using Patient Portal for evaluation of treatment data In Progress ...” The RN progress notes in January 2025 and February 2025 were reviewed and lacked documented evidence that the missing treatment data was discussed with the patient and the care giver at P4’s monthly clinic visits. On 2/11/25 at 11:40 AM, the CCPD Daily Flowsheets and the PatientHub Flowsheets from 11/20/24 to 1/1/25 were reviewed with Staff (S) 5, the Home Therapy Program Manager. S5 explained that P4 completes both the CCPD Daily Flowsheets and also enters treatment details into the PD cycler PatientHub Flowsheet which is then printed by the Home Therapies staff. S5 confirmed the missing treatment documentation on the flowsheets. S5 stated that the flowsheets are reviewed at clinic visits by the RN and Home Therapies staff should review them routinely. Facility policy titled, “Review and Documentation of Home Therapies Patient Health Data,” published 5/11/2023, stated, “ ... Review and Documentation of Health Data ... At a minimum, the home therapies nurse will perform a comprehensive monthly review of all treatment data regardless of the method of data submission. Data review will be discussed with the patient and /or care partner during the patient’s regular clinic visit and concerns will be addressed and documented accordingly ...” N.J.A.C. 8:43A-24.20(a)”