Fmc Deptford

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 39228 Based on observation, staff interview, and review of facility documents, it was determined the facility failed to ensure that one of one emergency cart and two of two emergency evacuation boxes contain all necessary equipment and information in the event of an emergency. Findings include: On 2/21/24 at 11:26 AM, Staff (S) 7, the Charge Nurse, stated that the facility had one Emergency Cart located on the Treatment Floor. S7 provided a binder that contained an itemized checklist of the contents of the cart and indicated that the cart was last checked in February of 2024. Review of the contents of the kit revealed that the following items indicated on the checklist were not present: - (1) box of masks - (1) package of white gowns - (1) box of Vacutainers - The cart also contained 24 Blue Chux pads. The par level on the checklist stated that 26 Blue Chux pads were needed. Upon interview with S7 at 1:10 PM, S7 stated that the items were missing from the cart and replaced the items at that time. On 2/21/24 at 1:15 PM, S7 stated that there was one Emergency Evacuation Box located on the Treatment Floor. The contents of the kit did not contain a copy of the current patient orders for 62 of 62 In-Center Hemodialysis patients on the facility census. Upon interview at 2:11 PM, S7 stated that the current dialysis orders for all 62 in-center Hemodialysis patients are printed by staff the night before a treatment day, kept at the nurse’s station, and then discarded at the end of each treatment day. On 2/22/24 at 10:45 AM, S10, a Registered Nurse, stated that the peritoneal (PD)/home hemodialysis (HHD) training room area in the facility had one Emergency Evacuation Box. S10 provided a document titled “Emergency Box Contents Log Home Therapy (HHD and PD) - Monthly” for review and stated that the box was last checked on 2/19/24. Review of the contents of the box revealed that the following items on the checklist were not present: - the checklist stated that there were twelve 10cc (cubic centimeter) syringes. The box contained only eight 10cc syringes - one CPR (cardiopulmonary resuscitation) ventilation mask w/ (with) one-way valve The above findings were confirmed with S10 at the time of discovery. Review of the facility policy titled, “Emergency Medications Equipment and Supplies,” published 5/1/23, stated, “... Emergency Cart: ... The emergency cart must be: ... Checked monthly or after use for contents ... An itemized log must be kept indicating the contents ... Emergency Evacuation Box: An emergency evacuation box must: ... Contain all patient and staff emergency contact information. ... An itemized log must be kept indicating the contents ...” N.J.A.C. 8:43A-15.1(d)”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 39228 Based on one of three observations for the cleaning and disinfection of the patient station, staff interview, and a review of facility policy, it was determined that the facility failed to ensure that after use, any non-disposable equipment brought into the dialysis station is disinfected before being removed from the dialysis station. Findings include: On 2/21/24 at 10:39 AM, S8, a RN, removed a portable oxygen (O2) concentrator from Station 19, which was occupied by a patient who had completed their dialysis treatment. S8 proceeded to place the O2 concentrator at the nurses station area on the treatment floor, adjacent to other portable equipment. S8 did not clean and disinfect the portable O2 concentrator before removing it from the station and prior to making it available for use. Upon interview with S8 at 11:05 AM, S8 stated that he/she did not clean and disinfect the O2 concentrator. At 1:42 PM, S7, the Charge Nurse, stated that the area on the treatment floor located near the nurses station, that contained other portable equipment was a clean area and that the equipment stored there should be clean. Review of facility policy and procedure titled, “Cleaning and Disinfecting the Dialysis Station,” published: 9/5/23, stated, “... General Cleaning ... After use, any non-disposable equipment and supplies brought into the dialysis station ... must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station. ...” N.J.A.C. 8:43A-24.8(b)”

“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: 39228 Based on two of three observations for the cleaning and disinfection of the patient station, staff interview, and a review of facility policy, it was determined that the facility failed to ensure that the patient station is cleaned and disinfected before setting up for use by the next patient. Findings include: On 2/21/24, during observation of the cleaning and disinfection of the dialysis stations, on the treatment floor, the following was revealed: At 10:20 AM, Staff (S) 9, a Registered Nurse (RN), cleaned and disinfected Station 14. At 10:25 AM, upon interview, S9 indicated that the station was clean. S9 then proceeded to set up the dialysis machine with clean dialysis tubing set. A piece of used gauze, a wrapper and a used bleach wipe were visible on both sides of the recliner chair. S9 explained that the trash/debris were from the previous patient and should have been picked up prior to setting up the machine. At 10:53 AM, in Station 19, after the patient left the station, S7, the Charge RN, cleaned and disinfected the dialysis machine and then exited the station. At that time, the rest of the station had not been cleaned and disinfected. At 11:00 AM, S8, a RN, entered Station 19 with a clean dialysis tubing set and proceeded to set up the dialysis machine for the next patient. At 11:01 AM, an interview with S7 was conducted. During the interview, S7 confirmed that only the dialysis machine had been cleaned and disinfected in Station 19 and that the remainder of the station, which included the recliner chair and chaise wall, had not been cleaned. At 11:02 AM, S7 then cleaned and disinfected the chair and the chaise wall behind the chair in Station 19. At 11:02 AM, an interview with S8 was conducted. S8 stated that he/she was not aware that only the dialysis machine was cleaned in Station 19 and he/she would not have set up the machine if he/she had known. At this time, S8 did not discard the clean dialysis tubing that had been set up in the machine prior to the entire station being cleaned and disinfected. A review of facility policy titled, “Cleaning and Disinfection of the Dialysis Station,” published 9/5/23, stated, “... Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: ... 3. Use a cloth wetted with 1:100 bleach solution or EPA [Environmental Protection Agency]-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P [blood pressure] cuff, hand sanitizer dispenser and holder, chaise wall behind chair ... 6. Pick up all trash or visible medical debris from around the patient chair. ...” N.J.A.C. 8:43A-24.8(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 48966 Based on one of one observation of the initiation of hemodialysis using a central venous catheter (CVC), review of facility documents, and staff interview, it was determined the facility failed to ensure the body of the catheter is cleaned when initiating hemodialysis. Findings include: On 2/21/24 at 11:38 AM in Station 17, Staff (S) 7, a Registered Nurse (RN), initiated hemodialysis through a right chest CVC. S7 removed the arterial thread cap, scrubbed the threads and end of the arterial hub for 15 seconds with an alcohol prep pad. S7 attached a syringe on the end of the arterial limb. S7 proceeded to remove the venous thread cap, scrubbed the threads and end of the venous hub for 15 seconds with an alcohol prep pad. S7 attached a syringe on the end of the venous limb. S7 did not clean the body of the catheter after cleaning the arterial and venous threads and the arterial and venous ends of the hub as required by facility policy. During an interview at 12:04 PM, S7 was asked about the procedure on how to clean the catheter limbs and S7 explained that the catheter limbs need to be wiped down first with alcohol then the threads and hubs of the catheter. S7’s personnel file was reviewed and indicated that a Fresenius Medical Care Direct Patient Care Skills Validation Checklist was completed on 8/10/23, which included initiation of dialysis with a CVC and scrub the hub. A review of the facility policy titled, “Initiation and Termination Using a Central Venous Catheter (CVC) published 07/05/2022, stated, “... Policy ... When initiating treatment, the body of the catheter will be cleaned after cleaning the threads and ends of the hub. ... However, cleaning the body, threads and ends of the luer lock (hub) with 70% sterile alcohol pads is acceptable. ... When initiating treatment, the body of the catheter will be cleaned after cleaning the threads and ends of the hubs ...” N.J.A.C. 8:43A-24.8(b)”

“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 three personnel records reviewed, staff interview and review of facility documentation, it was determined that the facility failed to ensure that all staff members undergo color blindness testing to correctly interpret colors while using color-coded strips to carry out the necessary functions of their job. Findings include: On 2/23/24 at 9:26 AM, a review of the personnel record for Staff (S) 7, a Registered Nurse, did not contain documentation of results for color blindness testing. During an interview at 12:29 PM, S2, the Facility Administrator, confirmed he/she was unable to find the color blindness testing results document for S7. A review of the facility policy titled, “Color Blindness Testing Policy,” published in 2019, stated, “... Policy- New -hire, rehire, or transfer staff working in a direct patient care or biomedical position are required to take the Ishihara Test for Color Blindness to ensure the ability to perform the essential functions of their jobs ... Performing the Test- Use the Ishihara Test Chart Book for color Blindness (14 Plates) ... 1. Ask person to identify the numbers seen in each plate and record on the answer sheet. Do not prompt the person in any way. 2. Review complete results and score the overall test as “pass” or “fail”. 3. Maintain documentation of test results in the employees medical file ...””