Fmcna - East Tulsa

“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: 34696 Based on observation, interview, and record review, the facility failed to ensure that all staff washed or sanitized their hands between each patient, station, and/or glove removal, citing one of three staff (LPN). Findings: A review of the “Hand Hygiene” policy dated 11/06/2023 showed, “Hands will be”...”Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water”...”Before and after contact with patients”...”Immediately after removing gloves”...”After contact with inanimate objects near the patient”...After contact with other objects within the patient station or treatment space.” On 09/02/2025 at 4:10 PM, during observation of care in the hemodialysis treatment area, the surveyor observed the LPN providing care to Patient #2 at station #2. The LPN removed their gloves and retrieved supplies from the clean supply cart near Station #16. The LPN did not wash or sanitize their hands after removing their gloves. On 09/02/2025 at 4:10 PM, the LPN said they should have sanitized their hands after removing their gloves.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34696 Based on observation, interview, and record review, the facility failed to ensure one of three staff (CCHT) wore appropriate personal protective equipment (PPE) during initiation and termination of dialysis treatments. Findings: A review of the “Personal Protective Equipment” policy dated 11/06/2023 showed, “Personal Protective Equipment (PPE) including a full-face shield or mask and protective eyewear with full side shield, fluid resistant gowns, and gloves, must be worn to protect employees from blood or other potentially infectious materials”...”PPE is used to protect employees who are occupationally exposed to blood”...”when performing procedures during which spurting or spattering of blood might occur (for example, during initiation and termination of dialysis)...” On 09/03/2025 at 10:45 AM, during observation of care in the hemodialysis treatment area, the surveyor observed the CCHT removed their gown and hung it between stations #5 and #12 where treatments were being initiated. At 10:47 AM, the CCHT said the gown only needed to be worn when initiating and terminating their assigned patients.”

“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: 34696 Based on observation, record review, and interview, the facility failed to maintain the building free from defects and/or hazards in one of five areas (hemodialysis treatment area). Findings: A review of the “General Cleanliness and Infection Control Guidelines” policy published 05/05/2025 showed, “All areas must be kept clean and organized, including but not limited to the treatment area, water supply room”...”Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff”...”Such cleaning should be done regularly using a schedule developed by the facility”...”Fans or air purifiers may not be used in treatment areas. (ex floor fans,box fans, individual portable fans).” On 09/02/2025,during observation of care in the hemodialysis treatment area, the following: At 3:25 PM, the surveyor observed an area approximately 12 inches by 12 inches of a dried white substance on the floor near station #4. At 3:30 PM, the surveyor observed an approximately 12 inch, black table fan, operating on a counter near the crash cart at station #5. At 3:32 PM, a second smaller, approximately four inch black fan, was observed in an under-counter cabinet at the “Lab Dirty” sink. On 09/02/2025 at 3:35 PM, the Charge Nurse II said the white substance should have been cleaned by the staff. The ATOM said that the fans should not be in the treatment area. At 4:15 PM, the surveyor observed that the countertops near stations #4 and between stations #14 and #15 were faded, porous, and and had white stains. The countertops did not allow effective cleaning. On 09/02/2025 at 4:20 PM, the Charge Nurse said the white spots on the countertops was paint.”

“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: 34696 Based on observation and record review, the facility failed to ensure 1) two of three malfunctioning machines (hemodialysis machines #959 and #474) were labeled, and 2) one of one chair with worn upholstery was removed from the hemodialysis treatment area. Findings: A review of the “Use of Hemodialysis and Ancillary Machine Repair and Return Tag” policy dated 11/04/2019 showed, “The Standard Repair Request tag will be filled out and affixed to the hemodialysis machine..”.”whenever it is removed from service.” On 09/02/2025 at 3:00 PM, during a tour of the facility, the surveyor observed hemodialysis machines #959 and #474 in the machine repair area. The Biomed said the malfunctioning machines had been removed from the hemodialysis treatment area. The machines were not labeled to prevent use. On 09/02/2025 at 3:10 PM, the ATOM, said machines #959 and #474 should have been labeled when moved into the machine repair area. On 09/03/2025 at 9:30 AM, the surveyor observed a CCHT sitting in a black office chair and providing care to patients at stations #3 and #4. The chair had a removable fabric seat cushion, and the ends of both armrests on the chair were worn and did allow for effective cleaning. On 09/04/2025 at 11:30 AM, the Charge Nurse II said the chair should not be in the treatment area.”