Fkc Stroudsburg

“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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, performing hand hygiene/donning clean gloves, for one (1) of two (2) ‘Access of AV (arteriovenous) Fistula or Graft for Initiation of Dialysis’ observations (Observation #1) and for two (2) of four (4) ‘Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft’ observations (Observations #1, Observation #4). Findings include: A review was conducted of facility policy/procedure on January 21, 2026 at approximately 11:30 a.m. Policy ‘Access Assessment and Cannulation’ ‘Assessment of Vascular Access’ Step (1) “.... If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patients access with soap and water. .... “ (2) “Wash hands and don PPE (personal protective equipment): gloves .....” ‘Skin Disinfection’ Step (1) “Disinfect cannulation site as follows ....” Observations conducted in the patient treatment area on January 15, 2026 between approximately 9:20 a.m. and 1:45 p.m. and on January 16, 2026 between approximately 11:20 a.m. and 11:45 a.m. revealed the following: Observation #1: Observation #1 of two (2) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 01/15/26 at approximately 10:35 a.m., of patient #10 at station #3, employee #14 washed the skin over the access site. Employee #14 did not perform hand hygiene/don clean gloves prior to applying antiseptic to the skin over the cannulation site/inserting needle. Policy ‘FX CorAL: Termination of Treatment using an Arteriovenous Fistula or Graft’ ‘Termination: Disconnecting the Patient’ Step (3) “Disconnect the bloodlines from the needle lines and remove the needles according to the Post Treatment Needle Removal Procedure.” ’ Policy ‘Post Treatment Fistula Needle Removal’ ‘Procedure’ “Step (2) “The person removing the needles will perform hand hygiene and don clean gloves. ...” Observation #1: Observation #1 of four (4) ‘Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft’ on 01/15/26 at approximately 10:15 a.m., of patient #11 at station #3, employee #14 disconnected the bloodlines. Employee #14 did not perform hand hygiene/don clean gloves prior to removing the needle. Observation #4: Observation #4 of four (4) ‘Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft’ on 01/15/26 at approximately 11:05 a.m., of patient #12 at station #1, employee #14 disconnected the bloodlines. Employee #14 did not perform hand hygiene/don clean gloves prior to removing the needle. An interview with the facility Administrator on January 21, 2026 at approximately 12:00 p.m. confirmed the above findings.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, observations, and an interview with the Administrator, facility failed to label supplies/equipment that are dedicated for use in the isolation area for one (1) of one (1) isolation room observations (Observation #1). Findings: A review was conducted of facility policy/procedure on January 21, 2026 at approximately 11:30 a.m. ‘Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg)’ ‘Equipment and Supplies’ “Separated dedicated supplies and equipment,including blood glucose monitors, must be used to provide care to the HBsAg positive patient: .....Equipment used for HBsAg positive patients should be reserved for the HBsAg positive patient unless repair or maintenance is needed.” “All supplies used in the isolation room/area such as clamps, blood pressure cuffs, testing reagents, etc. should be labeled “isolation” and not routinely removed.” Observations conducted in the patient treatment area on January 15, 2026 between approximately 9:20 a.m. and 1:45 p.m. and on January 16, 2026 between approximately 11:20 a.m. and 11:45 a.m. revealed the following: Observation #1: On 01/16/26 at approximately 11:30 a.m. the isolation room was inspected during the treatment of a HBsAg positive patient. Employee #6 assisted. One (1) stethoscope, one (1) bottle of residual chlorine reagent strips, one (1) large white clamp, several yellow hemostats inside a plastic bag, one (1) centrifuge, one (1) dialysis chair, one (1) dialysis machine, and one (1) medication pole were found labeled with red tape but were not labeled “isolation”. An interview with the facility Administrator on January 21, 2026 at approximately 12:00 p.m. confirmed the above findings.”

“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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure the patients prescription was set according to physician orders for one (1) of four (4) patient prescription checks during treatment observations (Observation #3). Findings include: A review was conducted of facility policy/procedure on January 21, 2026 at approximately 11:30 a.m. Policy ‘Pre-Treatment Safety Checks Procedure’ ‘Pre-Dialysis Safety Checks’ “Verify the following elements by two direct patient care staff members prior to treatment initiation: .... Prescribed dialysate composition: ....” ‘After Patient is Seated’ “The clinician initiating treatment must verify the prescribed set up matches the patient: ... Prescription: ...Dialysate composition ....Temperature....” Observations conducted in the patient treatment area on January 15, 2026 between approximately 9:20 a.m. and 1:45 p.m. and on January 16, 2026 between approximately 11:20 a.m. and 11:45 a.m. revealed the following: Observation #3: Observation #3 of four (4) patient prescription checks during treatment on 01/15/26 at approximately 1:30 p.m., of patient #8 at station #1, with the assistance of employee #7, the dialysate composition was not being utilized as ordered. The physician orders were ‘Dialysate Composition: 2.0 K (potassium) , 2.5 Ca. (calcium) ...” 3.0 K was being utilized. The physician order for the ‘Machine Temperature’ was 37 degrees. The machine was set at 36.5 degrees. A review of the patients treatment flow sheet reveals the patients treatment was initiated at approximately 12:13 p.m. The ‘Machine SETUP’ was ‘Performed’ by employee #7 and ‘Reviewed’ by employee #8. An interview with the facility Administrator on January 21, 2026 at approximately 12:00 p.m. confirmed the above findings.”

“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: 36372 Based on a review of facility policy/procedure, patient medical record review, and an interview with the facility Administrator, the facility failed to ensure a licensed nurse was made aware of patient hypotension/change in patients condition during treatment for one (1) of seven (7) in-center patient medical records (MR) reviewed (MR#3). Findings include: A review was conducted of facility policy/procedure on January 21, 2026 at approximately 11:30 a.m. Policy ‘Intradialytic Hypotension’ ‘Purpose’ “The purpose of this policy is to provide guidelines for the prevention, recognition, and immediate treatment of symptomatic hypotension occurring during the hemodialysis treatment.” ‘Definition’ (1) “Patients pre-treatment sitting SBP (systolic blood pressure) greater than or equal to 110 mmHg (millimeters of mercury) and then drops less than 90 mmHg during the treatment. .......” ‘Policy’ “..... Staff, patient, and/or care partner will report intradialytic episodes to the nurse in charge.” A review of patient medical records conducted on January 21, 2026 between approximately 9:30 a.m. - 11:30 a.m. revealed the following: MR#3, Date of admission 03/08/21: ‘Special Attentions: “Per Nurse Practitioner/Medical Director, keep MAP (mean arterial pressure) greater than 65.” Treatment flow sheet dated 01/07/26 reviewed. Treatment initiated at approximately 7:50 a.m. Blood pressure (BP) sitting was “117/25” (entered by Employee #2, patient care technician). BP standing “Cannot assess.” 8:07 a.m.: BP was “76/49” (MAP...58), (entered by Employee #1, patient care technician). 8:31 a.m.: BP was “79/51” (MAP...60.3), (entered by Employee #2, patient care technician). 9:03 a.m.: BP was “79/57” (MAP...64.3), (entered by Employee #1, patient care technician). 9:33 a.m.: BP was “78/32” (MAP...47.3), (entered by Employee #8, patient care technician). 10:06 a.m.: BP was “67/31” (MAP...43), (entered by Employee #1, patient care technician). 10:33 a.m.: BP was “69/38” (MAP...48.3), (entered by Employee #1, patient care technician). 11:08 a.m.: BP was “63/30” (MAP...41), (entered by Employee #1, patient care technician). 11:46 a.m.: BP was “73/33” (MAP...46.3), (entered by Employee #4, patient care technician). 11:54 a.m.: BP was “80/35”, (entered by Employee #8, patient care technician). ‘Post Dialysis Vitals and Evaluation’ BP Sit: “80/35”, (entered by Employee #8, patient care technician). The patients MAP was not maintained above 65 per orders nor no documentation provided of the personal care technicians notifying the nurse in charge of the patients lowered blood pressure readings during treatment. An interview with the facility Administrator on January 21, 2026 at approximately 12:00 p.m. confirmed the above findings.”