Fkc Episcopal

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 41684 Based on review of facility policy, observation, and an interview conducted with the Facility Administrator and Regional Director of Operations agency failed to ensure prepared filled syringes were separated from patient access areas and were not on medication carts and trays, (OBS #3). Findings included: A review of facility policy titled “Medication Preparation and Administration” conducted on June 11, 2025 at approximately 12:45 PM states, “Medications shall be prepared in a clean work area away from dialysis patient stations and delivered separately to each patient. Common medication carts and trays shall not be used to deliver medications from patient station to patient station. “ OBS #3 on 6/11/25 at approximately 10:05 AM revealed one (1) unlabeled heparin filled syringe sitting on top of a supply cart in front of station #9 in a patient access area. An interview conducted with the Facility Administrator and Regional Director of Operations on June 12, 2025, at approximately 10:00 AM confirmed the above findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 41684 Based on observations (OBS), review of facility policy and an interview with the facility administrator and regional director of operations, the facility failed to ensure staff/employees follow its policy for medication preparation for three (3) of three (3) medication preparation observations (OBS#1, 2, and 3). Findings include: A review of policy titled “Medication Preparation and Administration” on 6/11/25 at approximately 12:00 PM states, “Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with a new alcohol pad each time the vial is accessed with a needle using friction and 70% alcohol...” Observation of the treatment area was conducted on 6/11/25, from approximately 9:30 A.M. to 11:45 AM. OBS#1 was conducted on 6/11/25 at approximately 10:00 AM. Medication preparation performed by PCT #1. PCT #1 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial. OBS#2 was conducted on 6/11/25 at approximately 10:10 AM. Medication preparation performed by PCT #1. PCT #1 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial. OBS#3 was conducted on 6/11/25 at approximately 10:15 AM. Medication preparation performed by PCT #1. PCT #1 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial. An interview with the facility administrator and regional director of operations on 6/12/25, at approximately 10:00 AM confirmed the above findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 41684 Based on observations of the treatment area, and an interview with the facility administrator, the facility failed to maintain a safe, functional, and comfortable treatment environment for one (1) of one (1) observation, (OBS #2). Findings include: Facility was unable to provide a policy referring to item observed. Observation of the treatment area was conducted on 6/11/25, from approximately 9:30 AM to 11:45 AM. OBS #2. At approximately 10:10 AM, PCT #2 was observed plugging a patient’s electric blanket into the wall socket behind station #15. An interview with the facility administrator and regional director of operations conducted on 6/12/25, at approximately 10:00 AM confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 41684 Based on a review of facility policy, medical records (MR), and an interview with the Regional Director of Operations, the facility did not follow its policy for patient assessment and monitoring for five (5) of seven (7) MRs reviewed, (MR #1, 3, 4, 5. and 6). Findings include: A review of facility policy titled “Patient Assessment and Monitoring” conducted on September 11, 2024 at approximately 11:15 AM states, “If the PCT/LPN (patient care technician/licensed practical nurse) note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The nurse will notify the patient’s physician of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The registered nurse will assess/re-assess any findings addressed pre or during treatment as needed...During treatment: Blood Pressure: Recheck blood pressures after a drop that requires interventions...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings, Report to the nurse: Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressures greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic...Reported by patient: Report to the nurse any complaints by the patient during treatment...Document any findings and interventions in the medical record...Safety/Machine checks: Verify dialysate lines are attached and in correct position and DFR (dialysate flow rate) BFR (blood flow rate) and UFR (ultra filtration rate) is set and functioning per treating physician order...” A review of MRs was conducted on 6/11/2025 from approximately 12:15 PM to 2:00 PM. MR #1, Start of Care: 4/17/25. Dialysis orders included: BFR: 400; DFR: Manual 800. Review of treatment sheets for 5/29/2025 through 6/10/2025 revealed the following: 5/29/2025: DFR ran at 500 from 10:49 AM through 2:37 PM. There was no indication of reasoning for DFR to run at a different rate than prescribed. 6/5/2025: DFR ran at 700 from 10:50 AM through 2:50 PM. There was no indication of reasoning for BFR to run at a different rate than prescribed. 6/10/2025: DFR ran at 700 from 11:02 AM through 2:36 PM. There was no indication of reasoning for BFR to run at a different rate than prescribed. MR #3, Start of Care: 9/5/2023. Review of treatment sheets for 5/29/2025 through 6/10/2025 revealed the following: 6/10/2025: At 7:02 AM, RN documented B/P of 93/49. There is no documentation of a recheck of the blood pressure and no documentation of any interventions or assessment completed. MR #4, Start of Care: 10/14/15. Review of treatments sheets for 5/28/2025 through 6/9/2025 revealed the following: 5/28/2025: PCT documented at 6:00 AM, B/P 200/106. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the high blood pressure. Therefore, no documentation of any interventions or assessment was completed. 5/30/2025: PCT documented at 7:33 AM, B/P 84/48. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the low blood pressure. Therefore, no documentation of any interventions or assessment was completed. 6/6/2025: PCT documented at 6:05 AM, B/P 192/101. PCT documented at 6:34 AM. B/P 181/103. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the high blood pressure. Therefore, no documentation of any interventions or assessment was completed. MR #5, Start of Care: 3/2/2017. Dialysis orders include: BFR: 350; DFR: Manual 800. Review of treatment sheets for 5/28/2025 through 6/9/2025 revealed the following: 5/30/2025: DFR ran at 600 from 7:02 AM through 8:03 AM. There was no indication of reasoning for BFR to run at a different rate than prescribed. 6/4/2025: DFR ran at 600 from 6:02 AM through 8:15 AM. There was no indication of reasoning for BFR to run at a different rate than prescribed. 6/9/2025: DFR ran at 600 from 5:31 AM through 8:48 AM. There was no indication of reasoning for BFR to run at a different rate than prescribed. MR #6, Start of Care: 2/4/2025. Dialysis orders include: BFR: 350, DFR: Manual 800. Review of treatment sheets 5/28/2025 through 6/9/2025 revealed the following: 5/28/2025: DFR ran at 600 from 5:13 AM through 9:25 AM. There was no indication of reasoning for DFR to run at a different rate than prescribed. 6/4/2025: DFR ran at 600 from 7:36 AM through 9:01 AM. There was no indication of reasoning for DFR to run at a different rate than prescribed. 6/6/2025: DFR ran at 700 from 8:33 AM through 9:15 AM. There was no indication of reasoning for DFR to run at a different rate than prescribed. 6/9/2025: DFR ran at 600 from 6:35 AM through 9:13 AM. There was no indication of reasoning for DFR to run at a different rate than prescribed. An interview conducted with the Facility Administrator and Regional Director of Operations on 6/12/25, at approximately 10:00 AM confirmed the above findings.”