Fkc Bryn Mawr

“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: 41684 Based on observation of the clinical area, facility policy and an interview with the Regional Operations Director, the facility did not ensure infection control procedure regarding glove removal and handwashing for thee (3) of eleven (11) observations (OBS). (OBS# 4, 5, and 6). Findings include: A review of policy “Hand Hygeine” on May 14, 2024 at 12:30 p.m states: “Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water 1) before and after direct contact with patients, 2) Entering and leaving the treatment area, 3) Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications, 4) Immediately after removing gloves, 5) After contact with bloody fluids or excretions...6) After contact with inanimate objects near the patient, 7)When moving from a contaminated body site to clean site of the same patient, 8) After contact with the dialysis wall box, concentrate...9) After contact with other objects within the patient station or treatment space...” Observation of the clinical area was conducted on May 19, 2025, between 9:40 AM through 11:50 AM revealed the following: OBS #4. Station 16, PCT 5, After removing needles from patients AV fistula/graft, PCT moved to station 17 to turn off alarming machine. Did not discard gloves, perform hand hygiene and don new gloves. OBS #5. Station 17, PCT 5, After turning off alarm from station 17, PCT moved to patient at station 16 to place clamp on AV fistula/graft site. Removed gloves, but did not perform hand hygiene and don new gloves. OBS #6. Station 16, PCT 5, After placing clamp on patients AV fistula/graft site, PCT moved to patient at station 17 to remove tubing from patient. Did not discard gloves, perform hand hygiene and don new gloves. An interview with the Regional Operations Director conducted on May 20, 2025, at approximately 1:40 PM 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 during a tour of the facility, review of policy and procedure, and interview with the Facility Administrator, it was determined, that the facility failed to maintain a functional treatment environment by storing expired medications (OBS#1) and the facility failed to provide a safe environment for access to the crash cart (OBS#2). Findings include: A review of facility policy titled, “Medication Preparation and Administration” conducted on May 20, 2025, at approximately 1:25 PM states, “Monitoring Expired Medications: Expiration dates for all stored medications are to be monitored on a monthly basis...” A review of facility policy titled, “Emergency Equipment and Supplies” conducted on May 20, 2025, at approximately 1:30 PM states, “Emergency Cart: The emergency cart should be located where is is readily accessible during medical emergency situations and shall NOT be blocked by wheelchairs, equipment, or other facility supplies...” OBS#1. A tour of the dialysis unit treatment area on May 19, 2025, at approximately 10:45 AM revealed two (2) boxes of ten (10) vials each of Vancomycin 1 gram vials with an expiration date of 5/1/2025. OBS#2. A tour of the dialysis unit treatment area on May 19, 2025, at approximately 10:50 AM revealed access to the crash cart was blocked by two (2) trash containers. An interview with the Regional Operations Director conducted on May 20, 2025, at approximately 1:40 PM 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 three (3) of seven (7) MRs reviewed, (MR # 4, 6, and 7). 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 ill 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 5/19/2025 from approximately 1:20 PM to 2:20 PM and on 5/20/2025 from approximately 8:45 AM to 10:30 AM. MR #4, Start of Care: 9/18/15. Review of treatments sheets for 5/5/2025 through 5/16/2025 revealed the following: 5/16/2025: PCT documented at 11:10 AM, B/P 104/31. PCT documented at 11:30 AM, B/P 92/39. PCT documented at 12:02 PM, B/P 90/33. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the low blood pressure. MR #6, Start of Care: 3/17/2025. Dialysis orders include: BFR (blood flow rate): 400, DFR (dialysate flow rate): 800. Review of treatment sheets 5/5/2025 through 5/16/2025 revealed the following: 5/9/2025: BFR ran at 350 during entire treatment. There was no indication of reasoning for BFR to run at a different rate than prescribed. 5/12/2025: BFR at 2:55 PM was at 350 and DFR at 800. From 3:30 PM through 6:00 PM no BFR/DFR was recorded. 5/16/2025: PCT recorded at 2:35 PM, B/P 183/104. There was no recheck of blood pressure and no documentation of RN notification of the high blood pressure. At 3:34 PM through end of treatment at 6:48 PM, BFR was running at 325. There was no indication of reasoning for BFR to run at a different rate than prescribed. MR #7, Start of Care: 1/31/2023. Review of treatment sheets 5/5/2025 through 5/16/2025 revealed the following; 5/7/2025: PCT documented at 9:55 AM. Post treatment B/P 197/70 There is no documentation of blood pressure recheck or that the PCT notified the RN of the above findings and therefore, no RN patient assessment performed at the time of occurances. 5/9/2025: PCT documented at 9:30 AM, B/P 194/82. PCT documented at 9:55 AM, post treatment B/P 194/82. There is no documentation of blood pressure recheck or that the PCT notified the RN of the above findings and therefore, no RN patient assessment performed at the time of occurances. 5/16/2025: PCT documented at 6:36 AM, pre-treatment B/P 198/76. There is no documentation of blood pressure recheck or that the PCT notified the RN of the above findings and therefore, no RN patient assessment performed at the time of occurances. An interview conducted with the Regional Director of Operations on May 20, 2025, at approximately 1:40 PM confirmed the above findings.”