Fkc Chambersburg

“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: 39848 Based on review of policy/procedures, observations (OBS.) and an interview with the Agency Unit Manager and facility administrator, the facility failed to ensure staff performed handwashing/hand hygiene and wore gloves in four (4) out of fourteen (14) observations. (OBS # 1- # 4) Findings include: Review of Fresenius Kidney Care Clinical services hand hygiene on 9/20/24 at approximately 1:00 PM revealed: “ Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination.; Responsibility: All staff, patients, patient care givers ....and any other indirect patient care staff must follow the same requirements for hand hygiene.; Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub ... ; Hands will be decontaminated using alcohol-based hand rub or by washing hands with soap and water when: Before and after direct contact with patients, Before performing any invasive procedure such as vascular access cannulation.., immediately after removing gloves, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with other objects within the patient station or treatment space ... “ Floor observations conducted on 9/19/24 between 9:15 AM-11:30 AM and 9/20/24 between 12:00 PM-12:50 PM revealed: Observation (OBS) # 1: Patient care technician (PCT) # 1 observed on 9/19/24 at 10:00 AM discontinuing treatment on patient located in station # 5 and no glove change or hand hygiene performed after pulling second needle then touching dialysis machine. OBS # 2: Patient care technician (PCT) # 1 observed on 9/19/24 at 10:20 AM discontinuing treatment on patient located in station # 6 and no glove change or hand hygiene performed after removing blood line then touching dialysis machine. OBS # 3: Patient care technician (PCT) # 2 observed on 9/19/24 at 10:23 AM initiating treatment on patient located in station # 1 and no glove change or hand hygiene performed after hooking up blood lines to touching patient ’ s belongings and patient ’ s headphones. OBS # 4: Patient care technician (PCT) # 1 observed on 9/20/24 at 12:20 PM initiating treatment on patient located in station # 12 and no glove change or hand hygiene performed after connecting blood lines to touching patient ’ s belongings. An interview conducted with the facility clinical manager and facility administrator on 9/20/24 at approximately 1:20 PM 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: 39848 Based on review of policy/procedures, observations (OBS.) and an interview with the Agency Unit Manager and facility administrator, the facility failed to ensure proper disposal of expired medication and supplies for nine (9) of nine (9) observations (OBS # 1- # 9). Findings include: Review of Fresenius Kidney Care Clinical services storage of supplies on 9/20/24 at approximately 1:00 PM revealed: “ Purpose: The purpose of this policy is to provide guidelines for storage and handling of supplies. “ ; “ Background: Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged. “ ; “ Policy: “ Supplies must be rotated First in-First out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date. “ Facility treatment floor supply observations conducted on 9/18/24 from 1:10 PM-2:30 PM revealed: Observation (OBS) # 1: Review of medication area # 2 on 9/18/24 at 1:35 PM revealed: two (2) BD Precision Glide needle eighteen (18) gauge by one and a half inch (1.5) expired 6/30/24. OBS # 2: Review of medication area # 2 on 9/18/24 at 1:35 PM revealed: one hundred seventy-four (174) BD Filter needle with five (5) micron filter nineteen (19) gauge by half (0.5) inch expired 8/31/24. OBS # 3: Review of medication area # 1 on 9/18/24 at 2:00 PM revealed: fourteen (14) Luer lock cap set expired 7/7/24. OBS # 4: Review of Home therapy exam room # 1 on 9/19/24 at approximately 11:30 AM revealed: Four (4) BD Precision Glide needle twenty-one (21) gauge by one (1) inch expired 7/31/23. OBS # 5: Review of Home therapy exam room # 1 on 9/19/24 at approximately 11:30 AM revealed: One (1) bottle Aniosgel eighty-five (85) no perfume coloring (NPC) hand sanitizing gel hand rub seventeen (17) fluid ounces expired 11/2023. OBS # 6: Review of Home therapy exam room # 1 on 9/19/24 at approximately 11:30 AM revealed: One (1) bottle Pure Bright Germicidal ultra bleach expired 7/22/24. OBS # 7: Review of Home therapy exam room # 2 on 9/19/24 at approximately 11:40 AM revealed: One (1) bottle Pure Bright Germicidal ultra bleach expired 3/28/24. OBS # 8: Review of Home therapy exam room # 2 on 9/19/24 at approximately 11:40 AM revealed: eighty-five (85) Ultra-low total chlorine test strips expired 6/30/24. OBS # 9: Review of Home therapy exam room # 2 on 9/19/24 at approximately 11:40 AM revealed: Two (2) full boxes of 3M transpore surgical tape twelve (12) rolls per box expired 3/1/24. An interview conducted with the facility clinical manager and facility administrator on 9/20/24 at approximately 1:20 PM confirmed the above findings.”

“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: 39848 Based on observations and an interview with the facility unit manager and the facility administrator; the facility failed to maintain the integrity of the walls and the floors within the dialysis treatment area for seven (7) of seven (7) observations. (OBS #1-# 7) Findings include: Observation (OBS) # 1: Clean sink # 2 sink drain noted to be rusty and showing signs of corrosion, two (2) inches by two (2) inches circular hole noted under sink. OBS # 2: Dirty sink # 6 noted to have large, deep circular hole left back corner and cracks to sink floor. OBS # 3: Clean sink # 5 drain noted to be very rusty and signs of corrosion. OBS # 4: Floor behind treatment station # 4 revealed water damage. OBS # 5- # 7: multiple areas of water damage noted to floors around dialysis treatment stations and multiple nicks noted in the wood boards behind the dialysis treatment chairs. An interview conducted with the facility clinical manager and facility administrator on 9/20/24 at approximately 1:20 PM confirmed the above findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 39848 Based on review of policy, medical records (MR), and an interview with the facility administrator; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for one (1) out of five (5) patient prescriptions reviewed (MR # 1). Findings include: Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 9/20/24 at approximately 1:00 PM revealed: “ Purpose: The purpose of this policy is to provide guidance to Fresenius kidney care (FKC) direct patient care staff on assessment and monitoring patients before, during and after treatment.; Definitions: Date Collection: Gathering of objective and subjective information related to the patient ’ s health status as it corresponds to the ordered renal replacement.; During treatment: Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations.. “ ; “ Follow the steps below for monitoring patient and machine parameters during treatment: Machine parameters and extracorporeal circuit: Check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow setting is correct, and the prescribed flow is being delivered. “ Review of Fresenius Kidney Care Clinical services safety checks on 9/20/24 at approximately 1:00 PM revealed: “ Purpose: The purpose of this policy is to provide guidance on safety checks to prevent, detect, and treat complications; Policy: Safety checks will be performed pretreatment and every thirty (30) minutes or more frequently as needed once the treatment has begun. “ On September 20, 2024, between approximately 9:35 AM and 11:00 AM, review of patient orders and dialysis treatment flow sheets revealed: MR # 1: Start of care (SOC): 7/31/24: Physician orders dated: 7/31/24:”Blood Flow Rate (BFR) 350 and Dialysate Flow Rate (DFR) 700. Treatment flow dated: 9/5/24 showed DFR: 800. No documentation explaining the DFR difference from the prescribed DFR. No documentation showing the physician was notified. Treatment flow dated: 9/12/24 showed DFR: 800. No documentation explaining the DFR difference from the prescribed DFR. No documentation showing the physician was notified. Treatment flow dated: 9/14/24 showed BFR: 400 and DFR: 800. No documentation explaining the BFR and DFR difference from the prescribed BFR and DFR. No documentation showing the physician was notified. An interview conducted with the facility clinical manager and facility administrator on 9/20/24 at approximately 1:20 PM confirmed the above findings.”