Fkc Sayre

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 29512 Based on observations, review of policies and procedures, facility documentation, and staff interview, the facility failed to monitor the emergency cart timely and ensure that emergency supplies were not expired. Findings include: Review of the current policy entitled, “Emergency Medications, Equipment and Supplies,” revealed that “the medications and supplies ...must be maintained at the facility for emergency use. The emergency cart must be checked monthly or after use for contents, expirations, cleanliness, and proper functioning of all equipment.” Observations of the facility’s clinical area on 9/16/25 between approximately 10:00 AM and 11:45 AM revealed that 6 (six) Air life tri-flow 10 French suction catheters located in the emergency cart that expired on 9/5/25. Review of facility documentation entitled, “Crash Cart Contents,” dated July 2024, revealed that staff noted the above suction catheters were to expire on 9/5/25. There was no documentation after July 2024 (14 months prior to the survey) which indicated that staff checked the emergency cart. Interview conducted with the Facility Administrator on 9/16/25 at approximately 12:00 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: 21832 Based on review of facility policy, observations, and staff interview, the facility failed to ensure supplies were not expired. Findings include: Review of the current policy entitled, “Emergency Medications, Equipment and Supplies,” revealed that “the medications and supplies ...must be maintained at the facility for emergency use. The emergency cart must be checked monthly or after use for contents, expirations, cleanliness, and proper functioning of all equipment.” Review of the current policy entitled, “Storage of Supplies,” revealed that “supplies must be rotated first in-first out to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.” Observations of the facility’’s clinical area during a flash tour on 9/16/25 between approximately 10:00 AM and 11:45 AM revealed the following: 6 (six) Air life tri-flow 10 French suction catheters located in the emergency cart that expired on 9/5/25.”

“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: 29512 Based on a review of Facility Policies, Medical Record reviews (MR) and staff interview it was determined the facility failed to ensure the policy for blood pressure assessment was followed for two (2) of three (3) in center dialysis MR reviewed (MR#1, MR#2). Findings include: A review of facility policy Determination of Blood Pressure on 9/17/25 at 3:30 PM states, the purpose of this procedure is to provide guidance for measuring the patient’s blood pressure...Policy Incenter patients: Obtain blood pressure readings pre and post-dialysis sitting and standing (if applicable) and every 30 minutes or more during hemodialysis treatments as indicated.” Review of medical records on 9/17/25 from approximately 10:00 AM revealed the following: MR#1: Admit date 10/24/19: Treatment flow sheet dated 9/1/25 showed there was no blood pressure assessment from from 10:31 AM until 11:34 AM. Treatment flow sheet dated 9/3/25 showed there was no blood pressure assessment from from 9:31 AM until 10:31 AM. Treatment flow sheet dated 9/8/25 showed there was no blood pressure assessment from from 9:04 AM until 9:59 AM. MR#2: Admit date 11/26/24: Treatment flow sheet dated 9/11/25 showed there was no blood pressure assessment from from 10:57 AM until 12:38 AM. Treatment flow sheet dated 9/13/25 showed there was no blood pressure assessment from from 12:31 PM until 1:32 PM. An interview conducted with nurse manager on 9/17/25 at approximately 12:00 PM 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: 21832 Based on review of facility policy, observations, and staff interview it was determined the medical director failed to ensure the policy for medication security was followed. Findings include: Review of a current facility policy entitled, “Medication Preparation and Administration,” revealed that “the following steps must be taken for the (medication) securement: all medications will be kept in a locked cabinet except when in use.” Observation of the facility’s clinical area on 9/16/25 between approximately 10:00 AM and 11:45 AM revealed that there were two (2) unlocked cabinets and one (1) unlocked drawer located by the nurse’s station contained medications therein. Observation of the facility’s clinical area on 9/17/25 at 3:30 PM revealed that the above noted cabinets and drawer with medications therein continued to be unlocked. During both observations, patients were in the clinical area and receiving dialysis. An interview with the administrator on 9/17/25 at approximtely 3:45 PM confimed the above findings.”