Fkc Oil City

“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: 31759 Based on review of facility policy, observation (OBS), and staff (EMP) interview, the facility failed to ensure patients performed hand hygiene immediately after glove removal for one (1) of two (2) observations of discontinuation of dialysis with an arteriovenous fistula (AVF) (OBS#5.1). Findings included: Review of facility policy and procedure on December 17, 2025, at 11:30 a.m. showed, “Post Treatment Needle Removal ... Procedure ... Step 2. If the patient will be holding pressure on the [needle] site, assist patient in gloving hand to reduce blood contamination. ... 12. Remove and discard gloves. Perform hand hygiene per policy. Instruct patient holding the sites to perform hand hygiene.” Review of facility policy and procedure on December 17, 2025, at 11:30 a.m. showed, “Hand Hygiene ... The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. All staff, patients, ... must follow the same requirements for hand hygiene. ... Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ... When ... Immediately after removing gloves.” Observation (OBS#5.1) of discontinuation of dialysis with an AVF on December 15, 2025, at 10:35 a.m. at station 6 revealed EMP5 remove needles from patient’s arm, and cover sites with gauze dressing. The patient held pressure to gauze dressings with a gloved right hand to stop bleeding. Once bleeding had stopped, the patient removed his/her glove, gathered his/her belongings, and left the station without performing hand hygiene. Interview with EMP5 (registered nurse) after the observation at 10:45 a.m. confirmed findings.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 31759 Based on review of facility policy, National Kidney Foundation (NKF) Guidelines, observation (OBS), and interviews with staff (EMP) and patients, the facility failed to ensure one (1) of two (2) patients with an arteriovenous fistula (AVF) washed their access prior to disinfection of the AVF and initiation of dialysis (OBS#4.1). Findings included: Review of facility policy on December 17, 2025, 11:30 a.m. showed, “Access Assessment and Cannulation ... Assessment of Vascular Access Follow the steps below to assess the vascular access: Step 1 Action Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure.” According to NKF Guidelines, “Tips for Everyday Care of Your AV Fistula or Graft Prevent Infection ... Wash your access site before every dialysis treatment. Your dialysis center has hand washing sinks and antimicrobial soap.” Retrieved from https://www.kidney.org/sites/default/files/11-50-0216_va.pdf Observation (OBS# 4.1) on treatment floor on December 17, 2025, 11:30 a.m. revealed patient walk from waiting area to scale for assessment. The patient did not wash his/her access. The patient then proceeded to station 2 where EMP11 wiped the patient’s AVF with a disinfectant wipe, inserted both needles, and initiated dialysis. Interview with patient during her treatment confirmed she did not was her access. Interview with registered nurse (EMP8) who assessed patient prior to her walking to station 2 confirmed findings.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 31759 Based on review of facility policy, observation (OBS), and staff (EMP) interview, the facility failed to ensure a near miss incident was reported and documented for one (1) of one (1) observed dialysis prescription error near miss (OBS#5.2) Findings included: Review of facility policy on December 17, 2025, at 10 a.m. showed, “Patient Safety Event Reporting and Documentation ... The purpose of this policy is to provide guidelines for all clinical staff on identifying, reporting and documenting patient related Near Misses, Safety Events and Serious Safety Events in the In-Center and Home Therapy setting to: Provide a standardized process for management for all patient related safety events as defined in this policy ... Promote a culture of patient safety ... Definitions ... [A] Near Miss does not result in patient clinical harm, either through early detection or sheer luck. It is an unsafe situation that is indistinguishable from a safety event except for the outcome. ... Policy When a Near Miss ... event occurs, staff are required to report, document, and review the event as noted in this policy ... NEAR MISS ... Clinical Staff to notify: Clinic Manager ... Clinical Staff will perform documentation in the: ... Patient medical record if appropriate. Patient Safety Data Entry Site ... Clinical Manager or facility designee will review during Quality Assessment and Performance Improvement [QAPI] ... Below is a table that includes a list of categories, ... TREATMENT ORDERS NOT MET ... Incorrect Needle Used.” Review of facility policy on December 17, 2025, at 12 p.m. showed, “Quality Assessment and Performance Improvement Program (QAPI) ... The QAPI Committee will monitor data/information; prioritize areas for improvement; determine potential root causes; develop, implement, evaluate, and revise action plans that result in sustainable improvements in patient care. Elements to be reviewed in the QAI meeting include: ... Patient safety.” Observation (OBS#5.1) of initiation of dialysis with an arteriovenous fistula on December 16, 2025, at 10:10 a.m. at station 14 revealed EMP4 preparing to initiate the patient’s treatment. Just prior to inserting needles into the patient’s arm, EMP4 noted one of the patient’s two needles in her setup kit was the incorrect size (a near miss). EMP4 then left the station, retrieved the correct size needle, and initiated treatment. During interview with EMP1 (clinic manager) on December 17, 2025, at 11 a.m. he/she confirmed that EMP4 had not mentioned the above prescription error near miss to him/her. EMP1 then reviewed incident reports and confirmed it was also not documented, and that EMP4 was not on duty this date (his/her scheduled day off).”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 31759 Based on review of facility policy, clinical records (CR), hospitalization logs, infection logs, and staff (EMP) interview, the facility failed to record (centralized log book) and follow up on all patient infections in order to analyze and document the incidence of infections to identify trends and establish baseline information on infection incidence; develop recommendations and action plans to minimize infection transmission, promote immunization; and take actions to reduce future incidents for three (3) of three (3) incenter hemodialysis patients hospitalized for infections (CR1, CR2, & CR3). Findings included: Review of facility policy on December 17, 2025, at 12 p.m. showed, “Quality Assessment and Performance Improvement Program (QAPI) ... The QAPI Committee will monitor data/information; prioritize areas for improvement; determine potential root causes; develop, implement, evaluate, and revise action plans that result in sustainable improvements in patient care. Elements to be reviewed will include: ... Infection Surveillance.” Review of “Absence and Hospitalization” report from 6/15/2025 to 12/15/2025 on December 16, 2025, at 1 p.m. showed CR1 was admitted to hospital on 8/1/2025 for a urinary tract infection; CR2 was admitted to hospital on 9/26/2025 with Severe sepsis with septic shock and pneumonia; CR3 was admitted to hospital on 8/12/2025 with a urinary tract infection, and again on 10/18/2025 with another urinary tract infection and sepsis. Review of CR1 on December 17, 2025, at 9:30 a.m. showed a history and physical from 8/1/2025 hospitalization when patient was admitted and treated for a urinary tract infection (UTI) and acute bacterial bronchitis. Review of CR2 on December 17, 2025, at 9:40 a.m. showed a history and physical from 9/27/2025 hospitalization when patient admitted with sepsis related to pneumonia Review of CR3 on December 17, 2025, at 10 a.m. showed a history and physical from 8/12/2025 hospitalization when patient was admitted and treated for UTI sepsis. The patient was subsequently admitted for another UTI on 10/18/2025 with eventual discharge on 11/1/2025. Review of “Monthly Infection Tracking” log on December 17, 2025, at 10:30 a.m. did not show the above infections for CR1, CR2, and CR3 listed. Interview with EMP1 (clinic manager) on December 17, 2025, at approximately 11 a.m. confirmed above findings.”