Fmc San Juan

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47632 Based on observations made in the treatment area on 03/04/2025, it was determined that the facility failed to monitor the environment to ensure its sanitation and reduce the potential transmission of infectious agents within and between units, due to the lack of adherence to “standard precautions”. Findings include: During the observations made in the treatment area on 03/04/2025, the following was observed: 1. On 03/04/2025 at 10:27 AM, two (2) pots of Water Check Residual Chlorine were observed with no date when they were opened. 2. On 03/04/2025 at 10:31 AM, two (2) pots of Dyna-Hex 2 were observed with no date when they were opened. 3. During the observations made in the medication room with the employee #5 on 03/04/20225, the following was observed: a. On 03/04/2025 at 10:57 AM, thirteen (13) vial of Promethazine HCL 25 mg/ml expired on 02/2025. b. On 03/04/2025 at 11:04 AM, one (1) vial of Tuberculin Purified Protein was observed with no date when they were opened. c. On 03/04/2025 at 11:080AM, one (1) bottle of LiquaCel 16 gm protein was observed with no date when they were opened. The facility failed to ensure that the medications were labeled when they were opened, due to the increased potential for contamination with microorganisms. 47384 4. During the observations made in the treatment area on 03/04/2025, the following was observed: a. Sharp containers were observed with syringes and other biomedical waste were observed past the fill limit line. b. Drops of blood were observed on top of the lid of the Sharp container. 51829 5. On 03/04/2025 at 9:50 AM and 10:10 AM during the facility visit in the direct patient care area the following was identified: a. Two nursing professionals (# 2 and # 3) present use of gel coating on their nails. 17959 6. During the visual inspection in the hemodialysis treatment performed on 03/04/2025 at 9:15 AM through 12:30 PM it was observed the following: a. On 03/04/2025 at 9:10 AM during the disconnection process of patient located on station #10 it was observed that the female patient has a catheter on right side of her neck and maintain Oxygen at 3 liters by nasal canula. The register nurse (RN) employee #1 did not wash her hands and did not used a gloves, prepare the materials used to the disconnection process and place it on the right side of the treatment chair then went to the medication room, she removed her gown and placed it on the stand located in front of the room, she enter the room, did not wash her hands and did not put on gloves, took a medicine vial, did not disinfect the base of the medicine bottle she inserted the syringe needle and removed a portion of medicine. RN left the medicine room put on her gown and went to patient station #10, put a syringe on the right folding table. She put a pair of gloves however, did not wash her hands and then administered the medication, removed her gowns and discard cleaning her hands with hand sanitizer put another pair of gloves management the dialysis machine then with the same gloves took a blood sample of the catheter, removed her gloves and puts a pair of gloves management the hemodialysis machine and patient lines removed her gloves performed a dry cleaning removed and discard her gloves and goes to the medication room performed a handwashing with soap and water, prepare a syringe with heparin did not clean the bottle surface put a gown apply hand sanitizer and put a gloves. She removed the first line, disinfected and administered Heparin then removed the second line and discard, removed her gloves and applied hand sanitizer and gloves her hands, discard materials, removed gloves took a blood sample and goes to the laboratory area apply hand sanitizer and put a pair of gloves. Disinfected stethoscope and performed a respiratory assessment, disinfected stethoscope take patient blood pressure goes to the weight scale and weight the patient. She performed hand washing with soap and water. 7. On 03/04/2025 at 9:40 AM during the disconnection process of patient located on station #5 machine #16 it was observed that the male patient has a catheter on left side of his left thigh. The register nurse (RN) employee #2 did not wash her hands with soap and water performed dry cleaning with hand sanitizer put a pair of gloves prepare the materials used to the disconnection process then removed her gloves performed dry cleaning with soap and water however did not performed the hand washing accordance of the hand washing protocol before apply soap then apply a portion of water and soap dry her hands and rinse, then put a pair of gloves management the computer then continue the disconnection process, covered the area. When the disconnection finished, the patient went to the scale. However, the nurse did not perform the disconnection process according to policies and procedures. 8. On 03/04/2025 at 9:45 AM a patient bag was observed on the left side of the treatment chair station #7. 9. On 03/04/2025 at 9:50 AM during the observational round on station #8 between station #9 lacks biohazard trash can. 10. On 03/04/2025 at 10:08 AM sharp container located on the right side of the hemodialysis machine station#2 was observed the right side outside the screw loose, used syringes with blood content was observed on the interior of the sharp container. 11. On 03/04/2025 at 10:09 AM a large portion of water was observed on the floor between station #1 and #2. 12. On 03/04/2025 at 10:43 AM in patients stations #29, # 30, #31, #32, #33 and #34 dust and dirty were observed on the borders of the floor. 13. On 03/04/2025 at 10:43 AM one (1) plastic pot of Dyna-HEX 2 Lote 1021-154 Expired on 01/2026 lacks identification label and lack of signed and date when they were opened. 14. On 03/04/2025 at 10:45 AM one (1) plastic pot of Residual Chlorine (Water Cheek - RC ) Reagent Strips with bleach Indicator were observed and did not have of the date when they were opened and lack of signed. Lot- 2304303021 Expired on10/2025. 15. On 03/04/2025 at 10:45 AM brown spots were observed at the base of the hemodialysis machines. 16. On 03/04/2025 at 10:45 AM in patient station #3 dried blood stains were observed on the surface of the sharp container. 17. Pieces of paper were observed on different areas of the dialysis unit. 18. The television cables located on the panel at the back behind the hemodialysis chairs were observed directly on the floor. 19. On 03/04/2025 at 10:45 AM in different patient station white spots were observed on the surface and around the biohazard container. 20. Table of two boards located in the center of the unit was observed with dust and dirt. The first tablet showed a plastic basket and the inside wipes with Clorox 1:100 used to clean the hemodialysis chairs when the patient finishes treatment. In the second tablet, a bottle of Citrus II, a roll of tape, a face shield and a large cuff were observed. 21. The facility nurses failed to perform the connection and disconnecting process according to the Centers for Disease Control- CDC. The nurses change the gloves and wash hands with hand sanitizers not in accordance with the CDC guideline. CDC: RR-05 Wear disposable gloves when caring for the patient or touching patients’ equipment at the dialysis station. Staff must remove gloves and wash hands between patients or stations.”

“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: 47384 Based on observations made in the treatment area on 03/04/2025, it was determined that the facility failed to keep the facility maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. Findings include: 1. Water damage stains were observed on ceilings tiles of patient bathroom inside the unit. 2. Signs of wear were observed on the wooden doors of the bathrooms in the waiting area.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47632 Based on observations made in the treatment area on 03/04/2025, it was determined that the facility failed to ensure that all equipment is maintained and operated in accordance with the manufacturer’s recommendations. Findings include: During the observations made in the crash cart with the Charge Nurse employee #5 on 03/04/2025, the following were found: 1. On 03/04/2025 at 10:47 AM, seven (7) tracheostomy masks were observed expired on 01/2024. 2. On 03/04/2025 at 10 54 AM, it was observed that the oxygen tank regulator did not work and had a mechanic wrench instead of an appropiate oxygen tank key which was corrected. 47384 During observation of treatment area the followiwing was found: 3. Labtop power cords on computer #2 and Buffer Zone computer were observed with exposed electrical wiring not being protected by required plastic cover. 4. Dialysis machine on station #23 was observed with side leakage, personel was informed and machine was removed from unit. Apparent O-ring damage on machine.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, during the first shift and second shift of 03/04/2025 from 8:30 AM through 3:30 PM, it was determined that the facility failed to maintain Life Safety measures that complies with NFPA 101 (Life Safety Code), NFPA 99 (Health Care Facilities Code), NFPA 80 (Standard for Fire Doors and Other Opening Protectives) which could affect all patients receiving treatment and staff. Findings include: 1. Fire extinguisher was observed blocked by trash can, next to fire emergency exit in the waiting room. 2. Exit discharge leading to the interior parking lot, has a ramp which poses a safety risk for the evacuation of patients in wheelchairs or treatment chairs. It does not comply with NFPA 101 7.2.5. 3. At the moment of the survey, no written evidence that the fire doors in the facility had been inspected. To ensure that fire doors are working properly NFPA 80 (Standard for Fire Doors and Other Opening Protectives) section 5.2.1 mandates that fire doors should be inspected and tested at least once a year. 4. It was observed that the emergency exit leading to the rear parking lot of the unit (loading dock) has an aluminum door that does not comply with the NFPA 80 Fire Door regulation and code (it does not have a fire rating). 5. The following was observed on the fire pump room: a. Pressure gauge was observed missing plastic protective cover. b. Sprinkler heads were observed with plastic covers used for installation that should be removed. c. Penetration on compartment wall was observed sealed with a non-fire resistant material.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47632 Based on policies and procedure reviewed, observations, twelve (12) records reviewed (RR) on 03/04/2025 through 03/05/2025, it was determined that the facility failed to ensure monitor and document the patients’ blood pressure (B/P) and document nurse action when patients present hypotension and/or hypertension during dialysis treatment for 1 out of 12 record review (R.R #3). Findings include: 1. R.R #3 is a 69-year-old male admitted to the facility on 01/30/2025 with a diagnostic End Stage Renal Disease. During the record review performed on 03/05/2025 at 10:04 AM, the hemodialysis treatment three a week for four hours, Dializaer 180 NRe Optiflux, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 62 kilograms (kg). a. On 02/06/2025 at 6:34 PM, it was revealed that the Blood Pressure (BP) was 185/73mg/Hg. b. On 02/13/2025 at 3:20 PM through 4:32 PM, it was revealed that there was no presence of vital signs taken for one (1) hour and ten (10) minutes and 5:38 PM through 6:31 PM, it was revealed that there was no presence of vital signs taken for fifty-three (53) minutes. No evidence was found of nursing interventions or documentation for hypertension and vital sings.”

“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: 47384 Based on observational tour of the patient treatment area during the first shift, on 02/23/2023 from 8:00 AM through 12:00 PM, it was determined that the facility failed to be maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. Findings include: 1. Excessive dust particles were observed on top of counter tops behind treatment stations and on corners of floors. 2. Moisture damage was observed on the bottom part of gypsum board wall near station #31 3. It was observed on the area of stations #6 and #7 that the acoustic tiles were detached from the cross tee, this represents a risk of falling on patients.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47384 Based on observational tour of the patient treatment area during the first shift, on 02/23/2024 from 8:00 AM through 12:00 PM, it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. One of one emergency equipment cart was observed with expired equipment.This can affect 113 of 113 patients receiving treatment. Findings include: During inspection of the faclities emergency cart on 02/23/2024, 33 syringes (#18 gauge) were expired since June 30, 2022 and were at the cart for use with patients.”