Fmc Dialysis Services Andrews

“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: 22313 Based on observations and interview, the facility failed to ensure the Water Treatment Room was free of debris and clutter. The findings include: Observations in the Water Treatment Room on 2/13/2024 at 10:00 AM revealed the room had boxes/supplies stored on the floor. Salt pellets were observed near water treatment room sidewalls and under equipment. In an interview with the Biomedical Technician (BMT) #1 on 02/13/2024 10:15 AM, BMT #1 stated, “Yeah, it’s really crowded back here.””

“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: 30011 Based on observations, interviews, and review of facility policy and procedure, the dialysis facility failed to ensure 1 of 2 Registered Nurses (RN) failed to don the glove when touching the dialysis machine. (RN #2) The findings include: Observations on 02/14/24 at 09:30 AM in the dialysis treatment room revealed Registered Nurse (RN) #2 in dialysis station #5 silencing the dialysis machine alarm. RN #2 wrapped the glove around one finger and silenced the dialysis machine alarm in dialysis station #6. Observations on 02/14/24 at 9:45 AM in the dialysis treatment room revealed RN #2 silenced the dialysis machine alarm in dialysis station #6 with the glove wrapped around one finger. During an interview on 02/14/24 at 1:55 PM, RN #2 stated, “We are to use gloves every time we touch the machines.” Facility policy, entitled, “Personal Protective Equipment”, revealed, “Disposable gloves must be used...When touching any part of the dialysis machine or equipment at the dialysis station...”.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 22313 Based on observations, interviews, and review of facility policy and procedure, the facility failed to ensure patients and staff wear masks during dialysis treatment, and failed to ensure staff removed personal protective equipment (PPE) prior to exiting the dialysis treatment room. (Medical Doctor #1) The findings include: Random observations in the dialysis treatment room on 2/13/2024 at 1:40 PM revealed the patients in dialysis station #1, #3, #5 and #11 had face masks positioned below their nose/mouth during dialysis treatment. In an interview with Certified Clinical Hemodialysis Technician (CCHT)#2 at 1:56 PM, CCHT #1 stated, “We can’t make them if they don’t want to.” Facility policy, entitled, “Infection Control Practices”, reads, “.....patients and visitors are required to wear surgical face masks upon entry to the dialysis clinic and throughout the duration of dialysis treatment and discharge from the clinic post-treatment. Staff should ensure that the patient’s face mask is properly positioned over nose and mouth before approaching the patient.” 30011 Observations on 02/13/24 from 12:40 PM to 1:00 PM revealed Medical Doctor (MD) #1 rounding in the dialysis treatment room donned PPE. After rounding, MD #1 exited the dialysis treatment room wearing the PPE. During an interview on 02/14/24 at 8:40 AM, the Clinic Manager (CM) stated, “The MD is supposed to leave the PPE on the inside of the dialysis treatment room.” Facility policy, entitled, “Personal Protective Equipment”, revealed, “All Personal protective equipment shall be removed prior to leaving the treatment area...”.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 30011 Based on observations, interview, and review of facility policy, titled, “Medication Preparation and Administration”, reads, “Medications shall be prepared in a clean work area away from dialysis patient stations and delivered separately to each patient...”. , 1 of 2 Registered Nurses (RN) transported multiple patients’ medications to patients in the dialysis treatment room. (RN #2) The findings include: Observations on 02/13/24 at 11:24 AM in the dialysis treatment room revealed RN #2 transporting multiple labeled patients’ syringes with medication placed a syringe on top of the dialysis machine in dialysis station #4 that had no patient, dialysis station #7 with a patient, dialysis station #1 with a patient, and dialysis station #2 with no patient. Observations at 11:24 AM revealed RN #2 obtained the syringe on top of the dialysis machine in dialysis station #1 and administered the intravenous push medication to the patient. At 11:26 AM, RN #2 obtained the syringe on top of the dialysis machine in dialysis station #7 and administered the medication intravenous push. Observations on 02/13/24 at 12:35 PM in the dialysis treatment room revealed RN #2 transporting multiple cups of oral medications and placed the medication filled cup on the bedside table at dialysis station #1 and #2. Observation at 12:38 PM revealed RN #2 placed a cup of medication on the bedside table at dialysis station #6 and #7. During an interview on 02/14/24 at 1:56 PM, RN #2 stated, “Meds (medications) are to be passed out one at a time.””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 22313 Based on observations and interview, 1 of 2 Registered Nurses (RN) failed to clean the stethoscope before using the stethoscope to assess the patient. (RN #2) The findings include: Observation on 2/13/2024 at 10:46 AM in dialysis station #9 revealed RN #2 removed a stethoscope from around her neck, did not clean the bell of the stethoscope before assessing the patient. On 2/13/2024 at 1:45 PM, RN #2 stated, “I didn’t know I was doing that.””

“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: 30011 Based on observations, interview, and review of facility policy and procedure, the dialysis facility failed to ensure expired supplies were removed from the dialysis treatment room. The findings include: Observations on 02/14/24 at 9:15 AM in the dialysis treatment room revealed (11) Povidone-Iodine prep pads expired 10/22 and (60) Povidone-Iodine prep pads expired 11/23. During an interview on 02/14/24 at 9:16 AM, Registered Nurse (RN) #2 stated, “The techs (technicians) stock the supply carts but we don’t use these anymore.” Facility policy, entitled, “Expiration Dates Sterile supplies”, revealed, “Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date”.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 30011 Based on observations, interview, facility policy and procedure, and manufacturer’s guidelines, the dialysis facility failed to ensure Minncare disinfectant used for disinfection of the CWP reverse osmosis system was labeled accurately, and the CWP was disinfected weekly per manufacturer guidelines. The findings include: Observations on 02/13/24 at 10:04 AM in the water treatment room revealed the Minncare jug located in the CWP had the following dates on the back of the jug: 11/25/23, 12/11/23, 12/26/23 with the date 02/09/24 on the side of the jug. The expiration date on the jug was 05/29/24. During an interview on 02/13/24 at 2:10 PM, the Biomedical Technician (BMT) stated, “I have been mixing the jugs when they get to the bottom as long as it’s the same lot number and expiration date because these jugs are expensive, and I’m trying not to waste anything.” Review of the facility’s “CWP Disinfect Start” logs dated February 2024 on 02/14/24 at 1:40 PM revealed a Minncare disinfection was performed on 02/01/24. Observations of the Minncare container revealed no documentation on the container for the disinfection dated 02/01/24. During an interview on 02/14/24 at 2:15 PM, Certified Clinical Hemodialysis Technician (CCHT) #1 stated, “I draw a line on the bottle when I finish. I did not do the disinfect on 02/01/24. I was off that day.” During an interview on 02/14/24 at 2:41 PM, the BMT stated, “I will have to research to see who it was that performed the disinfection that day.” Review of manufacturer guidelines on 02/05/24 at 1:48 PM revealed, “Step 6 Mark the fluid level and the date on the disinfectant container with a permanent marker...”. Review of the facility’s “CWP Disinfect Start” logs dated December 2023 on 02/14/24 at 1:40 PM revealed a Minncare disinfection was performed on 12/01/23 with the next Minncare disinfection documented on 12/11/23 which was greater than 7 days. During an interview on 02/14/24 at 2:45 PM, the BMT stated, “We had a weather issue during that time, but it wasn’t as bad as we thought it would be, and they decided to make up for it on Monday. I don’t have any documentation related to our decision to do that.” Review of the manufacturer guidelines on 02/14/24 at 2:25 PM revealed, “As a guideline, MCP (Mar Cor Purification) recommends a minimum weekly chemical disinfection to ensure consistent product water microbiological quality...”.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 22313 Based on observations, review of facility policy, entitled, “Patient Assessment and Monitoring”, and interviews, the facility failed to ensure the patients’ access remained uncovered throughout the dialysis treatment. (Random Patient A, B, C, D, and E) The findings include: Observations on 02/13/2024 at 9:58 AM and 10:45 AM revealed Patient A at dialysis station #10, Patient B at dialysis station #8, and Patient C at dialysis station #2 had covered accesses at 9:58 AM. At 10:45 AM, Patient D at dialysis station #4 and Patient E at dialysis station #2 had covered accesses. In an interview with RN#2 at 10:48 AM, RN #2 stated, “They like to get up under those covers. We can uncover them, but they just cover them up again.” Facility policy, entitled, “Patient Assessment and Monitoring”, reads, “Access: Observe connections are secure and visible. Ensure access remains uncovered throughout the treatment.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 22313 Based on patient record review, interview, and review of the facility’s policy and procedure, the dialysis facility failed to ensure the physician authenticated the patient’s plan of care (poc) for 1 of 4 patient charts reviewed. (Patient.#1) The findings include: Record review on 2/14/2024 at 9:00 AM for Patient #1 revealed the patient was admitted on 11/28/2023 with a diagnosis of End Stage Renal Disease (ESRD). The patient’s chart revealed an interdisciplinary team (IDT) meeting for dated 12/6/2023. The IDT signatures on the patient’s plan of care revealed the physician did not sign the patients plan of care on 12/6/2023. The Registered Nurse, Social Worker, and Registered Dietitian were the only signatures dated 12/06/2023. During an interview on 2/15/2024 at 9:30 AM, the Clinic Manager verified the findings. 30011 Record review on 02/14/24 at 12:28 PM for Patient #2 revealed the patient was admitted on 03/13/19 with a diagnosis of End Stage Renal Disease (ESRD). Review of Patient #2’s Interdisciplinary team (IDT) Plan of Care (POC) meeting dated 04/06/23 revealed the physician signed the patient’s POC on 04/16/23, Registered Nurse (RN) on 04/07/23, Social Worker (SW) on 04/06/23, and the Registered Dietician (RD) on 04/06/23. During an interview on 02/14/24 at 9:00 AM, the Clinic Manager (CM) verified the findings.”