Dci Shelbyville

“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: 46831 Based on facility policy review, observation, and interview, the facility failed ensure all medications were in date for 1 of 1 (4/21/2025) days of observation on the treatment floor. The findings included: 1. Review of the facility policy “MEDICATION STORAGE” dated 09/01/2021, revealed, “...Medications will not be expired...” 2. Observations on the treatment floor on 4/21/2025 at 11:40 AM, revealed a bottle of Loperamide Hydrochloride Capsules 2 mg expiration date of 2/2025. The bottle had an opened date of 3/14/2025. An opened bottle of Glucose tablets was observed with no open date and no expiration date. 3. During an interview on 4/21/2025 at 11:43 AM, RN #1 stated the bottle of loperamide hydrochloride was opened on 3/14/2025, but the expiration date was 2/2025. 4. During an interview on 4/22/2025 at 2:00 PM, the NM stated all expired medications should be disposed of when out of date. The NM stated that staff should check the expiration date before opening and write the open date on the medication bottle after opening the medication.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46831 Based on policy review, medical record review and interview, the facility failed to ensure patients received the prescribed dialysis prescription for BFR and DFR during in-center hemodialysis for 4 of 7 (Patient #1, #3, #5, and #6) sampled patients. The findings included: 1. Review of the facility policy “Documentation of Abnormal Values & Prescription Deviations During Treatment,” dated 1/3/2018, revealed, “...Any deviation from the treatment prescription must also be documented and explained on the flowsheet...not obtaining ordered blood flow rate or dialysate flow rate...If, for instance, the ordered blood flow rate cannot be met because the arterial pressure will exceed clinic maximum of -250, then that must be stated...” 2. Medical record review for Patient #1 revealed an admission date of 9/11/2024 with diagnoses that included Type 2 Diabetes Mellitus. A physician’s order dated 3/31/2025 revealed dialysis 3 times per week for 5 hours with a BFR of 400 and a DFR of 800. Review of the 3/17/2025 Hemodialysis Flowsheet revealed the DFR was 600 from 1:34 PM to 5:00 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the DFR not being administered at the prescribed rate. Review of the 3/19/2025 Hemodialysis Flowsheet revealed the DFR was 600 from 12:04 PM to 4:36 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the DFR not being administered at the prescribed rate. Review of the 3/28/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:33 PM to 3:31 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/16/2025 Hemodialysis Flowsheet revealed the DFR was 600 from 12:01 PM to 3:01 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the DFR not being administered at the prescribed rate. 3. Medical record review for Patient #3 revealed an admission date of 8/26/2019 with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A physician’s order dated 4/11/2025 revealed dialysis 2 times per week for 4 hours with a BFR of 450 and a DFR of 600. Review of the 3/17/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 1:46 PM to 4:29 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/21/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 9:30 AM to 12:00 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/24/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 7:02 AM to 10:45 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/28/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 7:20 AM to 10:32 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/31/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 6:31 AM to 9:02 AM and 350 from 9:31 AM to 10:01 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 3/28/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 7:20 AM to 10:32 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/4/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 6:31 AM to 7:01 AM and 400 from 7:31 AM to 8:31 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/11/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 5:51 AM to 7:02 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/21/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 6:31 AM to 10:02 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. 4. Medical record review for Patient #5 revealed an admission date of 3/22/2022 with diagnoses that included Hypertensive Chronic Kidney Disease. A physician’s order dated 4/11/2025 revealed dialysis 3 times per week for 4 hours and 15 minutes with a BFR of 400 and a DFR of 600. Review of the 3/12/2025 Hemodialysis Flowsheet revealed the BFR was 200 from 9:24 AM to 10:59 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. 5. Medical record review for Patient #6 revealed an admission date of 3/21/2025 with diagnoses that included Hypertensive Chronic Kidney Disease. A physician’s order dated 4/18/2025 revealed dialysis 3 times per week for 3 hours and 30 minutes with a BFR of 300 and a DFR of 600. Review of the 3/31/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 12:10 PM to 3:39 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/11/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 12:30 PM to 3:08 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. Review of the 4/16/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 12:30 PM to 3:48 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the charge nurse or the physician was notified of the BFR not being administered at the prescribed rate. 6. During an interview on 4/22/2025 at 2:15 PM, the NM was asked to observe the flowsheets for Resident #1, #3, #5 and #6 and confirm the incorrect BFR/DFR. The NM stated she did not have to look at them because she was aware and had issues with staff not documenting when the BFR/DFR rate needed to be adjusted.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This Standard is not met as evidenced by: 36006 Based on observations, the facility failed to maintain 3 occupancy separation barrier walls. The findings included: 1. Observation on 04/22/2025 at 9:58 AM, revealed a penetration by an electrical conduit not sealed with fire stopping materials in the 1 hour fire rated gypsum board occupancy separation wall above the double doors by storage room 207. NFPA 101, 21.1.3.1 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition) 2. Observation on 04/22/2025 at 10:04 AM, revealed penetrations by an electrical conduit, metal clad cable, flexible electrical conduit, steel angle not sealed with fire stopping materials in the 1 hour fire rated gypsum board occupancy separation wall above the door to the lobby. NFPA 101, 21.1.3.1 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition) 3. Observation on 04/22/2025 at 10:21 AM, revealed a penetration by a red communication wire not sealed with fire stopping materials in the 1 hour fire rated gypsum board occupancy separation wall above the rear employee entrance door. NFPA 101, 21.3.7.1 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition) The Biomedical Techician was present when these findings were identified, and the Regionl Operations Director acknowledged these findings during the exit conference on 04/22/2025.”