Fmc Memphis Midtown

“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: 35244 Based on policy review, observation and interview, the facility failed to ensure proper hand hygiene to prevent the spread of potentially infectious bacteria was performed by 1 of 9 (Nurse #1) staff observed during 1 of 2 (9/30/2024) observation days on the dialysis treatment floor. The findings included: 1. Review of the facility’s “Hand Hygiene” policy (11/6/2023) revealed, “...Hands Will Be... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water... When... Immediately after removing gloves...” 2. Observations on 9/30/2024 beginning at 11:00 AM on the treatment floor revealed Nurse #1 assisted Random Patient #1 to the scale, then transferred Random Patient #1 to a wheelchair. Nurse #1 then removed gloves and donned a new pair of gloves without first performing hand hygiene. In an interview on 10/2/2024 at 10:30 AM, the Director of Operations verified hand hygiene should be performed after removing gloves.”

“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: 35244 Based on policy review, observation and interview, the facility failed to ensure appropriate use of PPE on the treatment floor during 1 of 2 (9/30/2024) observation days. The findings included: 1. Review of the facility’s “Personal Protective Equipment” policy (11/6/2023) revealed, “...Personal protective equipment including a full-face shield or mask and protective eye wear... must be worn to protect employees from blood or other potentially infectious materials...” 2. Observations on 9/30/2024 beginning at 10:45 AM revealed Nurse #2 performd CVC site care and CVC initiation for Random Patient #2 while wearing a face mask pulled down below her nose. In an interview on 10/2/2024 at 10:30 AM, the Director of Operations verified face masks should cover the nose when worn.”

“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: 33487 Based on policy review, medical record review and interview, the facility failed to ensure staff notified the RN of patient’s elevated blood pressure and failed to assess vital signs every 30 minutes for 4 of 10 (Patient #3, #4, #6, and #9) sampled patients reviewed. The findings included: 1. Review of the facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient... the registered nurse must assess the patient... During Treatment... Obtain blood pressure and pulse rate every 30 minutes...” 2. Medical record review for Patient #3 revealed an admission date of 6/12/2017 with diagnosis of ESRD. Review of the 9/2/2024 Treatment Record revealed Patient #3’s vital signs were assessed at 11:39 AM then not again until 12:59 PM, over an hour later. There were no documented assessments of vital signs between these times. In an interview on 10/1/2024 at 3:10 PM, the CM stated “...there should be at a minimum of 30 minutes and no greater than 45 minutes between vital signs documentation... There should have been another 2 sets of vital signs between 11:39 AM and 12:59 PM...” 3. Medical record review for Patient #6 revealed an admission date of 6/30/2020 with diagnoses that included HTN and ESRD. Review of the 9/7/2024 Treatment Record beginning at 8:35 AM revealed the following elevated/abnormal vital signs were assessed by a PCT: 8:35 AM- BP 195/121 9:08 AM- BP 176/110 9:30 AM- BP 204/126 There was no documentation a RN was notified of the elevated BP findings until 9:30 AM, an hour after the first elevated BP reading. Review of the 9/21/2024 Treatment Record beginning at 12:06 PM revealed Patient #6 was assessed with elevated BP readings at 12:06 PM, 12:30 PM, 1:00 PM, 1:25 PM. PCT #1 notified a RN of the elevated BP readings at 12:06 PM, 12:30 PM, 1:00 PM and 1:25 PM. There was no documentation of a RN assessment of Patient #6’s elevated BP readings until 2:00 PM, 2 hours after first notified of the elevated BP findings. In an interview on 10/1/2024 at 3:10 PM, the CM verified PCT’s should notify a RN of any abnormal or out of range vital signs when they are initially found. The CM also verified he expected RN’s to document an assessment of abnormal vital sign notification as soon as possible. 4. Medical record review for Patient #9 revealed an admission date of 7/3/2024 with diagnoses that included DM and ESRD. Review of the 9/11/2024 Treatment Record revealed Patient #9’s vital signs were assessed at 12:52 PM then not again until 2:00 PM, over an hour later. The facility failed to ensure Patient #9’s vital signs were assessed every 30 minutes.”