Fmc Columbia

“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: 49570 Based on facility policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of infectious bacteria by 2 of 2 (RN #3 and CCHT #2) staff members observed in the lab area. The findings included: 1. Review of facility policy, “Hand Hygiene” published 11/06/2023 revealed, “ ...prevent transmission of pathogenic microorganisms to patients and staff through cross contamination...hands will be ...decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water when ...before and after direct contact with patients ...entering and leaving the treatment area ...Immediately after removing gloves ...” 2. Observations in the lab area on 05/05/2025 at 10:44 AM, revealed RN #3 and CCHT #2 opened the lab refrigerator door with gloved hands. The front of the refrigerator contained two 8.5 in. x 11 in. size signs that stated, “REMOVE GLOVES AND SANITIZE HANDS BEFORE TOUCHING REFREIGERATOR.” 3. During an interview on 05/07/2025 at 11:18 AM, the CM verified that hand hygiene should be performed before and after removing gloves and before opening the lab refrigerator door.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure infection control measures were taken to protect items from contamination at 1 of 3 (Handwashing Sink #1) handwashing sinks. The findings included: 1. Review of facility policy, “Hand Hygiene” published 03/17/2023 revealed, “ ...to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination ...Sink Policy: The hand washing sinks may be used for both staff and patients. Soap and a supply of paper towels protected from contamination must be available at each sink ...” 2. Observations on the treatment floor on 05/05/2025 at 11:20 AM, revealed 18 packs of closed and 1 pack of open absorbent wipes (used to disinfect patient care items with bleach and dry areas washed) sitting around the sink that was being used by patients and staff for handwashing. 3. During an interview on 05/07/2025 at 11:18 AM, the CM confirmed that absorbent wipes should not be placed around the sink due to the potential for contamination.”

“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: 49570 Based on facility policy review, manufacturer’s guidelines for use and storage, observation, and interview, the facility failed to ensure the proper storage of medications to ensure patient safety measures were followed on 1 of 1 (05/05/2025) observation days. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” published 02/06/2023 revealed, “ ...Medication refrigerators are designated for the storage of medications ...” 2. Review of the manufacturer’s guidelines for use and storage revealed, “ ...store between 2°-8° C (36°-46° F) ...” 3. Observations in the supply storage area on 05/05/2025 at 9:30 AM, revealed three (3) 0.5 mL pre-filled influenza vaccines sitting on top of lab vacutainers instead of inside the medication refrigerator. 4. During an interview on 05/06/2025 at 11:18 AM, the CM confirmed that medications intended for storage in the refrigerator should always be kept in the refrigerator.”

“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: 49570 Based on facility policy review, observation and interview, the facility failed to ensure medications were labeled according to facility policy or discarded before their expiration date in 4 of 6 (3rd nursing station, medication room, main medication station, and medication refrigerator) medication prep/storage areas. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” published 02/06/2023, revealed, “To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control ...All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication ...Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded ...” 2. Observations at the main medication station on 05/05/2025 at 9:00 AM, revealed seven (7) vials of Ceftriaxone (antibiotic) 1 g with an expiration date of 02/2025. Observations at the medication refrigerator on 05/05/2025 at 9:10 AM, revealed nine (9) syringes of Influenza vaccine with an expiration date of 04/2025. Observations at the 3rd nurses’ station on 05/05/2025 at 10:00 AM, revealed four (4) Hep Lock 2ml syringes labeled with no initial or time. Observations in the medication room on 05/05/2025 at 10:20 AM, revealed one (1) bottle of calcium carbonate (dietary supplement used to treat low levels of calcium) 750 mg opened with no label, time, date, or initials. 3. During an interview on 05/05/2025 at 10:15 AM, RN #1 verified the above medications were not labeled per facility policy and confirmed that she had drawn up the medications earlier that morning and did not properly label the syringes. During an interview on 05/07/2025 at 11:18 AM, the CM verified that medications should be labeled per facility policy and should be checked monthly and discarded on or before their expiration date.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 46831 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed for 1 of 1 (Patient #8). The findings included: 1. Review of the facility policy titled “Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer” published 02/07/2022, revealed, “...The following supplies are needed for this procedure...Under pad-if existing pad is soiled...Ensure that a clean under pad is below the catheter limbs to protect the work area and the clothing...” 2. Medical record review for Patient #8 revealed an admission date of 03/14/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. Review of the physician’s order dated 4/25/2025 revealed Patient #8 was to receive hemodialysis treatments via AVF three times a week. 3. Observations at Station #36 on 05/05/2025 at 11:50 AM, revealed blood present on the under pad beneath the CVC. RN #2 began to perform discontinuation of treatment of a CVC and did not place a clean under pad beneath Patient #8’s catheter. 4. During an interview on 05/07/2025 at 11:18 AM, the CM stated a new under pad should be placed under the CVC when visibly soiled.”

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to follow infection control measures by not ensuring supplies were discarded before their expiration date on 1 of 1 (05/05/2025) observation days in 2 of 9 (crash cart and clean cart area 4) supply storage areas and failed to provide a safe environment by not locking 1 of 1 crash carts located on the treatment floor. The findings included: 1. Review of facility policy, “Emergency Medications, Equipment and Supplies” published 02/03/2025, revealed, “ ...An emergency cart, sometimes called ‘crash cart’ ...The Emergency cart must be checked monthly or after use for contents, expirations dates...Items approaching expiration must be reordered and replaced prior to the actual expiration date ... An emergency evacuation box must be checked monthly ...for ...expiration dates ...Items approaching expiration must be reordered and replaced prior to the actual expiration date ...The Emergency cart must be locked when not in use ...” Review of facility policy, “Storage of Supplies” published 04/05/2021 revealed, “ ...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired ...Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date ...” 2. Observations at the crash cart on 05/05/2025 at 11:30 AM, revealed the following expired supplies: Four (4) Tri-Flo Suction Catheters with an expiration date of 09/30/2024 Two (2) Vacutainer Blood Collection Sets with an expiration date of 04/30/2025 Observations in Clean Cart Area #4 on 05/05/2025 at 11:40 AM, revealed two (2) 50 mL syringes with an expiration date of 10/31/2024. Observations on the treatment floor on 05/05/2025 at 10:45 AM, revealed 1 of 1 crash carts unlocked and accessible to staff and patients. During an interview on 05/05/2025 at 11:18 AM the CM verified that all supplies should be routinely checked and discarded when expired and verified that the crash cart should be locked at all times.”

“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: 46831 Based on facility policy review, medical record review and interview, the facility failed to implement measures to address hypertensive episodes for 5 of 10 (Patient #1, #2, #3, #7 and #10) sampled patients. The findings included: 1. Review of the undated facility policy titled “Standing Orders 2025 ...MD Specific Blood Pressure and Heart Rate Parameters” revealed, “...Notify MD for permission to START tx if ...SBP<100 or >190, DBP>110 or <40, HR>120 or <40...Hypertension...Intradialytic HTN...Clonidine 0.1 mg PRN may repeat Q1 hour x3 for persistent SBP>190mmHg...Hypotension ...Sustained Hypotension during tx...NS 200ml Bolus, may repeat x2. Repeat BP in 5-10 min after each administration...check bp q 10 min until stable...” Review of the facility policy titled “Hypertension” published 09/07/2021, revealed, “...Treating Hypertension...Notify the nurse in charge if a patient has a systolic blood pressure greater than 180 mm/Hg and/or diastolic blood pressure greater than 100 mm/Hg...The RN will assess the patient and determine if further nursing interventions are needed...Document in patient’s treatment record...” Review of the facility policy titled “Hypotension” published 05/06/2024, revealed, “...Treating Hypotension...The PCT must immediately report signs and symptoms to the [ESRD Company] RN...The [ESRD Company] RN will assume care of the patient...Document in the [ESRD Company] treatment record and/or Contracted Entity electronic documentation system per contractual agreement...” 2. Medical record review for Patient #1 revealed an admission date of 3/11/2025 with diagnoses which IgA Nephropathy, Berger’s Disease, and End Stage Renal Disease. Review of the physician’s orders dated 04/25/2025 revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via a CVC. Review of the Treatment Sheet dated 04/07/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 12:53 PM and ended at 4:18 PM. The Patient’s blood pressures were as follows: 180/101 at 2:02 PM 175/101 at 2:34 PM 175/101 at 2:46 PM 182/100 at 3:00 PM Facility staff failed to address Patient #1’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/14/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 12:10 PM and ended at 4:12 PM. The Patient’s blood pressures were as follows: 189/101 at 12:18 PM 184/108 at 12:49 PM 180/104 at 1:00 PM 181/104 at 1:42 PM 178/102 at 2:02 PM 177/100 at 2:23 PM 196/107 at 2:54 PM 189/104 at 3:04 PM 197/101 at 3:29 PM 208/105 at 4:03 PM 185/115 at 4:12 PM Facility staff failed to address Patient #1’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/25/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 11:57 AM and ended at 3:44 PM. The Patient’s blood pressures were as follows: 189/104 at 12:23 PM 187/101 at 12:23 PM 191/98 at 2:45 PM 184/94 at 3:02 PM 192/102 at 3:24 PM Facility staff failed to address Patient #1’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/28/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 12:17 PM and ended at 4:24 PM. The Patient’s blood pressures were as follows: 188/105 at 12:18 PM. Facility staff failed to address Patient #1’s high blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 05/02/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 12:15 PM and ended at 4:22 PM. The Patient’s blood pressures were as follows: 199/105 at 12:19 PM 161/103 at 12:44 PM 181/92 at 1:04 PM 177/102 at 1:22 PM 184/98 at 1:41 PM Facility staff failed to address Patient #1’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. 3. Medical record review for Patient #2 revealed an admission date of 4/20/2023 with diagnoses which included Systemic Lupus Erythematosus and End Stage Renal Disease. Review of the physician’s orders dated 04/16/2025, revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via AVF. Review of the Treatment Sheet dated 03/26/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 9:49 AM and ended at 2:09 PM. The Patient’s blood pressures were as follows: 169/105 at 10:14 AM 174/103 at 10:23 AM 173/105 at 10:55 AM Facility staff failed to address Patient #2’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/09/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:23 AM and ended at 2:23 PM. The Patient’s blood pressures were as follows: 158/100 at 11:03 AM 163/103 at 12:08 PM 166/100 at 1:02 PM 165/102 at 1:22 PM Facility staff failed to address Patient #2’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 4/11/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:31 AM and ended at 2:36 PM. The Patient’s blood pressures were as follows: 175/105 at 11:21 AM Facility staff failed to address Patient #2’s high blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 4/16/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:36 AM and ended at 2:37 PM. The Patient’s blood pressures were as follows: 173/101 at 12:53 PM 183/109 at 2:02 PM Facility staff failed to address Patient #2’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 4/23/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:04 AM and ended at 2:06 PM. The Patient’s blood pressures were as follows: 169/105 at 10:04 AM 179/104 at 10:23 AM 186/106 at 10:42 AM 211/109 at 11:09 AM 209/116 at 11:26 AM 189/118 at 11:41 AM 183/101 at 12:07 PM Facility staff failed to address Patient #2’s high blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. 4. Medical record review for Patient #3 revealed an admission date of 07/28/2023 with diagnoses which included Acute Kidney Failure and End Stage Renal Disease. Review of the physician’s orders dated 05/02/2025, revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an CVC. Review of the Treatment Sheet dated 04/04/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:47 AM and ended at 2:14 PM. The Patient’s blood pressures were as follows: 171/126 at 1:31 PM Facility staff failed to address Patient #3’s high blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/07/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 11:06 AM and ended at 2:23 PM. The Patient’s blood pressures were as follows: 96/40 at 2:22 PM Facility staff failed to address Patient #3’s low blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/09/2025, revealed missed blood pressure and pulse documentation during treatment. The treatment was initiated at 10:58 AM and ended at 1:58 PM. The Patient’s blood pressures were as follows: 140/108 at 1:00 PM 92/72 at 1:44 PM Facility staff failed to address Patient #3’s blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/11/2025, revealed missed blood pressure and pulse documentation during treatment. The treatment was initiated at 10:40 AM and ended at 1:41 PM. The Patient’s blood pressures were as follows: 89/70 at 11:01 AM 99/58 at 1:29 PM Patient’s pulse was as follows: 37 at 11:24 AM Facility staff failed to address Patient #3’s low blood pressure and pulse. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/14/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 11:07 AM and ended at 2:14 PM. The Patient’s blood pressures were as follows: 96/67 at 12:22 PM 99/56 at 1:50 PM 91/55 at 2:13 PM Facility staff failed to address Patient #3’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/21/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:47 AM and ended at 1:59 PM. The Patient’s blood pressures were as follows: 88/54 at 11:13 AM 97/54 at 11:14 AM 90/44 at 11:20 AM 98/50 at 11:46 AM 99/59 at 12:42 PM Facility staff failed to address Patient #3’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 05/02/2025, revealed missed blood pressure and pulse documentation during treatment. The treatment was initiated at 10:48 AM and ended at 1:48 PM. The Patient’s blood pressures were as follows: 147/104 at 1:09 PM. Facility staff failed to address Patient #3’s high blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. 5. Medical record review for Patient #7 revealed an admission date of 03/14/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of the physician’s orders dated 04/30/2025 revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an CVC. Review of the Treatment Sheet dated 03/31/2025, revealed missed blood pressure and pulse documentation during treatment. The treatment was initiated at 11:38 AM and ended at 1:45 PM. The Patient’s blood pressures were as follows: 85/39 at 1:02 PM 90/43 at 1:30 PM 84/41 at 1:32 PM Facility staff failed to address Patient #7’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 05/02/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 11:32 AM and ended at 2:56 PM. The Patient’s blood pressures were as follows: 97/56 at 1:21 PM 98/54 at 1:47 PM 84/52 at 2:05 PM 88/57 at 2:22 PM Facility staff failed to address Patient #7’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. 6. Medical record review for Patient #10 revealed an admission date of 07/07/2023 with diagnoses which included Type 2 Diabetes Meletus and End Stage Renal Disease. Review of the physician’s orders dated 04/09/2025, revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an AVF. Review of the Treatment Sheet dated 04/09/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:17 AM and ended at 2:35 PM. The Patient’s blood pressures were as follows: 94/60 at 11:40 AM 94/60 at 11:53 AM 92/58 at 12:00 PM 92/54 at 12:20 PM 97/59 at 12:42 PM 92/60 at 2:35 PM Facility staff failed to address Patient #10’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/14/2025, revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:20 AM and ended at 2:39 PM. The Patient’s blood pressures were as follows: 98/61 at 1:48 PM 91/50 at 2:07 PM Facility staff failed to address Patient #10’s low blood pressure. There was no documentation the CN was notified or completed an assessment on the patient. Review of the Treatment Sheet dated 04/25/2025 revealed missed blood pressure documentation during treatment. The treatment was initiated at 10:11 AM and ended at 2:34 PM. The Patient’s blood pressures were as follows: 94/63 at 10:44 AM 98/57 at 11:40 AM 93/51 at 2:24 PM Facility staff failed to address Patient #10’s low blood pressures. There was no documentation the CN was notified or completed an assessment on the patient. 7. During an interview on 05/07/2025 at 11:18 AM, the CM stated if a patient experienced hypertension or hypotension during treatment, the PCT/CCHT should notify the CN, who should then assess the patient. The CM stated that all staff should document their notifications and interventions.”

“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: 51246 Based on facility policy review, observation, and interview, the facility failed to ensure infection control measures were taken during initiation and discontinuation of hemodialysis with an AVG/AVF on 1 of 2 (05/05/2025) observation days. The findings included: 1. Review of facility policy “Access Assessment and Cannulation” published 05/05/2025 revealed, “...Skin Disinfection: Step 1: Disinfect cannulation site as follows...70% isopropyl alcohol pad: using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating...Do not touch cannulation sites after skin disinfection...” 2. Observations at Station #31 on 05/05/2025 at 10:03 AM, revealed PCT #1 initiated hemodialysis on Patient #10. PCT #1 palpated and cleaned the access site, then re-palpated the access site with a gloved finger. PCT #1 failed to reclean the site before cannulation and did not allow for dry time. 3. During an interview on 05/07/2025 at 11:18 PM, the CM verified that if PCT #1 palpated the access site, it should have been re-cleaned before cannulation.”