Rcg Springfield

“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: 46831 49570 Based on review of facility policy, observation, and interview, the facility failed to maintain a sanitary environment on 1 of 1 (09/08/2025) observation days, when the facility failed to ensure expired supplies were not available for use, and failed to ensure sterile supplies were properly handled and not stored for patient use after opening. The findings revealed: 1. Review of facility policy, “Storage of Supplies” published 04/05/2021, revealed, “ ...The purpose of this policy is to provide guidelines for storage and handling of supplies ...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 ...” There was no documentation of a facility policy regarding the proper handling and storage of sterile supplies after opening. 2. Observations on the treatment floor on 09/08/2025 at 9:40 AM revealed the following expired supplies: a. Eighteen (18) TwinPack Hemodialysis Fistula Needles (connects blood lines to an internal arteriovenous fistula) 16 G x 1” with expiration date of 05/31/2025. b. Fifty (50) vacutainer safety lock needles (blood collection set used to collect blood samples from patients for diagnostic testing) 24 G x ¾” x 12” with expiration date of 03/31/2025. c. Forty-one (41) Vacutainers (connects venous blood samples for laboratory testing and analysis) with expiration date of 06/30/2025. Observations at the medication preparation area on 09/08/2025 at 10:00 AM revealed the following had been removed from their sterile packaging and were found open to air in drawers and a cabinet in the medication preparation area: a. twenty-one (21) 10 mL syringes with needles attached, b. three (3) 10 mL syringes with needles attached pre-labeled for heparin use on 09/09/2025 for three patients, c. c. three (3) 3 mL syringes with needles attached; all of which had been removed. During an interview on 9/8/2025 at 10:15 AM the FA verified the supplies had been opened and in drawers of the cabinet in the medication preparation area. 3. During an interview on 09/10/2025 at 10:39 AM, the FA stated, “Supplies should be checked monthly. I have instructed them (staff) to check weekly. The expired supplies should have been discarded. Sterile syringes should not be opened in advance. They should be opened right before use.””

“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 review of facility policy, observation, and interview, the facility failed to ensure pre-drawn medications were labeled with the date, time, and initials of the person who prepared the medications on 1 of 1 (09/08/2025) observation days. The findings included: 1. Review of facility policy “Medication Preparation and Administration” published 07/07/2025, revealed, “ ...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 ...These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration ...” 2. Observation of the treatment floor on 09/08/2025 at 9:13 AM, revealed the following unlabeled, pre-drawn medications in an unlocked storage drawer: a. Six (6) Venofer (an intravenous iron replacement therapy used treat iron deficiency anemia in CKD patients) 100 mg pre-drawn syringes with no date, time or initials present. b. One (1) Heparin (a blood thinner used to prevent new blood clots from forming and stop existing clots from getting bigger) 9000 units pre-drawn syringe with no date, time or initials present. c. Two (2) Heparin 8000 units pre-drawn syringes with no date, time or initials present. d. One (1) Heparin 6000 units pre-drawn syringes with no date, time or initials present. e. One (1) Heparin 5500 units pre-drawn syringes with no date, time or initials present. f. Two (2) Heparin 5000 units pre-drawn syringes with no date, time or initials present. g. Two (2) Heparin 4000 units pre-drawn syringes with no date, time or initials present. h. One (1) Heparin 2000 units pre-drawn syringes with no date, time or initials present. i. Four (4) Heparin 2200 units pre-drawn venous catheter lock with no date, time or initials present. j. Four (4) Heparin 2200 units pre-drawn syringe venous catheter lock with no date, time or initials present. 3. During an interview on 09/08/2025, RN #1 stated medications drawn up and not given immediately should be labeled with a date, time and initials of preparer. During an interview on 09/10/2025 at 10:39 AM, the FA stated, “If medications are drawn up and not given immediately, they should be labeled with the date, time, and initials of the nurse.””

“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: 46831 49570 Based on facility policy, observation, and interview, the facility failed to ensure medications and emergency equipment were secured in the treatment area on 1 of 1 (09/08/2025) observation days. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” published 07/07/2025, revealed, “ ...These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration ...All medications will be kept in a locked cabinet except when in use ...” Review of facility policy, “Emergency Medications, Equipment and Supplies” published 07/07/2025, revealed, “ ...The emergency cart must be locked when not in use ...” 2. Observations on the treatment floor on 09/08/2025 revealed multiple types of medications, including pre-drawn syringes, stored in an unlocked area. In addition, the facility’s emergency crash cart was observed to be unlocked. 3. During an interview on 09/10/2025 at 10:39 AM, the FA stated all medications including pre-drawn medications should be kept in the clear locked box on top of the medication station. She stated that the crash cart should be locked when not in use.”

“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: 49570 Based on review of facility policy, medical record review, and interview, the facility failed to ensure that hemodialysis was provided in accordance with the physician’s orders for 4 of 7 (Patient # 1, #2, #4 and #5) sampled patients reviewed. The findings included: 1. Review of facility policy, “Patient Assessment and Monitoring” published 05/01/2023, revealed, “ ...If the PCT/LPN note any changes or abnormal findings in the patient’s condition ...the registered nurse must assess the patient ...check prescribed blood flow is being achieved, or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ...” Review of facility policy, “Nursing Supervision and Delegation” published 11/06/2023, revealed, “ ...Any observed changes or abnormal findings in the patient’s condition ...must be reported to the registered nurse who will assess the patient ...documentation present ...The following criteria can be used as a guideline to identify when a PCT/LPN/LVN or RN shall refer a patient to the Team Leader/Charge Nurse for further assessment pre, during or post treatment ...Blood pressure: A systolic blood pressure greater than 180 mm/Hg and/or diastolic blood pressure greater than 100 mm/Hg ...” 2. Medical record review for Patient #1, admitted on 02/18/2019 with diagnoses including End Stage Renal Disease, revealed a physician’s order dated 08/01/2025 for hemodialysis with a BFR of 450 mL/min and a DFR of 800 mL/min. Review of the Hemodialysis Treatment Sheet dated 08/11/2025 revealed the DFR was set at 500 mL/min from 10:06 AM to 11:07 AM. There was no documentation to explain the deviation from the ordered DFR of 800 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 08/13/2025 revealed the BFR was set at 400 mL/min from 7:18 AM to 11:34 AM. There was no documentation to explain the deviation from the ordered BFR of 450 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 08/20/2025 revealed the DFR was set at 500 mL/min from 10:01 AM to 11:30 AM. There was no documentation to explain the deviation from the ordered DFR of 800 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 08/27/2025 revealed the BFR was set at 400 mL/min from 7:16 AM to 11:26 AM. There was no documentation to explain the deviation from the ordered BFR of 450 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 09/01/2025 revealed the BFR was set at 400 mL/min from 7:18 AM to 11:40 AM. There was no documentation to explain the deviation from the ordered DFR of 450 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 09/03/2025 revealed the DFR was set at 500 mL/min from 10:06 AM to 11:07 AM. There was no documentation to explain the deviation from the ordered DFR of 800 mL/min and no documentation the RN had been notified. 3. Medical record review for Patient #2, admitted on 03/03/2021 with diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease, revealed a physician’s order dated 08/09/2025 for hemodialysis with a BFR of 500 mL/min and a DFR of 500 mL/min. Review of the Hemodialysis Treatment Sheet dated 08/16/2025 revealed the BFR was set at 450 mL/min from 11:06 AM to 11:30 AM. There was no documentation to explain the deviation from the ordered BFR of 500 mL/min and no documentation the RN had been notified. Review of the Hemodialysis Treatment Sheet dated 06/19/2025 revealed the BFR was set at 425 mL/min from 9:31 AM to 10:36 AM and 350 mL/min from 11:08 AM to 11:44 AM. There was no documentation to explain the deviation from the ordered BFR of 500 mL/min and no documentation the RN had been notified. 4. Medical Record review for Patient #4, admitted on 06/20/2025 with diagnoses including End Stage Renal Disease and Hypertensive Chronic Kidney Disease, revealed a Hemodialysis Treatment Sheet revealed multiple hemodialysis treatment sheets that documented abnormal blood pressures with no documentation of interventions, assessment, or RN notification. Review of the Hemodialysis Treatment Sheet dated 08/18/2025 revealed the following abnormal blood pressures: 191/78 at 10:32 AM. There was no documentation of patient assessments, interventions, or whether the patient had been symptomatic, and no documentation the RN had been notified of the abnormal blood pressure reading. Review of the Hemodialysis Treatment Sheet dated 08/29/2025 revealed the following abnormal blood pressure: 96/63 at 2:08 PM. There was no documentation of patient assessments, interventions, or whether the patient had been symptomatic, and no documentation the RN had been notified of the abnormal blood pressure reading. Review of the Hemodialysis Treatment Sheet dated 09/03/2025 revealed the following abnormal blood pressure: 101/52 at 9:58 AM, 97/55 at 10:10 AM, 91/53 at 10:33 AM, and 99/62 at 12:33 PM. There was no documentation of patient assessments, interventions, or whether the patient had been symptomatic, and no documentation the RN had been notified of the abnormal blood pressure readings. Review of the Hemodialysis Treatment Sheet dated 09/05/2025 revealed the following abnormal blood pressures: 101/41 at 9:57 AM, 106/32 at 9:57 AM, 101/41 at 10:34 AM, 101/46 at 11:09 AM, 130/41 at 12:38 PM, 123/54 at 1:06 PM, and 134/114 at 11:36 AM. There was no documentation of patient assessments, interventions, or whether the patient had been symptomatic, and no documentation the RN had been notified of the abnormal blood pressure readings. 5. Medical Record review for Patient #5, admitted on 05/04/2024 with diagnoses including Type 2 Diabetes and End Stage Renal Disease, revealed a physician’s order dated 09/04/2025 for hemodialysis with a BFR of 400 mL/min and a DFR of 500 mL/min. Review of the Hemodialysis Treatment Sheet dated 09/04/2025 revealed the BFR was set at 300 mL/min from 5:55 AM to 7:33 AM. There was no documentation to explain the deviation from the ordered BFR of 400 mL/min and no documentation the RN had been notified. 6. During an interview on 09/10/2025 at 10:39 AM, the FA stated that anytime the BFR or DFR was changed the reason should be documented on the flowsheet and the RN should be notified of the change. The FA also stated anytime the blood pressure is outside of facility policy parameters that the RN should be notified so the patient could be assessed.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 49570 Based on review of the facility’s HIPAA Notice of Privacy Practices, observation, and interview, the facility failed to ensure medical records were maintained in a secure manner on 3 of 3 (09/08/2025, 09/09/2025, 09/10/2025) observation days. The findings revealed: 1. Review of the facility’s, “HIPAA Notice of Privacy Practices” effective date 04/26/2022, revealed, “...Our privacy obligations ...make sure that your PHI is kept private ...” 2. Observations on 09/08/2025, 09/09/2025, and 09/10/2025 revealed medical records stored in cardboard boxes inside a closet located in the back storage room. The storage room door was found to be unlocked on each of the three observation days. On 09/09/2025, a maintenance worker not employed by the facility was observed accessing the back storage room while the closet containing patient medical records remained unsecured. 3. During an interview on 09/10/2025 at 10:39 AM, the FA stated that medical records should not be accessible by outside vendors performing work inside of the facility. She stated the records found in the closet were supposed to have already been archived.”