Fmc Collierville

“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: 46831 Based on policy review, observation and interview, the facility failed to ensure the hand hygiene policy to decrease the risk of infection was followed for 2 of 8 (CM and CCHT #1) staff observed providing patient care on the treatment floor. The findings included: 1. Review of the facility’s “Hand Hygiene” policy dated 11/6/2023 revealed, “...The purpose of the policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination...Caution Regarding Fingernails...Do not wear artificial fingernails, extenders or nail wraps when having direct contact with patients...Natural fingernail length shall be kept to ¼ inch or less...” 2. Observations on the treatment floor on 11/17/2025 from 8:50 AM until 2:30 PM, revealed CCHT #1 providing direct patient care. The CCHT’s fingernails were painted and over ¼ in length. 3. Observations on the treatment floor on 11/17/2025 and on 11/18/2025 revealed the CM providing direct patient care. The CM’s fingernails were painted and over ¼ inch in length. 4. During an interview on 11/19/2025 at 9:12 AM, the CM stated fingernails should be no longer than the end of the fingers to prevent infections. The CM continued and stated, “mine are too long.””

“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 policy review, observation and interview, the facility failed to ensure expired medications were not available for use in 2 of 2 (Medication Storage Cabinet and Medication Storage Refrigerator) medication storage areas observed. The findings included: 1. Review of the facility’s “Medication Preparation and Administration” policy dated 7/7/2025 revealed, “...When preparing medications, if the vial is not used immediately in its entirety, the nurse...must place the date and time the vial was opened on the medication label along with their initials. Note: to ensure all vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the date and time the vial was opened...Label any open multi-dose vial that is not used immediately and store vial accordingly...Any open multi-dose vials must be discarded 28 days after opening or per manufacturer’s expiration date...” 2. Observations in the Medication Storage Cabinet on 11/17/2025 at 9:16 AM, revealed 2 open and unlabeled multi-dose vials of Heparin. During an interview on 11/17/2025 at 10:20 AM, the CM verified the open vials of Heparin were unlabeled. 3. Observations in the Medication Storage Refrigeration on 11/18/2025 at 2:06 PM, revealed 1 open and unlabeled multi-dose vial of Tuberculin Purified Protein Derivative (PPD) During an interview on 11/18/2025 2:07 PM, RN #1 confirmed the open vial of PPD was unlabeled. 4. During an interview on 11/19/2025 at 9:12 AM, the CM stated “every vial [multi-dose vial of medication] opened should be dated and initialed.””

“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 Based on policy review, observation, and interview, the facility failed to ensure medications were secured in a locked crash cart to protect patient safety. The findings included: 1. Review of the facility’s “Emergency Medications, Equipment and Supplies” dated 7/7/2025, revealed, “...An emergency cart, sometimes called ‘crash cart’ contains emergency equipment and medications for medical emergencies ...The emergency cart must be: Locked when not in use...” 2. Observations on the treatment floor on 11/17/2025 at 2:08 PM revealed the crash cart with the security bar in place; however, the lock had been removed. Medications were stored inside this area and were accessible to unauthorized individuals. 3. During an interview on 11/17/2025 at 2:38 PM, the CM verified that the crash cart should be locked at all times except when in use.”

“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 physician’s orders for BFR and/or DFR were followed for 3 of 7 (Patient #1, #3, and #7) sampled in-center hemodialysis patients, and failed to ensure physician’s orders for dialysate were followed for 1 (Random Patient #1) in-center hemodialysis patients observed on the treatment floor. The findings included: 1. Review of the facility’s “Patient Assessment and Monitoring” policy dated 5/1/2023 revealed, “...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 the facility’s “Pre-Treatment Safety Checks Procedure” dated 2/6/2023 revealed, “...Verify the following elements by two direct patient care staff members prior to treatment initiation...Prescribed dialyzer...Prescribed dialysate composition: Verify proper delivery of dialysis prescription: Machine is connected to an acid concentrate that matches prescription. Verify by matching label on valve panel or concentrate jug...The clinician initiating treatment must verify the prescribed set up matches the patient...Prescription Dialyzer...Dialysate composition...Dialysate flow rate...” 2. Medical record review for Patient #1 revealed an admission date of 7/9/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. Review of the physician’s orders dated 9/25/2025 and 11/6/2025 revealed a BFR of 400 and a DFR of 600. Review of the Treatment Sheet dated 10/25/2025 revealed the DFR was 800 from 9:17 AM until 12:17 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. Review of the Treatment Sheet dated 11/4/2025 revealed the DFR was 800 from 12:07 PM until 12:41 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. Review of the Treatment Sheet dated 11/6/2025 revealed the BFR was 350 from 10:23 AM until 11:48 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 3. Medical record review for Patient #3 revealed an admission date of 10/18/2024 with diagnoses which included Type II Diabetes Mellitus and ESRD. Review of the physician’s orders dated 9/20/2025, 11/6/2025, and 11/11/2025 revealed a BFR of 400 and a DFR of 800. Review of the Treatment Sheet dated 10/23/2025 revealed the BFR was 300 from 11:21 AM until 1:02 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Treatment Sheet dated 11/11/2025 revealed the BFR was 350 from 1:48 PM until 3:06 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Treatment Sheet dated 11/15/2025 revealed the BFR was 350 from 11:53 AM until 2:49 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 4. Medical record review for Patient #7 revealed an admission date of 1/24/2020 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. Review of the physician’s orders dated 9/27/2025, 10/28/2025, and 11/11/2025 revealed a BFR of 400 and a DFR of 600. Review of the Treatment Sheet dated 10/21/2025 revealed the BFR was 350 from 11:06 AM until 2:37 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Treatment Sheet dated 11/1/2025 revealed the BFR was 350 from 12:29 PM until 2:30 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. During an interview on 11/19/2025 at 9:12 AM, the CM stated staff should document the reason why they cannot meet the prescribed BFR and/or DFR during treatment and should also notify the physician. 5. Medical record review for RP #1 revealed an admission date of 9/21/2024 with diagnoses which included Type 1 Diabetes Mellitus and ESRD. Review of the physician’s orders dated 11/10/2025, revealed a Dialysate of 2.0 K, 3.0 Ca, 1.0 Mg, and 100 Dextrose (N2301). Observation on the treatment floor on 11/16/2025 at 2:02 PM, revealed RP #1 receiving a dialysate of 2.5 K, 3.0 Ca. There was no documentation why the dialysate was not delivered at the ordered prescription of 2.0 K, 3.0 Ca. There was no documentation the physician was notified. During an interview on 11/17/2025 at 2:56 PM, the CM stated the dialysate should have been at the prescribed rate, should always be checked prior to initiation of dialysis, and should never be changed without a MD order.”