Fmc Hendersonville

“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: 33763 Based on policy review, observation, and interview the facility failed to ensure hand hygiene was performed per policy by 1 of 6 (PCT #1) staff members observed providing direct patient care on the treatment floor. The findings included: 1. Review of the facility’s “Hand Hygiene” policy dated 11/6/2023 revealed, “...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Before and after direct contact with patient...Immediately after removing gloves...After contact with inanimate objects near the patient...” 2. Observations on the treatment floor at Stations #12 and #13 on 8/18/2025 at 9:50 AM, revealed PCT #1 performed hand hygiene, donned gloves and entered data into the dialysis machine at Station #13 where RP #1 was receiving hemodialysis. The machine at Station #12 where RP #2 was receiving hemodialysis began to alarm. Without removing her gloves, performing hand hygiene and donning new gloves, PCT #1 moved to Station #12 and silenced the alarm Observations on the treatment floor at Station # 12 on 8/18/2025 at 9:55 AM revealed PCT #1 discontinuing hemodialysis treatment via an AV fistula for RP #2. PCT #1 performed hand hygiene, donned gloves and began re-infusing the extracorporeal circuit, then disconnected the dialysis tubing from the machine. PCT #1 removed her gloves, then gathered additional supplies and donned new gloves without performing hand hygiene. PCT #1 then removed the first needle from the Patient’s arm and applied a pressure dressing. The PCT removed the gloves and repositioned a wheelchair and stool in the walk way, then donned new gloves without performing hand hygiene, and reinforced the pressure dressing on the Patient’s arm. Without removing the gloves or performing hand hygiene, PCT #1 removed the 2nd needle and applied a pressure dressing over the site. PCT #1 failed to perform hand hygiene between glove use repeatedly. During an interview on 8/19/2025 at 4:10 PM, the FA verified hand hygiene should be performed between glove use and when moving from one station to another.”

“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: 33763 Based on policy review, observation, and interview, the facility failed to ensure pre-filled syringes of medications were labeled per policy on 1 of 1 (8/18/2025) observation days, and failed to ensure aseptic technique was followed by 1 of 2 (RN #1) RNs observed who administered IV medications on the treatment floor. The findings included: 1. Review of the facility’s “Medication Preparation and Administration” policy dated 7/7/2025, 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...The 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...Disinfect IV ports prior to accessing, using friction and 70% alcohol, iodophor or chlorhexidine/alcohol agent...Cleanse the diaphragm with a new alcohol wipe each time an IV port is assessed...” Review of the facility’s “Medication Preparation and Administration Procedure” policy dated 8/30/2024, revealed, “...Use of Saline Line needle injection port for Administering Medication...Wipe the injection port with an alcohol wipe...” 2. Observations at the medication station on 08/18/2025 at 9:03 AM, revealed the following improperly labeled medications: Fourteen (14) 10 ml syringes pre-filled with Heparin (medication used to prevent and treat blood clots by thinning the blood) with no time or initials noted. Twenty (20) 3 ml syringes pre-filled with Heparin with no time or initials noted. One (1) 10 ml syringe pre-filled with Venofer (medication used to treat iron deficiency anemia) with no time or initials noted. Three (3) 3 ml syringes pre-filled with Venofer with no time or initials noted. During an interview on 8/19/2025 at 3:45 PM, the FA stated pre-filled syringes should be labeled with date, time, and initials. 3. Observations on the treatment floor at Station #6 on 8/18/2025 at 12:30 PM, revealed RN #1 failed to clean Patient #1’s injection port prior to inserting the syringe and administering IV medication to the patient. 4. Observations on the treatment floor on 8/18/2025 at 12:36 PM, revealed RN #1 failed to clean RP #3’s injection port prior to inserting the syringe and administering IV medication to the patient. During an interview on 8/19/2025 at 3:56 PM, the DO stated all injection ports should be cleaned prior to inserting the syringe and administering medications.”

“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: 33763 Based on policy review, medical record review, and interview, the facility failed to ensure measures to decrease the risk of catheter related infections were followed when they failed to perform CVC exit site care and dressing changes per facility policy for 1 of 4 (Patient #7) sampled patients reviewed with CVCs. The findings included: Review of the facility’s “Central Venous Catheter (CVC) Dressing Change” policy dated 5/6/2024 revealed, “...Catheter related infections are one of the leading causes of hospitalization and death. Strict infection control practices and adherence to the catheter dressing change procedure is essential to prevent serious complications...Perform catheter exit-site care and dressing replacement prior to initiation of treatment...” Medical record review revealed Patient #7 was admitted to the facility on 7/20/2011 with diagnoses which included Membranous Nephropathy and End Stage Renal Disease. Review of the physician’s orders dated 7/29/2025 and 8/12/2025 revealed the Patient was to receive hemodialysis treatments via a CVC 3 times a week. Review of the hemodialysis Treatment Sheets dated 7/31/2025, 8/2/2025, 8/5/2025, 8/7/2025, 8/9/2025, 8/12/2025, and 8/14/2025 revealed no documentation CVC exit site care or dressing changes were performed. During an interview on 8/19/2025 at 4:00 PM, the DO stated CVC exit site care and dressing changes should be performed prior to initiating hemodialysis treatments via a CVC.”

“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: 33763 Based on policy review, medical record review and interview, the facility failed to ensure physician’s orders for BFR were followed for 2 of 5 (Patient # 4 and #6) sampled incenter hemodialysis patients. The findings included: 1. Review of the facility’s “Patient Assessment and Monitoring” policy dated 5/1/2023 revealed, “...Check machine settings and measurements...Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow...” 2. Medical record review for Patient #4 revealed an admission date of 6/6/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. A physician’s order dated 7/15/2025 revealed a BFR of 400. Review of the hemodialysis Treatment Sheet dated 8/9/2025 revealed the BFR was 300 from 11:38 AM to 3:10 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 #6 revealed an admission date of 3/11/2023 with diagnoses which included Type 2 Diabetes Mellitus and ESRD. A physician’s order dated 5/31/2025 revealed a BFR of 400. Review of the hemodialysis Treatment Sheet dated 7/8/2025 revealed the BFR was 350 from 11:38 AM until 1:35 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 hemodialysis Treatment Sheet dated 7/16/2025 revealed the BFR was 350 from 1:03 PM until 2:05 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. During an interview on 8/19/2025 at 3:55 PM, the DO stated if staff are unable to meet the prescribed BFR, they should document the reason why.”