Fkc Goodlettsville

“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 facility policy, observation, and interview, the facility failed to ensure medications were labeled properly with an open date, time, and initials of the nurse for 1 of 1 (7/21/2025) observation days. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” published 02/06/2023, revealed, “...When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT (If allowed by state regulations), must place the date and time the vial was opened on the medication label along with their initials...To ensure all open 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...” 2. Observation on the treatment floor on 07/21/2025 at 9:01 AM revealed the following unlabeled medications with no open date, time, or initials present: One (1) opened bottle of Clonidine Hydrochloride (medication used for high blood pressure) 0.1 mg tablets. One (1) opened bottle of Glucose Gummies (medications used to increase blood sugar level). Two (2) opened bottles of Sterile Water (used to dilute powdered medications) injectable vials. One (1) opened bottle of Extra Strength Antacid (medication used to treat heartburn). 3. During an interview on 07/21/2025 at 2:33 PM, the CM stated any opened medications should have a 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 Based on facility policy, observation, and interview, the facility failed to ensure medications and supplies were discarded before their expiration date for 1 of 1 (7/21/2025) observation days. The findings included: 1. Review of facility policy “Storage of Supplies” published 04/05/2021, revealed, “...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...” Review of facility policy “Medication Preparation and Administration” published 07/07/2025, revealed, “...Monitoring Expired Medications...Expiration dates for all stored medications are to be monitored on a monthly basis...Expired medications are to be discarded via [named dialysis clinic Kidney] off-site return program or in accordance with local and/or state law...” 2. Observation of the treatment floor on 07/21/2025 from 9:06 AM through 1:45 PM, revealed the following expired medications: a. Pneumococcal Vaccine-Polyvalent (vaccine used to prevent pneumococcal disease caused by 23 different serotypes) was stored in the medication refrigerator with expiration date of 03/2024. b. Four (4) undated Anaphylactic Kits (medications that are used during an emergency allergic reaction) stored in the storage cabinet contained the following expired medications: Four (4) Benadryl (over-the-counter medications used for mild allergic reactions) Tablets 25 mg with expiration date of 09/2024. Four (4) SoluMedrol (a steroid medication used to reduce inflammation and suppress the immune system response) 40 mg/vial with expiration date of 04/2024. Four (4) Adrenalin (a medication used to increase blood flow to the heart) 1 mg/ml with expiration date of 04/2024 c. Two(2) boxes of Glutose (oral glucose gel that quickly elevated blood sugar levels)15 Oral Glucose Gel stored in the crash cart with expiration date of 06/30/2025. 3. Observations of the treatment floor on 07/21/2025 from 9:06 AM through 1:45 PM, revealed the following expired supplies: Forty (40) BD Vacutainers Safety Lok Blood Collection Set (used for collecting blood samples from a vein) with expiration date of 07/31/2021. One (1) BD Vacutainers Safety Lok Blood Collection Set with expiration date of 11/30/2021. Five (5) BBL Culture Swabs (a sterile speciman used for collecting and transporting aerobic and anaerobic bacteria) with expiration date of 11/30/2021. 4. During an interview on 07/21/2025 at 12:10 PM, RN #1 stated the expired medication should not have been on the treatment floor but should have been discarded. During an interview on 07/21/2025 at 2:33 PM, the CM stated she expected staff to check medications on a regular basis and discard any expired medications.”

“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 5 of 5 (Patients #1, #2, #3, #4 and #5) sampled patients received the prescribed dialysis prescription for BFR. The findings included: 1. Review of the facility policy “Patient Monitoring and Safety Checks During Hemodialysis Treatment” published 09/05/2023, revealed, “...DFR, BFR, and UFR is set and functioning per treating physician’s order...” 2. Medical record review for Patient #1 revealed an admission date of 02/28/2024 with diagnoses that included Hypertension and End Stage Renal Disease (ESRD). A physician’s order dated 07/16/2025 revealed dialysis 3 times per week for 4 hours and 0 minutes with a BFR of 450 and a DFR of 800. Review of the 06/30/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 5:47 AM to 6:42 AM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 5:37 AM to 7:07 AM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 07/11/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 6:43 AM to 7:37 AM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 07/18/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 5:39 AM to 9:13 AM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. 3. Medical record review for Patient #2 revealed an admission date of 01/09/2025 with diagnoses that included Type 2 Diabetes Mellitus and End Stage Renal Disease (ESRD). A physician’s order dated 07/07/2025 revealed dialysis 3 times per week for 4 hours and 0 minutes with a BFR of 400 and a DFR of 800. Review of the 06/27/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 8:33 AM to 9:22 AM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/02/2025 Hemodialysis Flowsheet revealed the BFR was 450 from 6:58 AM to 9:33 AM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 6:44 AM to 9:21 AM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. 4. Medical record review for Patient #3 revealed an admission date of 04/23/2025 with diagnoses that included Acute Kidney Failure (AKI). A physician’s order dated 07/07/2025 revealed dialysis 3 times per week for 3 hours and 30 minutes with a BFR of 350 and a DFR of 500. Review of the 06/23/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:40 PM to 2:45 PM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/27/2025 Hemodialysis Flowsheet revealed the BFR was 345 from 11:18 AM to 2:34 PM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/30/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 11:05 AM to 2:50 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/02/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:34 PM to 2:37 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/04/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 10:32 AM to 12:42 PM during treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 11:16 AM to 2:47 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/11/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 11:17 AM to 2:46 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/16/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 11:21 AM to 2:49 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. 5. Medical record review for Patient #4 revealed an admission date of 10/28/2020 with diagnoses that included Type 2 Diabetes Mellitus and End Stage Renal Disease (ESRD). A physician’s order dated 07/07/2025 revealed dialysis 3 times per week for 3 hours and 30 minutes with a BFR of 400 and a DFR of 500. Review of the 06/23/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 12:03 PM to 2:38 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/25/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 12:08 PM to 3:10 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/27/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 11:49 PM to 3:23 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/30/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 11:47 AM to 3:16 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/02/2025 Hemodialysis Flowsheet revealed the BFR was 250 from 11:50 AM to 3:22 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:35 PM to 3:45 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/09/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 12:39 PM to 3:03 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/14/2025 Hemodialysis Flowsheet revealed the BFR was 450 from 12:08 PM to 2:35 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/16/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:07 PM to 3:05 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/18/2025 Hemodialysis Flowsheet revealed the BFR was 350 from 12:12 PM to 3:07 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. 6. Medical record review for Patient #5 revealed an admission date of 11/23/2022 with diagnoses that included Acute Kidney Failure which led to End Stage Renal Disease (ESRD). A physician’s order dated 07/18/2025 revealed dialysis 3 times per week for 3 hours and 30 minutes with a BFR of 350 and a DFR of 800. Review of the 06/25/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:07 PM to 2:34 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 06/27/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:18 PM to 2:35 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/02/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:37 PM to 3:03 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:08 PM to 2:33 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/09/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:20 PM to 3:33 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/14/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 1:38 PM to 3:30 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/16/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:36 PM to 2:41 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. Review of the 07/18/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 1:11 PM to 3:08 PM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not administered at the prescribed rate. 7. During an interview on 07/22/2025, the CM stated there should be documentation to support any BFR not run at the prescribed rate and notification of the MD.”