Fkc Dyersburg

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure adequate Infection control measures were taken to ensure patient safety and a clean and sanitary environment. The findings included: 1. The facility failed to appropriately dispose of biohazard supplies on the treatment floor. Refer to V111 2. The facility failed to ensure staff members performed hand hygiene during patient care. Refer to V113 3. The facility failed to ensure non-disposable equipment was disinfected between patients to decrease the risk of infection. Refer to V116 4. The facility failed to ensure dialysis machines and stations were adequately cleaned to prevent cross-contamination. Refer to V122 5. The facility failed to ensure expired medications were disposed of and not readily available for use on the treatment floor; failed to ensure medications were properly labeled for patient use; and failed to ensure staff properly cleaned access lines before administration of medications to prevent cross-contamination. Refer to V143”

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure biohazard materials were discarded in appropriate containers by 1 of 2 (RN #1) nurses observed. The findings included: 1. Review of facility policy, “General Cleanliness and Infection Control Guidelines” dated 11/04/2024, revealed, “...Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping ...” 2. Observations on the treatment floor at Station #3 on 04/07/2025 at 11:24 AM, revealed RN #1 discontinued the dialysis treatment via AVG/AVF on RP #6. After disconnecting the bloodlines from RP #6, RN#1 placed ends of blood lines in small biohazard sharps container on side of dialysis machine. RN #1 then pulled the bloodlines from the machine specific biohazard sharps container and placed the lines in the designated larger biohazard sharps container. 3. During an interview on 04/23/2025 at 11:57 AM, the CM verified that blood lines should not be placed in the machine specific biohazard sharps container.”

“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 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 3 of 4 (RN #1, RN #2 and PCT #1) staff observed on the treatment floor. The findings included: 1. Review of facility policy, “Hand Hygiene” dated 11/06/2023, revealed, “...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...before administration of parental medications...Immediately after removing gloves...” Review of facility policy, “Medication Preparation and Administration” dated 02/06/2023, revealed, “...The following steps must be taken to ensure infection control. Perform hand hygiene prior to...administering medications...” 2. Observations on the treatment floor at Station #8 on 04/07/2025 at 10:52 AM, revealed RN #1 initiated hemodialysis on RP #3, touched the dialysis station’s keyboard and screen, removed gloves and did not perform hand hygiene before moving on to the next area. Observations on the treatment floor at Station #2 on 04/07/2025 at 11:08 AM, revealed RN #2 performed exit site care on RP #4. RN #2 removed the old dressing from CVC site and failed to remove gloves, perform hand hygiene, and don clean gloves before cleaning CVC exit site and applying new dressing. Observations in the medication room on 04/07/2025 at 12:33 PM, revealed RN #2 donned gloves, drew up Heparin into a syringe, and left the medication room. Upon exiting the medication room, RN #2 touched the door and door handle before proceeding to RP #1’s station. RN #2 did not change gloves before administering the medication via AVG to RP #1. Observations on the treatment floor at Station #9 on 04/22/2025 at 10:15 AM, revealed PCT #1 initiated of dialysis via an AVG/AVF on RP #2. PCT #1 did not perform hand hygiene after palpating the access site and before cleaning the site for cannulation. 3. During an interview on 04/23/2025 at 11:57 AM, the CM verified that hand hygiene should be performed before and after removing gloves, after removing soiled dressings, before administering medications, and after palpating AVG/AVF access sites.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49570 Based on policy review, observation, and interview, the facility failed to ensure infection control measures were taken to prevent potential cross contamination between patients by 2 of 4 (PCT #1 and RN #1) staff observed. The findings included: 1. Based on facility policy, “Cleaning and Disinfecting the Dialysis Station” dated 09/05/2023, revealed, “...dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between use...After use, any non-disposable equipment and supplies brought into the dialysis station (ex.Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station...” 2. Observations at Station #8 on 04/07/2025 at 10:52 AM, revealed RN #1 used a stethoscope on RP #3 and did not sanitize it before or after use. Observations at Clean Sink #1 on 04/07/2025 at 12:19 AM, revealed PCT #1 used an electronic thermometer to check a patient’s temperature and did not clean the thermometer after contamination. Observations at Clean Sink #1 on 04/22/2025 at 10:15 AM, revealed PCT #1 used an electronic thermometer to check a patient’s temperature and did not clean the thermometer after contamination. 3. During an interview on 04/23/2025 at 11:57 AM, the CM confirmed that electronic thermometers and stethoscopes should always be cleaned after each patient use.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure appropriate cleaning and disinfection of dialysis stations was performed by 2 of 2 (CCHT #1 and RN #2) staff members observed. The findings included: 1. Review of facility policy “Use of Priming Buckets” dated 05/06/2024, revealed, “...At the completion of the patient treatment, remove the priming bucket or approved removable container, and dispose of the Normal Saline in the utility room hopper or dirty sink...After routine surface disinfection with 1:100 bleach solution, replace on machine...” Review of the facility policy “Cleaning and Disinfecting the Dialysis Station” revealed, “...The Centers for Medicare and Medicaid Services has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients...dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses...Dialysis Station...Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment...BP cuff ...” 2. Observations on the treatment floor at Station #1on 04/07/2025 at 10:50 AM, revealed CCHT#1 failed to wipe the internal and external surfaces of the prime waste container while disinfecting the dialysis machine. Observations on the treatment floor at Station #1 on 04/21/2025 at 10:34 AM, revealed RN#2 failed to wipe the internal and external surfaces of the prime waste container while disinfecting the diaylsis machine and failed to wipe down the blood pressure cuff and tubing. 3. During an interview on 04/23/2025 at 11:57 AM, the CM verified that the prime bucket should be dumped and wiped down with bleach after each treatment and confirmed that the BP cuff and tubing should be cleaned with bleach after each patient.”

“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, failed to ensure infection control measures were taken to decrease the risk of infection during medication administration, and failed to ensure medications were discarded before their expiration date on 1 of 2 (04/07/2025) observation days. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” dated 02/06/2023, revealed, “To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control...Labeling vials...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 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 immediately and store vial accordingly ...Disinfect IV ports prior to accessing, using friction and 70% alcohol, iodophor or chlorhexidine/alcohol agent ...Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded ...” 2. Observations at the nurses’ station on the treatment floor on 04/07/2025 at 9:56 AM, revealed the following medications not properly labeled: Two (2) Heparin Lock 2ml syringes labeled with no time or initial Three (3) Heparin lock 1ml syringes labeled with no time or initial One (1) Heparin vial 30,000 units opened with no label, time, date, or initial Three (3) Doxercalciferol (used to lower parathyroid hormone) vials opened with no label, time, date, or initial One (1) Tuberculin Mantoux (used to test for TB) 1ml vial opened with no label, time, date, or initial One (1) Epogen (used to treat anemia) 20,000 units 1ml vial with no label, time, date, or initial Observations in the medication room on 04/07/2025 at 11:43 AM, revealed the following medications not properly labeled: One (1) bottle of Cinacalcet HCl (used to manage hyperparathyroidism) 30mg opened with no label, time, date, or initial One (1) bottle of LiquaCel (protein supplement) concentrated protein opened with no time, date, or initial During an interview on 04/07/2025 at 11:30 AM, the CM verified the above medications were not labeled per facility policy. 3. Observations on the treatment floor on 04/07/2025 at 12:33 PM, revealed RN #2 administered Heparin to RP #1 via an AVG/AVF. RN #2 did not clean the end of the bloodline with alcohol before administering the Heparin. The bloodline was observed uncapped and hung from the patient’s arm upon RN #2’s arrival to the station. During an interview on 04/23/2025 at 11:57 AM, the CM confirmed that bloodlines should always be cleansed with alcohol prior to medication administration. 4. Observations in the medication room on 04/07/2025 at 10:00 AM, revealed the following expired medications: Twenty-Eight (28) capsules of diphenhydramine (used to treat allergic reactions) 25 mg with an expiration date of 03/2025 During an interview on 04/07/2025 at 11:30 AM, the CM verified the diphenhydramine was expired. During an interview on 04/23/2025 at 11:57 AM, the CM verified that all medications should be routinely checked and discarded when expired.”

“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, observation, and interview, the facility failed to provide a safe environment by not ensuring supplies were discarded before their expiration date on 1 of 2 (04/07/2025) observation days and by not locking 1 of 1 crash carts located on the treatment floor. The findings included: 1. 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. Store acid concentrates in accordance with the Acid Concentrate Storage and handling policy ...” 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 ...” 2. Observations on the treatment floor on 04/07/2025 at 11:30 AM, revealed the following expired supplies: CRASH CART Five (5) Senior Tongue Blades with an expiration date of 01/03/2024 Two (2) Yankauers (medical suction tool) with suction tubing with an expiration date of 08/12/2023 Seven (7) Luer lock cap sets (used to seal the connectors on a vascular access device) with an expiration date of 10/27/2024 One (1) box of 200 Alcohol Prep Pads with an expiration date of 10/2023 One (1) box of 800 gloves size large with an expiration date of 03/2025 EMERGENCY BOX Six (6) Winged Collection Sets (set which consists of a needle, two wings, a flexible transparent tubing and a connector) with an expiration date of 01/31/2025 Seven (7) Stay Safe Caps (used to safely disconnect the catheter extension set during peritoneal dialysis) for Peritoneal Dialysis with an expiration date of 01/31/2025 Observations in the supply room on 04/07/2025 at 11:40 AM, revealed the following expired supplies: One (1) bottle of Bicarb (dialysate used to help correct metabolic acidosis) with an expiration date of 11/01/2023 One (1) bottle of Bicarb with an expiration date of 02/13/2024 One (1) bottle of hand sanitizer with an expiration date of 12/2023 Four (4) bottles of distilled white vinegar with an expiration date of 09/08/2024 Ten (10) bags of Peritoneal Dialysis solution with an expiration date of 03/2025 Twenty-four (24) fluid warmer disposable sets with an expiration date of 08/13/2024 During an interview on 04/07/2025 at 11:30 AM, the CM and BioMed verified the above expired supplies. 3. Observations on the treatment floor on 04/07/2025 at 11:07 AM, revealed the crash cart was unlocked and accessible to staff and patients. During an interview on 04/23/2025 at 11:57 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-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: 49570 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 2 of 2 (04/07/2025 and 04/22/2025) observation days. The findings included: 1. Review of facility policy “Access Assessment and Cannulation” published 05/06/2024 revealed, “...Assessment of Vascular Access: Step 1: Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the patient is unable to wash their own access, the staff ...should wear gloves to wash the patient’s access with soap and water ...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 ...” Review of the facility policy titled, “Post Treatment Fistula Needle Removal” dated July 01, 2024, revealed, “...To provide instruction for fistula and graft needle removal at the end of the dialysis treatment to minimize access trauma and achieve optimal hemostasis...Once hemostasis is achieved: ...Remove the gauze ...Place Band-Aid, adhesive dressing or gauze dressing secured with clean tape ...” 2. Observations on the treatment floor at Station #12 on 04/07/2025 at 9:38 AM, revealed CCHT #1 initiated hemodialysis on Random Patient #7. CCHT #1 palpated and cleaned the access site, applied numbing spray, then re-palpated the access site. CCHT #1 failed to reclean the site before cannulation. During an interview on 04/23/2025 at 3:30 PM, the FA verified that CCHT #1 should have cleaned the site before cannulation. 3. Observations on the treatment floor at Station #7 on 04/07/2025 at 12:19 PM, revealed PCT #1 initiated hemodialysis on Random Patient #1 via an AVF/AVG. PCT #1 failed to ensure the access site was cleaned with soap and water prior to cleansing with alcohol. PCT #1 failed to clean the access site per facility policy by scrubbing one access site with alcohol for eight seconds and the other access site for five seconds instead of thirty seconds per facility policy. PCT #1 failed to allow the alcohol to dry per facility policy. After cleaning the access sites with alcohol, PCT #1 palpated the access site with a gloved finger and did not reclean before cannulation. 4. Observations on the treatment floor at Station #1 on 04/07/2025 at 10:35 AM, revealed RN #2 performed post dialysis exit care on RP #5. RN #2 failed to replace the blood soiled bandage/gauze on the needle sites once hemostasis was achieved. Observations on the treatment floor at Station #3 on 04/07/2025 at 11:24 AM, revealed RN #2 performed post dialysis exit care on RP #6. RN #2 failed to replace the blood soiled bandage/gauze on the needle sites once hemostasis was achieved. During an interview on 04/23/2025 at 11:57 AM, the CM verified that the bandage should be changed after hemostasis was achieved. 5. Observations on the treatment floor at Station #7 on 04/07/2025 at 12:50 PM, revealed CCHT #1 re-cannulated RP #1 after having problems with the access site. CCHT #1 removed the access needle and cleaned the site with soap and water. CCHT #1 did not remove the soap from access area before cleaning the access site with alcohol for 2 seconds instead of thirty seconds per facility policy. CCHT #1 then palpated the access site with a gloved finger, recleaned with an alcohol swab for 8 seconds instead of 30 seconds; sprayed the access site with numbing spray and then re-palpated the access site with a gloved finger. CCHT #1 failed to reclean the access site before cannulation. 6. Observations on the treatment floor at Station #9 on 04/22/2025 at 10:15 AM, revealed PCT #1 initiated hemodialysis on Random Patient #2 via an AVF/AVG. PCT #1 failed to ensure the access site was cleaned with soap and water prior to cleaning with alcohol; failed to clean the access site per facility policy by scrubbing one access site with alcohol for twenty two seconds instead of thirty seconds per facility policy, and failed to allow the alcohol to dry per facility policy. After cleaning the access site with alcohol, PCT #1 palpated the access site with a gloved finger and did not reclean before cannulation.”