Fmc South Dallas County

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 50181 Based on record review and interview, the facility staff failed to provide documented evidence that fire drills and quarterly emergency preparedness was completed with all facility staff and patients. This deficient practice has the likelihood to cause harm to the health and safety of all patients and staff within the facility during the event of an emergency. Findings: Patients 13 and 14 record review indicates they did not receive the education due to being absent and there is no evidence the review was attempted upon their return to the facility. There is no evidence that the ancillary staff (administrative assistant, social worker, dietician and technical manager) participate in the fire drills quarterly or receive the required education to ensure they understand their role in the event of a fire or other emergency requiring evacuation. In an interview with the Clinical Manager, she confirmed the above and verbalized understanding of the importance of ensuring patients who miss the fire drill and review receive the education within the quarter and that all staff have the required training.”

“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: 50181 Based on observation and staff interview, the facility’s direct patient care (DPC) staff failed to change gloves and/or perform appropriate hand hygiene after glove removal between dirty and clean tasks. During a tour of the facility treatment floor on 07/09/2024, the surveyor observed Personnel #13 remove gloves without washing hands or using hand sanitizer prior to donning new gloves and resetting another patient’s machine. Personnel #13 was also observed picking up trash at station 26 then resetting a machine alarm with the same gloves. Personnel #13 was observed donning one glove to reset a machine and not sanitizing after glove removal and prior to going to the next patient station. Personnel #6 was observed removing gloves after performing a dirty task without washing her hands or using hand sanitizer before going to the next patient. The Clinic Manager was with the surveyor during the observations and all findings were reported to her. She provided on the spot education to each staff member explaining the breaches in infection control and expectations.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 50181 During personnel record review and staff interview the facility failed to ensure all staff members had initial Hepatitis B labs drawn to determine immunity or susceptibility to Hepatitis B and to further determine the need for the Hepatitis B vaccination or if immunity is present.This deficient practice has the likelihood to potentially expose patients and staff to the Hepatitis B virus. Findings: In review of Personnel #5 employee health records a Spectra Laboratory Order dated 04/05/2023 indicates the following lab tests were ordered: Hepatitis B Antigen, Hepatitis B Antibody and Core Hepatitis B Antibody; however, no results are available for review. In an interview with the Clinical Manager (Personnel #1), she stated she reviewed the orders and results in the Spectra application but no results were found. She called the lab and they were unable to produce results or a reason why they were not resulted. The Clinic Manager stated the labs were drawn 07/09/2024 when this was discovered. Upon receipt of results further interventions will be determined based on lab values.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 50181 Based on observation and staff interview during a facility tour on 07/09/2024 the facility failed to ensure expired supplies were discarded on or before the expiration date and not available for patient and staff use in the facility. Findings included: During a tour of the facility treatment floor on the morning of 07/09/2024, the following expired supplies were found and available for patient use: 1 Hand on the treatment floor with an expiration date of 05/2024 In an interview with the Clinic Manager (Staff #1) on 07/09/2024 she confirmed the supplies were expired and still available for patient and staff use.”

“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: 50181 Based on observation and interview, the facility staff failed to ensure personnel #6 provided appropriate central venous catheter (CVC) care during treatment initiation to decrease the risk of infection. This deficient practice had the likelihood to place all patients with a CVC as their vascular access for dialysis at risk for infection due to cross-contamination. Findings: Personnel #6 removed the white end caps off of both normal saline syringes then laid both syringes down on the blue chux pad on the chair side table allowing the ends to be exposed to potential contaminants prior to connecting them to the CVC lumens and systemically infusing the normal saline via the CVC. An interview with personnel #6 cofirmed the above findings and she verbalized understanding of the importance of not allowing the syringes to be exposed to contaminants prior to CVC care. The observations were discussed with the Clinical Manager with verbalized understanding of the breach in CVC care.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 30377 Based on direct patient care observation and staff interview the facility failed to ensure that the dialysis machine was properly set up with the blood tubing placed in the air detector segment prior to machine testing to ensure proper functioning of equipment alarms prior to the initiation of hemodialysis per manufacturer recommendations. The Findings included: During observation of the treatment floor on 07/09/2024 at approximately 10:10 a.m. it was observed that two dialysis machines (# 4 and # 34) were not properly set up per the manufactures’s recommendations. The two machines did not have blood tubing placed in the air detector clamp segment prior to machine testing. The Clinic Manager was with the surveyor during the observations and acknowledged the patient care technician did not set up the machine per the facility’s policy and the manufacture’s recommendations. She provided on the spot education to the staff member. The machine was retested.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 30377 Based on medical record review and staff interview the facility failed to reassess the patient’s allergy status after the patient was discharged from the hospital to ensure that the patient’s allergy status was updated and current in the facility’s medical records. Findings were: Review of medical records on 7/10/24 revealed the following: Patient #5 Review of patient’s # 5 paper chart and electronic medical record for the dialysis clinic on 7/10/24 stated that the patient was admitted to the facility on 10/14/2020. The records stated that the patient had NO KNOWN DRUG ALLERGIES (NKDA). Review of patient #5’s hospital records dated 4/08/24 from Methodist Health System it stated that the patient was allergic to Reglan. In an interview with (staff #2) on 7/09/24 she acknowledged the above findings. She stated she was unaware, per the patient’s last hospital records, that the patient was allergic to Reglan.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 30377 Based on review of hemodialysis flow sheets and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment and notify the physician when appropriate. The findings included: Review of hemodialysis flow sheets dated 7/09/24 and 7/10/24 in the facility conference room revealed the following discrepancies: Patient # 9 Flow Sheet Dated: 7/08/24 - Blood pressure ranged from 193/82 to 151/62 with heart rate from 63-80. Post Vitals: 178/81 heart rate 68. Patient discharged from facility 2.7 kilograms above estimated dry weight. No documentation was found that the registered nurse addressed the hypertension at time of occurrence. No documentation was found that the registered nurse notified the physician of the post weight prior to discharge. Patient # 15 Flow Sheet Dated: 7/08/24 - Blood pressure ranged on treatment from 193/104 to 127/74 with heart rate from 80-106. No documentation was found that the registered nurse addressed the hypertension at time of occurrence. An interview conducted with (Staff #2) on 7/10/24 following her own review of the findings revealed she was unaware of the discrepancies found in the flow sheets.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 30377 Based on personnel file review and staff interview the facility failed to ensure annual skills validation and annual written competency tests were completed on employees to determine their competency necessary to perform their job duties. Findings were: Review of personnel files on 7/09/24 and 7/10/24 revealed the following deficiencies: Staff #5 (Registered Nurse) had his annual RN exam due 6/21/24 that was not completed as of 7/9/24 when the recertification survey was initiated. Staff #4, #5, and #14 had annual skills validation due 6/21/24 that was not completed as of 7/09/24 when the recertification survey was initiated. In an interview with the facility manager on 7/09/24 she acknowledged the above deficiencies.”