Fresenius Medical Care West Pearland

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 Based on medical record review and interview, the facility failed to ensure it is in compliance with applicable Federal, State and local laws and regulations: 1. In that all patients admitted to the facility were seen by a physician once every two weeks, citing of 5 of 12 patients (Patients # 10, 12,13, 16, 17 ) whose clinical records did not include documentation of evidence that they were seen by a physician every two weeks. (Texas State Regulations determine the minimum visit schedule is every 14 days). 2. The facility failed to ensure that oxygen tanks were stored and identified according to Federal and State laws that regulated medical gases according to “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Four oxygen tank cylinders observed on the treatment floor with regulators attached were not properly identified as full or empty. Findings: During medical record review in the facility on 01/15/2025 along with clinic manager, staff ID #G it was noted the physician failed to document progress notes every 14 days as required. Records Reviewed: Patient ID #10 Records documented a physician progress notes for the following dates in the patient records by physician ID #K: 11/06/2024,12/11/202, 12/27/2024. Patient ID #12 Records documented a physician progress notes for the following dates in the patient records by physician ID #K: 10/14/2024,11/13/2024, and 11/27/2024, 12/20/2024. Patient ID #13 Records documented a physician progress notes for the following dates in the patient records by physician ID #K: 11/27/2024, 12/18/2024. Patient ID #16 Records documented a physician progress notes for the following dates in the patient records by physician ID #K: 10/17/2024,11/14/2024, and 12/03/2024,12/18/2024. Patient ID #17 Records documented a physician progress notes for the following dates in the patient records by physician ID #K: 10/23/2024, 11/13/2024, and 12/18/2024, 01/06/2025 Interview in the conference room on 01/15/2025 at 16:00 PM with the clinic manager, staff #G confirmed there was no documentation of every 2-week physician visits by physician ID #K. No additional information was received prior to exit of the survey. Record Reviewed: Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified as full or empty and stored separately. NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. “ A cylinder is considered “full” provided it still has its seal from the supplier. Once the seal has been removed, the cylinder is no longer considered full and cannot be stored with full cylinders. “ NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. Findings: Observation of the patient care area on 01/15/2025 at 12:05: PM along with the facility clinical manager, staff ID #G, four oxygen tanks were observed in the patient treatment area. All four oxygen tanks were observed to have been opened for use with regulators attached to the cylinders and were not labeled as full or empty. Interview with staff #G on 01/15/2025 at12:10 PM confirmed the oxygen tanks were not able to be identified if they were full or empty and oxygen cylinders.”