Bma - Farmville

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 45736 Based on medical record review, interview and document review, the facility failed to provide documentation of training in Emergency Preparedness (EP) for four (4) of six (6) In-Center Hemodialysis (ICHD) patients. The findings include: A surveyor conducted a review of ICHD patient medical records on June 2, 2025 and June 3, 2025. During the review, the surveyor identified the following: Patients #2, #3, #7 and #8 did not have documentation of initial or ongoing EP training. Patient #2, was admitted on May 20, 2025 and did not have documentation of initial EP training. Patient #3 was admitted on October 5, 2023 and did not have documentation of initial or ongoing EP training. Patient #7 was admitted on May 26, 2025 and did not have documentation of initial EP training. Patient #8 was admitted on May 2, 2025 and did not have documentation of initial EP training. During an interview with Staff Member #1, the afternoon of June 3, 2025, they indicated that everyone receives training but Staff Member #1 was not aware that this needed to be documented for each patient. A facility policy, Guidelines for Emergency Preparedness, last revised July 3, 2023, revealed, in part, “...Patient Education: Facility Staff must educate patients on: Evacuation procedures. Emergency Disconnection Procedures. Emergency Meal Plan. Facility Contact Information. Shelter Information. Transportation Information. Emergency preparedness...””

“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: 21229 Based on observation, staff interview and facility document review, the facility failed to ensure medications, when opened, were labeled according to facility policy and maintained in a hygienic manner. The findings include: During observations in the dialysis treatment area, on June 2, 2025 (from approximately 10:00 a.m. until 12:30 p.m.), the surveyor observed three (3) multi-dose vials of Heparin 30,000 units/30 ml (units per thirty milliliters) 1,000 units/ml (one-thousand units per milliliter), stored in drawers at different locations on the unit. One was in the cabinet facing “pod 2 (two)”, second in the cabinet at “pod 4” and third in the drawer of medications prep area. Each multi-dose vial had been accessed, and contained the expiration date October 2026, however, the vials were not dated as to when they were first opened by staff. The surveyor also found a 16oz (sixteen ounce) bottle of hydrogen peroxide* in a drawer with the expiration date of November 2025, however, when picking up the bottle, the cap was not closed and liquid spilled on the surveyors hands. The surveyor also observed a used tube of Muciprocin** 2% (two percent) in the drawer which had no screw cap on the tube. There was no date as to when the tube was opened. The facility policy “Medication Preparation and Administration was reviewed and evidenced, in part: “...Labeling Vials: When preparing medications, if the vial is not used immediately in it’s entirety, the nurse or PCT (Patient Care Technician) (If allowed by state regulations) must place the date and time the medication was opened on the medication label 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 used immediately and store vial accordingly...” On June 2, 2025 at 3:00 p.m., the surveyors discussed the observations with Staff Member #1 (Clinic Manager) who stated that Muciprocin was ordered for each individual patient, and was confused as to why there would be an opened tube without screw cap in the drawer. Staff Member #1 also indicated that the staff should not be leaving medication vials that are not dated and initialed when opened, as this is the policy of the facility...” **According to www.drugs.com (accessed 6/4/25 at 8:00 a.m.). “Muciprocin is an antibiotic used to treat skin infections. The ointment must be kept in its original packaging (cap intact) to prevent contamination...the ointment has a shelf life for a year, however effectiveness may diminish over time once opened...” and * “Hydrogen Peroxide (disinfectant) must be stored with the container tightly sealed in order to prevent air exposure leading to decomposition of the product...””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 45736 Based on medical record review, interview and document review, it was determined that the facility failed to provide documentation that the patient’s Plan of Care (POC) was signed by the patient or a reason for their refusal to sign, for eight (8) of eight (8) patient medical records reviewed. The findings include: A review of eight (8) medical records for six (6) In-Center Hemodialysis (ICHD) patients, one (1) Peritoneal Dialysis (PD) patient and one (1) Home Hemodialysis patient, revealed that eight (8) of eight (8) patient medical records failed to contain documentation of the patient’s signature or documentation of a reason for their refusal to sign the POC. During an interview with Staff Member #1, the afternoon of June 2, 2025, they indicated that they were not aware that the facility needed to print the page for the patient to sign or document their refusal. Staff Member #1 indicated that the POCs are reviewed with the patient and moving forward, they will ensure all patient’s will either sign the signature page or the staff will document patient’s refusal to sign the POC. A facility policy, Comprehensive Interdisciplinary Assessment and Plan of Care, last revised July 3, 2023, revealed, in part, “...Comprehensive Assessment Participation and Plan of Care Review...The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan of care. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record...””