Fmc - Virginia Beach

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 42725 Based on observation, interview and facility policy review, the facility staff failed to remove expired supplies from the emergency cart. The findings included: During the flash tour on 11/27/23, a surveyor conducted a review of the contents in the facility’s emergency cart and evacuation kit. The following were discovered during the review: One (1) - Nasal cannula tubing - expired 6/14/23 One (1) - Yankauer catheter - expired 11/22/23 The surveyor notified SM #9 of the expired supplies while on the treatment floor who immediately replaced the nasal cannula and started working on replacing the yankauer catheter. On 11/27/23 at 3:45 p.m., the surveyors discussed the findings with SMs #1, 3 and 5 and requested a policy regarding the contents of the emergency cart. On 11/28/23, a review of the facility’s policy titled, Emergency Medication, Equipment and Supplies, was conducted and reads, in part: “...Emergency cart: ... The emergency cart must be: ... Checked monthly or after use for contents, expiration dates... Items approaching expiration must be reordered and replaced prior to the actual expiration date...”. At the exit conference on 11/28/23 at 3:45 p.m., the findings were reviewed again with SMs #1, 3 and 5.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 45736 Based on observations and document review, it was determined that the facility staff failed to adhere to the facility’s policy, specific to the removal of PPE (personal protective equipment) when leaving the treatment floor. The findings included: On 11/27/23 at 1:05 p.m., during the flash tour, Staff Member #8 (Nurse Practitioner SM#8) was observed entering the treatment floor. SM#8 remained on the treatment floor until approximately 2:30 p.m., when they exited the treatment floor and entered the office space of the facility. SM#8 failed to remove their PPE gown. SM#8 did remove their PPE gown but then proceeded to place the gown back on while still in the office space and spoke with SM#6 (Social Worker) for approximately ten (10) minutes. A facility policy, Personal Protective Equipment, published 02/14/2018, version 5, evidenced, in part, “Purpose: The purpose of this policy is to identify exposure to hazardous chemicals, blood, or other potentially infectious material...Policy...All personal protective equipment shall be removed prior to leaving the treatment area.” These findings were discussed with SM#1 (Clinical Manager) SM#3 (Regional Operations Director) and SM#5 (Registered Nurse) on 11/27/23 at 3:45 p.m. and again at the exit conference on 11/28/23 at 3:45 p.m.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 42725 Based on observations and document review, it was determined the facility staff failed to place the access needles in the sharps container after removal for three (3) of four (4) observations. The findings included: On 11/27/23 at 1:25 p.m., a surveyor observed SM #12 removing an access needle for a patient at station #1. Upon removal, SM #12 capped the needle and laid it down on the tray. SM #12 placed gauze and tape to the patient’s access site. Once completed, SM #12 picked up the capped needle and disposed of it in the sharps container. SM #12 repeated the same process for the second needle removal. At 2:03 p.m., SM #12 was observed removing an access needle for a patient at station #2. SM #12 removed the needle, capped it and laid it on the tray. SM #12 placed gauze and tape over the access site. Once completed, SM #12 picked up the capped needle and disposed of it in the sharps container. SM #12 repeated the same process for the second needle removal. At 2:20 p.m., SM #13 was observed removing an access needle for a patient at station #5. SM #13 removed the needle from the access site, capped it and laid it down on the tray. SM #13 repeated the same steps for the second needle. After providing post-dialysis care to the patient, SM #13 picked up both of the capped needles and placed them in the sharps container for disposal. On 11/27/23 at 3:45 p.m., the surveyors discussed the findings with SMs #1, 3 and 5 and requested a policy regarding discontinuation of treatment for a AV (arteriovenous) graft/fistula. A facility’s policy titled, Termination of Treatment Using an Arteriovenous Fistula or Graft and Optiflux Single Use Ebeam Dialyzer, was reviewed. The policy referenced another policy titled, Post Treatment Fistula Needle Removal. The surveyors requested and received this policy from SM #1. The policy titled, Post Treatment Fistula Needle Removal, was reviewed and read, in part: “...Procedure... 1... Ensure a sharps container is easily accessible... 6. Carefully remove the needle... Engage the safe needle device per manufacturer’s instructions for use. Discard needle in sharps container...”. At the exit conference on 11/28/23 at 3:45 p.m., the findings were reviewed again with SMs #1, 3 and 5.”

“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: 45736 Based on observation and facility document review, it was determined the facility staff failed to ensure that proper cleaning and disinfecting of equipment was performed. The findings included: On 11/27/23 at 1:30 p.m., during the flash tour, the surveyor observed the following: Staff Member #10 (Patient Care Technician SM#10) was observed cleaning dialysis station thirteen (13). SM#10 failed to clean the dialysis station counter above the wall box. A facility policy, Cleaning and Disinfecting the Dialysis Station, published 09/05/2023, version 14, was reviewed and evidenced, in part, “Purpose: The purpose of this policy is to provide guidance to prevent the spread of infectious disease in accordance with the appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff and visitors...Background:...a dialysis station must be cleaned and disinfected between dialysis patients. The chair and 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.” These findings were discussed with SM#1 (Clinical Manager) SM#3 (Regional Operations Director) and SM#5 (Registered Nurse) on 11/27/23 at 3:45 p.m. and again at the exit conference on 11/28/23 at 3:45 p.m.”

“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: 45736 Based on observations and document review, it was determined that the facility staff failed to maintain a safe environment for dialysis patients, staff, and the public by not labeling opened medications as per the facility’s policy. The findings included: During the flash tour on 11/27/23 at approximately 12:35 p.m., one (1) surveyor observed seven (7) oral medications cups that were labeled with the medication, route, dose, and name of patient but failed to include the date, time and initials of the person who prepared the medication. A facility policy, Medication Preparation and Administration, published 09/05/2023, version 10, stated, in part, “Labeling Reconstituted Medication Solutions and Syringes: All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication...Oral medications not being administered immediately must also be labeled as indicated above.” These findings were discussed with SMs #1, 3 and 5 on 11/27/23 at 3:45 p.m. and again at the exit conference on 11/28/23 at 3:45 p.m.”