Fresenius Kidney Care Indian River

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure staff cleaned and disinfected the stethoscope after use and before use on another Patient for one (1) of one (1) Staff Members (SM), SM # 2. The findings include: On December 2, 2025, at 11:00 AM, SM # 2 was observed at Station # 3 performing an assessment. SM # 2 failed to clean and disinfect the stethoscope after use on the Patient before placing around neck. On December 2, 2025, at 11:30 AM, SM # 2 was observed at Station # 5 performing an assessment. SM # 2 failed to clean and disinfect the stethoscope before or after use on the Patient. On December 3, 2025, at 2:00 PM, a review of the facility’s policy titled “Infection Control” revealed in part “Noncritical medical equipment, which includes equipment that touches only intact skin (e.g., stethoscope), must be disinfected with 1:100 bleach.” On December 3, 2025, at 2:15 PM, interview with SM # 1 and # 5 indicated staff are expected to clean stethoscopes after use and before use on another Patient.”

“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: 41450 Based on staff record review, staff interview and facility documentation review, the facility staff failed to offer Hepatitis B vaccination for one (1) staff member (SM), SM #4, out of a survey sample of three (3) staff members reviewed for immunization. The findings include: Facility staff failed to offer Hepatitis B vaccination to SM #4. On 12/3/25 at approximately 11:30 AM, staff record reviews were conducted and revealed that Staff Member (SM) #4, hired on 10/13/25, had no documentation of Hepatitis B immunization. Lab results for SM #4 dated 11/6/25 read, “Patient does not have immunity to hepatitis B virus”. On 12/3/25 at approximately 1:30 PM, an interview was conducted with SM #1 who confirmed the findings and stated, “It is my expectation for all personnel to be offered the Hepatitis B vaccine, if needed, at the time of hire, and documented in their personnel file”. On 12/3/25 at approximately 2:00 PM, review of the facility’s policy titled, “Employee Requirements for Testing and Vaccination for Hepatitis B”, dated 4/5/2021, subtitle, “Policy”, page 1, read, “The Hepatitis B vaccine shall be offered to all employees upon hire or rehire...prior to vaccine administration, draw the hepatitis B antibody (anti-HBs) to determine susceptibility...if susceptible, offer vaccine...if the employee declines, a signed declination must be maintained in the employee file” and page 3, subtitle “Documentation”, read, “Hepatitis B vaccination status shall be documented in the employee’s vaccination record including: signed consent or declination forms, dates of all the hepatitis B vaccinations...”.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure staff obtained pre and post standing blood pressures (BP) on Patients for one (1) of six (6) Patients (P), P # 1. The findings include: On December 3, 2025, at 11:00 AM, the clinical record review for P # 1 revealed the following: The flowsheet dated November 21, 2025 revealed the pre treatment standing BP was documented as 120/69. The post treatment standing BP was documented as “cannot assess”. The nursing evaluation at 12:13 p.m. revealed ambulation status “ambulates without assistance”. The flowsheet dated November 23, 2025 revealed the pre and post treatment standing BP was documented as “cannot assess”. The nursing evaluation at 11:36 AM revealed ambulation status “ambulates without assistance”. The flowsheet dated November 25, 2025 revealed the pre and post treatment standing BP was documented as “cannot assess”. The nursing evaluation at 12:00 PM revealed ambulation status “ambulates without assistance”. The flowsheet dated November 28, 2025 revealed the pre and post treatment standing BP was documented as “cannot assess”. The nursing evaluation at 12:01 PM revealed ambulation status “ambulates without assistance”. The flowsheet dated December 1, 2025 revealed the pre and post treatment standing BP was documented as “cannot assess”. The nursing evaluation at 11:59 AM revealed ambulation status “ambulates without assistance”. On December 3, 2025, at 2:00 PM, a review of the facility’s policy titled “Determination of Blood Pressure” revealed in part “blood pressure measurements in patients with kidney failure are most often indicators of changes in fluid status. Obtain blood pressure readings pre and post dialysis sitting and standing (if applicable) and every 30 minutes or more during the hemodialysis treatment as indicated.” On December 3, 2025, at 2:15 PM, interview with Staff Members # 1 and # 5 indicated staff are expected to obtain pre and post standing BP if the Patient can stand.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure staff sign the plan of care within 30 days if unable to sign at time of the meeting or attending remotely per the facility policy for one (1) of six (6) Patients, P # 6. The findings include: On December 3, 2025, at 1:45 PM, the clinical record review for P # 6 revealed the following: The plan of care meeting was dated September 16, 2025. The Social Worker signed the plan of care on October 27, 2025 (attended remotely), greater than 30 days. On December 3, 2025, at 2:00 PM, a review of the facility’s policy titled “Plan of Care” revealed in part “The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting.” On December 3, 2025, at 2:15 PM, interview with Staff Members # 1 and # 5 indicated staff are expected to follow the policy.”

“POC-PT/FAMILY EDUCATION & TRAINING CFR(s): 494.90(d) The patient care plan must include, as applicable, education and training for patients and family members or caregivers or both, in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to educate and ensure Patients perform hand hygiene post treatment for one (1) of five (5) Patients, P # 7. The findings include: On December 2, 2025, at 11:20 PM, P # 7 was observed holding access sites post treatment with a gloved hand at Station # 15. P # 7 removed the glove and failed to perform hand hygiene before exiting the facility. No staff member educated P # 7 on performing hand hygiene after holding access sites and removing glove before exiting facility. On December 3, 2025, at 2:00 PM, a review of the facility’s policy titled “Hand Hygiene” revealed in part “Patients should perform hand hygiene if able, prior to and after each dialysis treatment.” On December 3, 2025, at 2:15 PM, interview with Staff Members # 1 and # 5 indicated staff are expected to educate Patients on hand hygiene.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 41450 Based on staff record review, staff interview and facility documentation review, the medical director failed to ensure that facility staff implemented the facility’s health and safety policy for three (3) staff members (SM), SM #2, SM #3, and SM #4, out of a survey sample of three (3) staff members reviewed for tuberculosis testing. The findings include: Facility staff failed to complete Tuberculosis (TB) testing for SM #2, SM #3, and SM #4 in accordance with the facility’s policy entitled “Employee Tuberculosis Testing”. On 12/3/25 at approximately 11:30 AM, staff record reviews were conducted and revealed the following: SM #2, hired on 10/17/22, received the initial dose of a two-step Mantoux tuberculin skin test (TST) method on 3/24/25 which resulted as “negative” on 3/26/25. There was no documentation for the administration of the required second dose. SM #3, hired on 3/26/18, received the initial dose of a two-step Mantoux tuberculin skin test (TST) method on 3/17/23 which resulted as “negative” on 3/20/23. There was no documentation for the administration of the required second dose. SM #4, hired on 10/13/25, received the initial dose of a two-step Mantoux tuberculin skin test (TST) method on 11/5/25 which resulted as “negative” on 11/7/25. There was no documentation for the administration of the required second dose. On 12/3/25 at approximately 1:45 PM, an interview was conducted with SM #1 who confirmed the findings and stated, “I thought that only one TB skin test was needed, I didn’t know that there was supposed to be two”. The facility policy for TB testing, monitoring, and surveillance was requested and received. On 12/3/25 at approximately 2:00 PM a review of the facility’s policy titled, “Employee Tuberculosis Testing”, dated 5/5/2025, page 1, read, “TB testing using the two-step tuberculin skin test (TST) method is required upon hire” and page 2 read, “If first step TST result is negative, administer second TST within 1-3 weeks”.”