Uva Augusta Dialysis

“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, interview and document review, the facility failed to label one (1) vial turbersol (sterile solution for tuberculosis testing) when the it was opened and failed to remove nine (9) vials of expired Covid vaccines . The findings include: During the flash tour on May 12, 2025, a surveyor inspected the facility’s vaccine and medication refrigerator and found one (1) vial of turbersol that was not labeled with the opened date and nine (9) Covid vaccine syringes that had expired on March 29, 2025. During an interview with Staff Member #3, the afternoon of May 12, 2025, they indicated that the vial of turbersol should have been labeled when opened and if a vial is found and not labeled, it is discarded by the facility. When asked about the expired Covid vaccines, they indicated that those too, should have been removed and not available for use. A facility policy, Management of Out of Date, Unusable, or Returned Medications Pharmacy SOP, Last revised, December 2, 2024, revealed, in part, “...1.iii. All medications that have expired or will soon expire are removed from stock...” The surveyor asked for a policy on dating medications when opened and that policy was not received prior to the exit conference.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45736 Based on medical record, interview and document review, the facility failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) for two (2) of eight (8) in-center dialysis patients included in the sample. The findings include: Patient #2: The surveyor reviewed six (6) dialysis treatment records from April 25, 2025 to May 3, 2025. Patient #2 had a dialysis prescription with BFR of 450. On May 3, 2025, the BFR was documented as 400 from 12:26 PM until 1:55 PM, when it was changed to 350 and remained at 350 until 4:25 PM, the end of the treatment session. Patient #2’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed. Patient #5: The surveyor reviewed six (6) dialysis treatment records from March 24, 2025 to April 9, 2025. Patient #5 had a dialysis prescription with BFR of 350. On April 9, 2025, the BFR was documented as 200 from 2:08 PM until 2:36 PM, when it was changed to 350 until 2:39 PM. The BFR was changed again to 300 at 2:39 PM and remained at 300 until 5:24 PM, the end of the treatment session. Patient #5’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed. During an interview with Staff Member #3, the afternoon of May 13, 2025, Staff Member #3 indicated that the reason for the alteration of BFR should be documented in the patient’s clinical record. A facility policy, Outpatient Hemodialysis Guidelines, last revised February 2024, was reviewed but did not contain information specific to the facility requirement to document when there is an alteration in the patient’s BFR.”