Fmc - Kaukauna

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 47413 Based on record review, observation and interview the facility staff failed to ensure that supplies were not past expiration dates in 1 of 1 patient treatment areas observed in a total of 1 patient treatment areas observed. Findings include: A review of the facility’s policy #47543 titled, “Storage of Supplies” Version 3 last published 11/03/2025 revealed, “... Supplies must be rotated in First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date...” Examples of expired supplies observed in the treatment area on 01/07/2026 at 9:10 AM: -(13) thirteen 14 gauge fistula needle sets with an expiration date of 12/31/2025. During an interview on 01/07/2026 at 9:55 AM, Registered Nurse C stated that she would discard the expired supplies.”

“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: 47413 Based on record review, observation and interview, the facility staff failed to complete disinfection of all equipment in the dialysis station for 2 of 2 dialysis stations (Stations #4, 5) observed being cleaned in a total of 16 observations of patient care. Findings Include: A review of the facility’s policy #47806 titled, “Cleaning and Disinfecting the Dialysis Station” Version 15 last published 09/02/2025 revealed, “... Dialysis station: ... Dialysis machine/cycler and attachments such as IV pole... Externally disinfect the dialysis machine... after each dialysis treatment...” During an observation on 01/07/2026 at 8:50 AM, Certified Clinical Hemodialysis Technician D was observed cleaning Station #4 and did not wipe down the IV pole or hooks. During an observation on 01/07/2026 at 9:11 AM Certified Clinical Hemodialysis Technician E was observed cleaning Station #5 and did not wipe down the IV pole or hooks. During an interview on 01/08/2026 at 10:17 AM with Facility Administrator A, she stated that all surfaces of the dialysis machine need to be cleaned.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 47413 Based on record review, observation and interview, facility staff failed to cleanse central venous catheter (CVC) hubs per facility policy in 1 of 2 patients (Patient #6) observed with a CVC and failed to perform CVC exit site care using aseptic technique for 1 of 2 patients (Patient #4) observed with a CVC in a total sample of 16 observations of patient care. Findings Include: A review of the facility’s policy #69106 titled, “FX CorAL: Termination of Treatment using a Central Venous Catheter” Version 1 last published 01/19/2024 revealed, “... Threads and end of the luer lock (hub) must be scrubbed with 70% sterile alcohol pad... for 10-15 seconds any time caps are removed, or bloodlines are disconnected (i.e. End of treatment)...” A review of the facility’s policy #45664 titled, “Changing the Catheter Dressing Procedure” Version 8 last published 05/02/2025 revealed, “... Removal of Dressing and Inspection of Site... 8. Discard dressing and remove gloves. Perform hand hygiene... Cleansing the Site... 2% Chlorhexidine and 70% alcohol... Clean the exit site beginning in the center and continuing outward the area... for 30 seconds... “ During an observation on 01/07/2026 at 9:40 AM, Registered Nurse B was observed discontinuing dialysis on Patient #6’s CVC. Registered Nurse B cleansed Patient #6’s CVC red hub with an alcohol pad for 5 seconds, 5 seconds less than as per facility policy and cleansed the CVC blue hub with an alcohol pad for 8 seconds, 2 seconds less than as per facility policy. During an observation on 01/07/2026 at 10:15 AM, Registered Nurse B was observed performing exit site care on Patient #4’s CVC. Registered Nurse B removed the old CVC dressing, and did not change her gloves or perform hand hygiene before cleaning the CVC site. Registered Nurse B cleansed Patient #4’s CVC site for 15 seconds, 15 seconds less than per facility policy. During an interview on 01/08/2026 at 10:20 AM, Facility Administrator A stated that staff need to scrub the CVC hubs for 10-15 seconds, that gloves need to be changed after a dressing is removed, and that the CVC site should be scrubbed for 30 seconds.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to ensure the administration of the pre-treatment Heparin bolus was at least 3 to 5 minutes prior to the initiation of dialysis, per facility policy, in 3 of 5 in-center hemodialysis patients (Patients #2, 3, 4) with current active orders for Heparin boluses in a total universe of 5 medical records reviewed. Findings Include: A review of the facility’s policy #25919 titled, “Heparinization” Version 5 last published 11/24/2025 revealed, “... Following heparin administration, wait 3-5 minutes to allow systemic anticoagulation to occur...” A review of Patient #2’s current in-center hemodialysis orders revealed an order for 3,000 units of Heparin bolus. A review of the treatment sheet dated 12/31/2025 revealed Patient #2’s dialysis was started at 7:51 AM. “Bolus/Intermittent” revealed the Heparin bolus was documented as given at 7:55 AM, 4 minutes after the initiation of dialysis. A review of Patient #3’s current in-center hemodialysis orders revealed an order for 1,000 units of Heparin bolus. A review of the treatment sheet dated 11/13/2025 revealed Patient #3’s dialysis was started at 8:00 AM. “Bolus/Intermittent” revealed the Heparin bolus was documented as given at 7:58 AM, 2 minutes before the initiation of dialysis. A review of Patient #4’s current in-center hemodialysis orders revealed an order for 3,000 units of Heparin bolus. A review of the treatment sheet dated 12/23/2025 revealed Patient #4’s dialysis was started at 10:18 AM. “Bolus/Intermittent” revealed the Heparin bolus was documented as given at 10:17 AM, 1 minute before the initiation of dialysis. Review of the treatment sheet dated 12/30/2025 revealed Patient #4’s dialysis was started at 10:10 AM. “Bolus/Intermittent” revealed the Heparin bolus was documented as given at 10:10 AM, the same time as initiation of dialysis. During an interview on 01/08/2026 at 9:39 AM with Facility Administrator A, she stated that the heparin bolus needs to be given 3-5 minutes prior to initiation of dialysis.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to ensure abnormal findings during the course of hemodialysis treatments were assessed and documented by nursing staff in 1 of 5 patients (Patient #5) in-center medical records reviewed in a total universe of 5 medical records reviewed. Findings Include: A review of the facility’s policy #57226 titled, “Intradialytic Hypotension” Version 3 last published 07/01/2024 revealed, “... Staff... will report intradialytic hypotensive episodes to the nurse in charge...” A review of Patient #5’s treatment sheet dated 12/21/2025 revealed the following physician order: “Call MD for SBP <100...”. Patient Care Technician L documented at 12:08 PM a blood pressure of 71/41. There was no documentation of blood pressure being noted as outside of ordered parameters, notification of the Registered Nurse, or that the Registered Nurse assessed Patient #5 as a result until a recheck blood pressure was documented at 12:34 PM. During an interview on 01/08/2026 at 9:45 AM, Facility Administrator A stated, “That should be an instant recheck.””

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47413 Based on record review, observation and interview, facility staff failed perform skin antisepsis prior to cannulation in 2 of 2 patients (Patients #7, 11) observed for initiation of dialysis using an AV fistula/graft in a total of 16 observations of patient care. Findings Include: A review of the facility’s policy #45175 titled, “Access Assessment and Cannulation” Version 5 last published 05/05/2025 revealed, “... Disinfect cannulation site... 70% isopropyl alcohol pad... clean the access site beginning in the center and continuing outward... for 30 seconds...” During an observation on 01/07/2026 at 9:16 AM, Certified Clinical Hemodialysis Technician D was observed initiating dialysis on Patient #7’s AV fistula/graft and cleaned the vascular access site #2 with an alcohol wipe for 27 seconds, 3 seconds less than per policy. During an observation on 01/07/2026 at 9:25 AM, Registered Nurse B was observed initiating dialysis on Patient #11’s AV fistula/graft and cleaned both vascular access sites with an alcohol wipe for 10 seconds, 20 seconds less than per policy. During an interview on 01/08/2026 at 10:18 AM, Facility Administrator A stated that the scrub time needs to be 30 seconds.”