A
. BUILDING
______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
A
ND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2020
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
312552
09/03/2020
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
2 HAMILTON HEALTH PLACE
FRESENIUS MEDICAL CARE HAMILTON
HAMILTON, NJ 08690
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 000 INITIAL COMMENTS V 000
This was a Federal COVID-19 Focused Infection
Control Survey (NJ00137713) conducted on
September 3, 2020. Fresenius Medical Care
Hamilton is in compliance with 42 CFR, Part 494,
Conditions for Coverage (CfC) for End Stage
Renal Disease Facilities. Standard level
deficiencies were evident.
V 113 IC-WEAR GLOVES/HAND HYGIENE
CFR(s): 494.30(a)(1)
Wear disposable gloves when caring for the
patient or touching the patient's equipment at the
dialysis station. Staff must remove gloves and
wash hands between each patient or station.
This STANDARD is not met as evidenced by:
V 113
Based on observations conducted and review of
facility policy conducted on 9/3/20, it was
determined that the facility failed to ensure that
staff perform hand hygiene in accordance with
facility policy.
Findings include:
Reference: Facility policy titled, Hand Hygiene,
states, " ... Hands Will Be ... Decontaminated
using alcohol-based hand rub or by washing
hands with antimicrobial soap and water ...
When ... [bullet] before and after direct contact
with patients ... [bullet] After contact with body
fluids or excretion, mucous membranes,
non-intact skin, and would dressings if hands are
not visibly soiled. [bullet] After contact with
inanimate objects near the patient. ..."
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
(X6) DATE
10/01/2020
A
ny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete OQKT11
Event ID:
Facility ID: NJ22707
If continuation sheet Page 1 of 5
A
. BUILDING
______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
A
ND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2020
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
312552
09/03/2020
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
2 HAMILTON HEALTH PLACE
FRESENIUS MEDICAL CARE HAMILTON
HAMILTON, NJ 08690
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 113
Continued From page 1
V 113
1. During observation at 11:36 AM, Staff #5
inserted two needles into the patient in Station
#13's right upper arm arteriovenous fistula (AVF)
and secured the sites with tape to the patient's
arm. Staff #5 then collected the medical waste
from the chairside table and disposed of it in the
trash can located outside of the station.
a. Staff #5 re-entered the station and touched
the dialysis machine's touchscreen, keyboard,
and the hemodialysis machine bloodlines. Staff
#5 then connected the hemodialysis machine
bloodlines to both patient access lines.
(i) Staff #5 did not remove his/her gloves and
perform hand hygiene after he/she disposed the
medical waste, prior to touching items near the
patient, and before connecting the patient's
access lines to the hemodialysis machine
bloodlines.
2. At 11:50 AM, in Station #20, Staff #4 was
observed typing on the hemodialysis machine's
keyboard. Staff #4 then connected both of
Patient #1's CVC catheter limbs to the
hemodialysis machine bloodlines and touched
the hemodialysis machine's touchscreen,
keyboard, and the patient's television. This in not
in accordance with the reference above.
V 147 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 ...
V 147
FORM CMS-2567(02-99) Previous Versions Obsolete OQKT11
Event ID:
Facility ID: NJ22707
If continuation sheet Page 2 of 5
A
. BUILDING
______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
A
ND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2020
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
312552
09/03/2020
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
2 HAMILTON HEALTH PLACE
FRESENIUS MEDICAL CARE HAMILTON
HAMILTON, NJ 08690
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 147
Continued From page 2
V 147
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:
Based on observation conducted on 9/3/20 and
review of facility policy, it was determined that the
facility failed to ensure staff followed aseptic
technique when accessing a Central Venous
Catheter (CVC) on two (2) out of two (2) patients
(Patient #4 and Patient #6)
Findings include:
Reference: Facility procedure titled, Initiation of
FORM CMS-2567(02-99) Previous Versions Obsolete OQKT11
Event ID:
Facility ID: NJ22707
If continuation sheet Page 3 of 5
A
. BUILDING
______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
A
ND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2020
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
312552
09/03/2020
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
2 HAMILTON HEALTH PLACE
FRESENIUS MEDICAL CARE HAMILTON
HAMILTON, NJ 08690
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 147
Continued From page 3
V 147
Treatment Using a Central Venous Catheter and
Optiflux Single Use Ebeam Dialyzer, states, " ...
Prior to initiation: Flushing the Catheter Lumens
... 1. Remove the syringe filled with blood from
the arterial catheter limb and immediately attach
a 10 mL saline filled syringe. 2. Discard the
syringe with blood into the appropriate hazardous
receptacle. 3. Open catheter limb clamp and
gently flush limb with saline, then re-clamp. 4.
Repeat Steps 1 [one] through 3 [three] for the
venous catheter limb. ... Initiation of Treatment:
Connecting the Blood Lines ... 3. Remove the
10 mL syringe from the arterial catheter limb. 4.
Connect the arterial line to the arterial catheter
limb, using aseptic technique. Firmly insert the
male luer of the bloodline into the female luer of
the arterial catheter limb, while twisting in the
opposite direction. 5. Remove the venous
bloodline from the priming bucket; disconnect
recirculation connector while maintaining sterility
of the patient end. 6. Remove the 10 mL syringe
from the venous catheter limb. 7. Connect the
venous line to the venous catheter limb, using
aseptic technique. ..."
1. At 11:05 AM, in Station #1, Staff #7 initiated
hemodialysis treatment through a CVC to Patient
#6.
a. A clean pad on the chairside table was
observed with the following supplies on top:
multiple clean gloves, two (2) pre-filled saline
flushes, multiple alcohol pads, one (1) vacutainer
adapter, one (1) vial, and two (2) empty syringes
onto the pad.
b. Staff #7 wiped the blue catheter limb with an
alcohol pad, attached an empty syringe, and
FORM CMS-2567(02-99) Previous Versions Obsolete OQKT11
Event ID:
Facility ID: NJ22707
If continuation sheet Page 4 of 5
A
. BUILDING
______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
A
ND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2020
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
312552
09/03/2020
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
2 HAMILTON HEALTH PLACE
FRESENIUS MEDICAL CARE HAMILTON
HAMILTON, NJ 08690
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 147
Continued From page 4
V 147
aspirated approximately two (2) ml of blood into
the empty syringe. Staff #7 then repeated the
same procedure for the red catheter limb.
c. Staff #7 then changed his/her gloves,
performed hand hygiene, removed the syringe
filled with 2 ml of blood from the red catheter
limb, attached a vacutainer adapter, and placed
the syringe filled with two (2) ml of blood on the
clean pad, next to the pile of multiple clean
gloves.
(i) Staff #7 doffed his/her gloves, performed
hand hygiene, and donned a pair of gloves
obtained from the chairside table.
d. Staff #7 removed the syringe filled with two (2)
ml of blood from the blue catheter limb, attached
a pre-filled saline flush, and set the syringe filled
with 2 ml of blood on the clean pad next to the
pile of multiple clean gloves.
(i) Staff #7 doffed his/her gloves, performed
hand hygiene, and donned a pair of gloves
obtained from the chairside table. Staff #7 then
proceeded to connect the hemodialysis machine
to the patient and initiate hemodialysis treatment.
Staff #7 did not maintain aseptic technique as
required by the above reference.
2. At 11:50 AM, in Station #20, Staff #4 was
observed typing on the hemodialysis machine's
keyboard. Staff #4 then, while wearing the same
gloves, connected both of Patient #1's CVC
catheter limbs to the hemodialysis machine
bloodlines. Staff #4 did not maintain aseptic
technique as required by the above reference.
FORM CMS-2567(02-99) Previous Versions Obsolete OQKT11
Event ID:
Facility ID: NJ22707
If continuation sheet Page 5 of 5
