Davita Greene County Dialysis

“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: 49894 Based on observations, review of facility policies, and staff interview, it was determined the faciltiy failed to ensure staff followed policies related to infection prevention and control, which could result in transmission of bacteria and poor patient outcomes. This affected Patient Identifier (PI) # 7 in one of two observations of accessing the Arteriovenous Fistula/Arteriovenous Graft (AVF/AVG) and had the potential to negatively affect all patients, staff, and vistors of the facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Revision Date: 4/23 Hand Hygiene 1. All teammates, Physicians or Non-Physicians will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, ...d. after patient and dialysis delivery system contact, ...g. before touching clean areas such as supplies, supply cart, and chairside keyboard/mouse. ...7. Disposable gloves will be worn... a. Gloves should be changed when: ...ii. When going from a “dirty” area or task to a “clean” area or task iii. When moving from a contaminated body site to a clean body site of the same patient... Facility Policy: AVF or AVG Cannulation with NIPRO or Medisystems Safety Fistula Needles and Administration of Heparin Doses Policy Number: 1-04-01E Revision Date: 10/22 Procedure: ...16. Remove gloves, perform hand hygiene, and put on new gloves prior to cannulation. An observation was conducted on 3/12/25 at 9:55 AM with Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician, accessing the AVF/AVG for initiation of dialysis for PI # 7 at station 5. After obtaining the patient’s vital signs, EI # 4 left the patient station, removed his/her gloves, failed to perform hand hygiene, and entered the supply storage area located off of the treatment floor. EI # 4 re-entered the treatment floor with a jug of acid required for patient treatment, entered the patient station, placed the jug on the machine, and without performing hand hygiene retrieved gloves from the box of clean gloves, and donned them. After removing the patient’s bandage securing his/her numbing cream, EI # 4 exited the patient station to obtain a wash cloth with soap and water to wash the patient’s access. Without removing his/her gloves, entered the package of clean wash cloths (used for multiple patients) located in the common area. EI # 4 wet and applied soap to the wash cloths, re-entered the patient station, and washed the patient’s access. After locating, palpating, and auscultating the AVF/AVG, EI # 4 failed to remove his/her gloves, perform hand hygiene, and don new gloves. After performing skin antisepsis, EI # 4 failed to remove his/her gloves, perform hand hygiene, and don new gloves before cannulating the AVF/AVG. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Facility Administrator, who confirmed staff failed to perform hand hygiene per facility policy.”

“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: 49894 Based on observations, review of facility policies, and staff interview, it was determined the facility failed to ensure staff and patients wore Personal Protective Equipment (PPE) per facility policy. This affected Patient Identifier (PI) # 7 in one of two observations of access of the Arteriovenous Fistula/Graft (AVF/AVG) and PI # 8 in one of two observations of initiation of dialysis with a Central Venous Catheter (CVC) including CVC exit site care, and had the potential to affect all 43 patients dialyzing at the facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Revision Date 4/23 PPE ( i.e. gown, gloves, eye protection, face shield) ...5. Appropriate PPE will be worn...PPE is to be: a. Removed prior to leaving the treatment area. ...c. PPE is not to be worn in non-treatment areas... Facility Policy: CVC with Clearguard HD Antimicrobial End Caps Procedure Policy Number: 1-04-02B Revision Date: 10/24 Materials required: ...2 Face masks Procedure: Put on PPE and provide a mask to the patient. Teammate and patient will wear masks covering the nose and mask during this procedure. 1. An observation was conducted on 3/12/25 at 9:55 AM with Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician, accessing the AVF/AVG for PI # 7 at station 5. EI # 4 left station 5 and entered the supply storage area located off the treatment floor without taking off his/her PPE (gown and face shield). An interview was conducted on 3/12/25 with EI # 1, Facility Administrator, who confirmed staff failed to remove PPE prior to leaving the treatment area. 2. An observation was conducted on 3/12/25 at 10:40 AM with EI # 3, Registered Nurse, initiating dialysis with a CVC and performing CVC exit site care for PI # 8 at station 7. During the entire procedure, the mask on PI # 8 was worn below the nose and was not corrected by EI # 3. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, who confirmed staff failed to ensure the patient wore his/her mask covering the nose during initiation of dialysis with a CVC and CVC exit site care.”

“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: 49894 Based on review of facility policy, observations, and staff interview, it was determined the facility failed to ensure staff performed initiation of dialysis with a Central Venous Catheter (CVC) and CVC exit site care per facility policy. This affected Patient Identifier (PI) # 8 in one of two observations of initiation of dialysis with a CVC and PI # 4 in one of two observations of CVC exit site care and had the potential to affect all patients dialyzing with a CVC at this facility. Findings Include: Facility Policy: CVC with Clearguard HD Antimicrobial End Caps Procedure Policy Number: 1-04-02B Revision Date: 10/24 ...8. Holding catheter with the nondominant hand and using aseptic technique, clean exit site with 2% Chlorhexadine/70% Isopropyl Alcohol swab for a minimum of 30 seconds...Then wait 60 seconds for air dry time. ...16. ...One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads, and end of hub thoroughly with friction making sure to remove any residue... 1. An observation was conducted on 3/12/25 at 10:40 AM with Employee Identifier (EI) # 3, Registered Nurse (RN), performing CVC exit site care for PI # 8 at station 7. EI # 3 scrubbed the exit site for 15 seconds and failed to scrub the CVC exit site for a minimum of 30 seconds per facility policy. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Facility Administrator, who confirmed staff failed to perform CVC exit site care per facility policy. 2. An observation was conducted on 3/12/25 at 10:52 AM with EI # 2, RN, initiating dialysis with a CVC for PI # 4 at station 4. EI # 2 scrubbed each catheter hub for 10 seconds each and failed to scrub each catheter hub for 15 seconds each per facility policy. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Facility Administrator, who confirmed staff failed to scrub each catheter hub for 15 seconds per facility policy.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 49894 Based on observation and staff interview, it was determined the facility failed to restrict access to the water purification and storage system to authorized users only. Failure to restrict access to the water purification and storage area had the potential to negatively affect all 43 patients dialyzing at the facility. Findings include: A Flash Tour was conducted on 3/11/25 at 10:30 AM. A tour of the water room with Employee Identifier (EI) # 5, Biomedical Technician, revealed the door the water purification and storage area was not secure and did not restrict access to authorized users only. EI # 5 confirmed the door to the water purification and storage area is never locked. The door to the water room is accessible from the supply storage area where supply shipments are delivered. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Facility Administrator, who confirmed the facility failed to restrict access to the water purification and storage area to authorized users only.”

“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: 49603 49894 Based on review of medical records (MR), facility policy, and staff interview, it was determined the facility failed to ensure staff: 1. Notified the physician of post weights above or below 1 kilogram (kg) from the Estimated Dry Weight (EDW). 2. Notified the physician of Systolic Blood Pressure (SBP) greater than 200 and/or Diastolic Blood Pressure (DBP) greater than 120. 3. Offered Clonidine (medication to lower blood pressure) to patients with SBP greater than 200 and/or DBP greater than 120 per the physician’s order. This deficient practice affected Patient Identifiers (PI) # 1, PI # 5, PI # 3, and PI # 4 in four of five MR reviews and had the potential to affect all 43 patients dialyzing at the facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Revision Date: 4/24 Intradialytic Data Collection/Assessment ...b. At a minimum obtain and document the following: i. Blood pressure ...11. Abnormal findings outside of the patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician [or Nonphysician Practioner (NPP) if applicable] as needed of changes in patient status. Post Treatment Data Collection/Assessment ...17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician (or NPP if applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings: Fluid Status: Post-treatment If a patient is above or below 1 kg from the target weight. Blood Pressure: Predialysis: Systolic greater than 180 millimeters of mercury (mm/Hg) or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure-Intradialytic: Systolic greater than 180 millimeters of mercury (mm/Hg) or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood pressure: Post Treatment: Standing SBP greater than 140 mm/Hg or less than 90 mm/Hg, Standing DBP greater than 90 mm/Hg or less than 50 mm/Hg Sitting BP for patients that cannot stand: Sitting SBP greater than 140 mm/Hg or less than 90 mm/Hg, Sitting DBP greater than 90 mm/Hg or less than 50 mm/Hg 1. PI # 1 was admitted to the facility on 6/6/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Interdisciplinary Team Patient Profile Worksheet ( IDT PPW) revealed an order dated 9/6/24 for Clonidine 0.10 Milligram (mg), oral, every four hours as needed. Provider Instructions: If patient asymptomatic, do not treat hypertension during the first hour of treatment. After first hour, if systolic greater than (>) 200 and/or diastolic > 120, administer Clonidine 0.2 mg by mouth (po). After 30 min, if systolic still >180 and/or diastolic > 110, give Clonidine 0.1 mg po. After 30 more minutes, if systolic >180 and or diastolic > 110 notify physician. Review of the Treatment Details Report (TDR) dated 2/25/25 revealed SBP > 200 and DBP > 120 at the start of treatment at 9:53 AM until 10:53 AM; DBP > 120 at 10:53 AM until end of treatment at 12:48 PM. Further review of the treatment sheet revealed no documentation the patient was offered and declined or administered Clonidine per physician’s order and/or the physician was notified of the patient’s blood pressure (BP). Review of the TDR dated 3/6/25 revealed a post weight 2.6 kg above the EDW. There was no documentation the physician was notified of the post weight. An interview was conducted on 3/13/25 at 12:31 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed staff failed to notify the physician of post weights above 1 kg from the EDW and failed to administer Clonidine per physician’s order and notify the physician. 2. PI # 5 was admitted to the facility on 7/9/22 with a diagnosis of ESRD. Review of the TDR dated 2/18/25 revealed a post weight 2.2 kg above the EDW. Review of the TDR dated 2/25/25 revealed a post weight 1.9 kg above the EDW. There was no documentation of notification of the physician of the post weights for either treatment day. An interview was conducted on 3/13/25 at 12:29 PM with EI # 1, who confirmed staff failed to notify the physician of post weights above or below 1 kg from the EDW. 3. PI # 3 was admitted to the facility on 3/16/23 with a diagnosis of ESRD. Review of the IDT PPW revealed an order dated 3/16/23 for Clonidine 0.1 mg, oral, Every 4 hours as needed. Provider Instructions: If pt asymptomatic, do not treat hypertension during the first hour of treatment. After first hour, if systolic > 200 and/or diastolic > 120, administer Clonidine 0.2 mg po. After 30 min, if systolic still >180 and/or diastolic > 110, give Clonidine 0.1 mg po. After 30 more minutes, if systolic >180 and or diastolic > 110 notify physician. Review of the TDR dated 2/25/25 revealed SBP > 200 at the start of treatment at 8:00 AM and remained > 200 until treatment end at 11:59 AM. Further review of the treatment sheet revealed no documentation the patient was offered and declined or administered Clonidine per physician’s order and/or the physician was notified of the patient’s BP. Documentation Post-Treatment Vitals revealed a sitting BP of 242/81. There was no documentation the physician was notified of the post-treatment BP. An interview was conducted on 3/13/25 at 12:30 PM with EI # 1, who confirmed staff failed to administer Clonidine per physician’s order for SBP > 200 and/or notify the physician of SBP > 200. 4. PI # 4 was admitted to the facility on 1/13/25 with a diagnosis of ESRD. Review of the IDT PPW revealed an order dated 1/9/25 for Clonidine 0.20 mg, Every 30 minutes as needed. Provider Instructions: If pt asymptomatic, do not treat hypertension during the first hour of treatment. After first hour, if systolic > 200 and/or diastolic > 120, administer Clonidine 0.2 mg by po. After 30 min, if systolic still >180 and/or diastolic > 110, give Clonidine 0.1 mg po. After 30 more minutes, if systolic >180 and or diastolic > 110 notify physician. Review of the TDR dated 2/26/25 revealed a post-treatment standing BP of 161/115. There was no documentation the physician was notified of the post-treatment standing BP of 161/115. Review of the TDR dated 2/28/25 revealed a post-treatment sitting BP of 157/113 and post-treatment standing BP of 150/111. There was no documentation the physician was notified of the post-treatment sitting BP of 157/113, or standing BP of 150/111. Review of the TDR dated 3/3/25 revealed the pre-treatment sitting BP of 179/127 and standing BP of 176/121. Further review of the TDR revealed the patient’s BP was 159/124 at the termination of treatment, and post-treatment sitting BP was documented 158/113. There was no documentation the patient was offered and declined or was administered Clonidine per physician’s order and/or the physician was notified of pre-treatment or post-treatment blood pressures. Review of the TDR dated 3/5/25 revealed pre-treatment sitting BP of 156/113. Further review of the TDR revealed intra-dialytic blood pressure of 157/120 and BP 195/166 at the termination of treatment. There was no documentation the patient was offered and declined or was administered Clonidine per physician’s order and/or the physician was notified of pre-treatment, intra-dialytic, and/or post-treatment blood pressures. Review of the TDR dated 3/7/25 revealed the pre-treatment sitting BP was documented 149/111. Further review of the TDR revealed BP 141/127 at the termination of treatment. There was no documentation the physician was notified of the pre-treatment BP or BP at the termination of treatment. Review of the TDR dated 3/10/25 revealed pre-treatment sitting BP documented 164/123 and standing BP 179/128. Further review of the TDR revealed post-treatment sitting BP 150/111 and standing BP 145/111. There was no documentation the physician was notified of pre-treatment or post-treatment blood pressures. An interview was conducted on 3/13/25 at 12:27 PM with EI # 1, who confirmed staff failed to offer/administer Clonidine for high blood pressures and/or notify the physician of pre-treatment BP, intra-dialytic BP, or post-treatment BP per facility policy.”

“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: 49894 Based on review of medical records (MR), facility policy, and staff interview, it was determined the facility failed to ensure staff documented when the dialysis prescription was not being met, including the inability to obtain the prescribed Blood Flow Rate (BFR), and the reason the dialysis prescription was not being met, interventions, and patient response. This affected Patient Identifier (PI) # 4 in three of six Treatment Details Reports (TDR) reviewed for this patient and had the potential to negatively affect all 43 patients dialyzing at the facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nurse Assessment Policy Number: 1-03-08 Revision Date: 4/24 Intradialytic Data Collection/Assessment ...9. Intradialytic treatment monitoring and data collection...includes: ...b. At a minimum, obtain and document the following: ...iii. Blood and dialysate flows... 10. If the prescription is not being met (including ...inability to obtain prescribed BFR) the reason will be documented... ...13. All findings, interventions, and patient response will be documented in the patient record. PI # 4 was admitted to the facility on 1/13/25 with a diagnosis of End Stage Renal Disease. Review of the TDR dated 2/26/25 revealed a Hemodialysis Prescription that included a BFR of 400. Further review of the TDR dated 2/26/25 revealed the BFR documented as 350 from the start of treatment at 10:57 AM to the termination of treatment at 1:57 PM. There was no documentation of why the BFR was not as prescribed, interventions, or patient response. Review of the TDR dated 2/28/25 revealed a Hemodialysis Prescription that included a BFR of 400. Further review of the TDR dated 2/28/25 revealed the BFR was not as prescribed. There was no documentation of why the BFR was not as prescribed, interventions, or patient response. Review of the TDR dated 3/5/25 revealed a Hemodialysis Prescription that included a BFR of 400. Further review of the TDR dated 3/5/25 revealed the BFR was 350 from the start of treatment at 10:11 AM until 11:20 AM without documentation of why it was not as prescribed. BFR at 10:54 was documented “BFR 400 as prescribed”. An interview was conducted on 3/13/25 at 12:27 PM with Employee Identifier # 1, Facility Administrator, who confirmed the staff failed to document when the dialysis prescription was not being met, including inability to obtain the prescribed BFR, and the reason the dialysis prescription was not being met, interventions, and patient response.”

“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: 49894 Based on observations, review of the facility policy, and staff interview, it was determined the facility failed to ensure staff followed facility policy when accessing the Arteriofistula/Arteriovenous Graft (AVF/AVG) for initiation of dialysis. This affected Patient Identifiers (PI) # 6 and PI # 7 in two of two observations of accessing the AVF/AVG for initiation of dialysis and had the potential to negatively affect all patients dialyzing with a AVF/AVG. Findings include: Facility Policy: AVF or AVG Cannulation with NIPRO or Medisystems Safety Fistula Needles and Administration of Heparin Doses Policy Number: 1-04-01E Revision Date: 10/22 Skin Antiseptic: Povidone Iodine Effective Contact Time: 30 seconds Air Drying Time: 2 minutes Skin Antiseptic: Isopropyl Alcohol 70 % Effective Contact Time: 60 seconds Air Drying Time: 15 seconds Procedure ...5. Perform inspection, auscultation, and palpation... 8. Locate and palpate the skin cannulation sites prior to skin preparation. ...10. While maintaining aseptic technique, prep each planned site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. 11. ...moving from the center out and allow to dry. 12. ...apply alcohol using a circular rubbing motion, center out, for 60 seconds and allow to dry for 15 seconds. 13. Do not palpate insertion site once area has been prepped. ...22. Avoid flipping or rotating needles. 1. An observation was conducted on 3/12/25 at 8:55 AM with Employee Identifier (EI) # 2, Registered Nurse, accessing the AVF/AVG for PI # 6 at station 2. EI # 2 cleaned the arterial insertion site with 70% Isopropyl Alcohol for five seconds and the venous insertion site with 70 % Isopropyl Alcohol for ten seconds and failed to clean the arterial and venous insertion sites with 70 % Isopropyl Alcohol for 60 seconds each and allow to dry for 15 seconds before applying Povidone Iodine. EI # 2 cleaned the arterial and venous insertion sites with Povidone Iodine for five seconds each and failed to clean the arterial and venous insertion sites with Povidone Iodine for 30 seconds each. After cleaning the venous access site, EI # 2 palpated the insertion site, and failed to re-clean it before cannulation. After cannulating both the arterial and venous sites, EI # 2 immediately flipped both needles 180 degrees. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Faciltiy Administrator, who confirmed the faciltiy failed to ensure staff followed facility policy when accessing the AVF/AVG for initiation of dialysis. 2. An observation was conducted on 3/12/25 at 9:55 AM with EI # 4, Certified Clinical Hemodialysis Technician, accessing the AVF/AVG for initiation of dialysis for PI # 7 at station 5. EI # 4 cleaned the arterial and venous insertion sites for seven seconds each with 70 % Isopropyl Alcohol and failed to clean the arterial and venous insertion sites with 70 % Isopropyl Alcohol for 60 seconds each and allow to dry for 15 seconds before applying Povidone Iodine. EI # 4 failed to clean the arterial and venous insertion sites with Povidone Iodine for 30 seconds and allow to dry for 2 minutes before cannulating each site. After cannulation of both the arterial and venous needles, EI # 4 immediately flipped both needles 180 degrees. An interview was conducted on 3/13/25 at 12:22 PM with EI # 1, Faciltiy Administrator, who confirmed the faciltiy failed to ensure staff followed facility policy when accessing the AVF/AVG for initiation of dialysis.”