Davita Boaz Dialysis

“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: 49894 Based on observations, review of facility policy, and staff interview it was determined the facility failed to ensure staff performed disinfection of the dialysis station per facility policy in one of two observations of station disinfection. This deficient practice had the potential to negatively affect all 40 patients dialyzing at the facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Revision Date: 4/23 ...Disinfection: 12. Cleaning and/or disinfection of equipment and work surfaces... b. Use an appropriate disinfectant... ii. Sufficient disinfectant should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disnfectant contact time... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair...) and frequently contacted by healthcare personnel (e.g., control panel, top, front, and sides of dialysis machine,...) ...ii. Priming containers are to be emptied prior to disinfection. An observation was conducted on 3/25/25 at 12:30 PM with Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician, cleaning station 4. After emptying the prime waste container, EI # 4 failed to wipe all internal and external surfaces of the prime waste container before placing it back on the dialysis machine. After disinfecting the dialysis chair, EI # 4 failed to allow the chair to dry before returning the chair to its upright position. An interview was conducted on 3/27/25 at 11:30 AM with EI # 1, Facility Administrator, who confirmed staff failed to clean and disinfect the dialysis station per facility policy.”

“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 observation, review of facility policy, and staff interview, it was determined the facility failed to ensure staff did not flip cannulation needles after insertion. This deficient practice affected Patient Identifier (PI) # 1 in one of two observations of accessing the Arteriovenous Fistula/Graft (AVF/AVG) and had the potential to negatively affect all patients dialyzing with an AVF/AVG at the facility. Findings include: Facility Policy: AV Fistula or Graft Cannulation With Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Policy Number: 1-04-01E Revision Date: 10/22 Procedure: ...22. ...Avoid flipping or rotating Needles An observation was conducted on 3/26/25 at 9:25 AM with Employee Identifier (EI) # 6, Registered Nurse, accessing the AVF for PI # 1 at station 12. After inserting the cannulation needles into both the arterial and venous access, EI # 6 immediately flipped the cannulation needles 180 degrees, without first checking patency. An interview was conducted on 3/27/25 at 11:30 AM with EI # 1, Facility Administrator, who confirmed staff failed to follow policy for AVF/AVG cannulation.”

“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: 49603 Based on review of the medical record, the facility policy, and interview, it was determined the facility failed to ensure the Registered Nurse (RN) followed the facility policy and performed and documented a nurse assessment evaluation prior to the first dialysis treatment in one of one new patient record reviews. This affected Patient Identifier (PI) # 5 and had the potential to affect all in-center patients admitted to this facility. Findings include: Facility Policy: Initial Patient Nursing Assessment for New Patients Policy Number: 1-03-07 Revision Date: 4/24 POLICY: 1. A registered nurse (RN) as required by federal regulation will perform an initial pretreatment evaluation of all patients prior to the initiation of their first treatment at the facility. 2. The minimal nursing evaluation prior to initiating treatment for a patient new to the facility should include: a. Neurologic; b. Respiratory; c. Cardiovascular; d. Gastrointestinal; e. Fluid status; f. General assessment; g. Personal; h. Subjective Complaints; and i. Access: assessment. 1. PI # 5 was admitted to the facility on 1/18/25 with a primary diagnosis of End Stage Renal Disease. Review of the 1/18/25 Treatment Details Report documentation revealed the initial dialysis treatment was started at 7:31 AM and the initial nurse assessment was documented at 9:00 AM, which was 89 minutes later. An interview was conducted on 3/27/25 at 11:33 AM with Employee Identifier # 1, Facility Administrator, who confirmed staff failed to document the initial RN assessment prior to the initiation of the first dialysis treatment. 49894”