Davita Russellville 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: 41624 Based on observations, facility policy, and interview, it was determined the facility failed to ensure staff followed the facility policy for hand hygiene and PPE (personal protective equipment). This affected one of two observations of Discontinuation of Dialysis with Central Venous Catheter (CVC) for an unsampled patient, and had the potential to negatively affect all patients with a CVC that dialyze at this facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy number: 1-05-01 Revision Date: April 2023 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Hand Hygiene: 1. All teammates, physicians, and non-physicians will perform hand hygiene (HH): ...c. after contamination with blood or other infectious material, ...g. before touching clean areas such as supplies... ...3. Use of an alcohol-based hand rub may be substituted for handwashing... PPE: ...7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station... ...a. Gloves should be changed when: ...ii. When going from a “dirty” area or task to a “clean” area or task... 1. An observation of discontinuation of dialysis with a CVC by Employee Identifier (EI) # 2, Registered Nurse, was conducted at station 7 on 1/24/24 at 11:28 AM for an unsampled patient. During the observation, EI # 2 touched and pulled the garbage can closer to him/her while wearing gloves, then proceeded to place a new clean field under the CVC limbs without changing gloves and performing HH. EI # 2 failed to perform HH and change gloves when going from a dirty area to a clean task per policy. An interview was conducted on 1/25/24 at 2:29 PM with EI # 1, Facility Administrator, who confirmed EI # 2 failed to perform HH per policy.”

“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: 41624 Based on observations, review of facility policies, and interview, it was determined the staff failed to ensure: 1. Contaminated prime waste was not emptied in a designated clean area. 2. Medications were stored in cabinet(s) or under supervision by the licensed teammate per facility policy. This did affect one of two observations for cleaning and disinfection of the dialysis station, and one random observation of prepared medications for an unsampled patient, and had the potential to negatively affect all 45 patients who dialyzed at the facility. Findings include: Facility Policy: Medication Policy Policy Number: 1-6-01 Revision Date: October 2023 Purpose: To provide guidance for medication management in the facility... Policy: ...11. ...Non-refrigerated medications are to be stored in cabinet(s)... or if not under supervision by the licensed teammate... Facility Policy: Infection Control For Dialysis Facilities Policy Number: 1-05-01 Revision Date: April 2023 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. ...Disinfection: ...13. At the end of each treatment, the dialysis station will be cleaned and disinfected. ...ii. Priming containers are to be emptied prior to disinfection. Facility Hygiene: 16. Clean areas should be clearly designated...clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. 1. During observations of care on 1/23/24 at 7:56 AM, the surveyor observed two syringes labeled, “Heparin,” on the chair side table top at station 1, which was vacant. The staff failed to store the Heparin in cabinet(s) or under supervision by the licensed teammate as per facility policy. An interview was conducted on 1/23/24 at 8:20 AM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed the heparin syringes were not stored per policy. 2. An observation of cleaning and disinfection of the dialysis station was conducted on 1/23/24 at 2:55 PM with EI # 3, Certified Clinical Hemodialysis Technician (CCHT), at station 6. During the observation, EI # 3 removed the prime bucket from the dialysis machine and emptied the prime waste contents into the designated clean sink. EI # 3 failed to keep the clean area separated from a contaminated area per facility policy. An interview was conducted on 1/25/24 at 2:29 PM with EI # 1 who confirmed facility policy was not followed to keep designated clean and contaminated areas separated.”

“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: 41624 Based on observations, facility policy and interview, it was determined the facility failed to ensure staff followed the facility policy for cleaning and disinfection of the dialysis station between patients in one of two observations of dialysis station disinfection. This had the potential to affect all 45 patients who dialyzed at this facility. Findings include: Facility Policy Number: 1-05-01 Title: Infection Control for Dialysis Facilities Revision Date: April 2023 Purpose: To minimize the spread of infections or blood borne pathogens in the dialysis facility environment. Disinfection ...13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings ...dialysis chair, tray tables....and frequently contacted by healthcare personnel ... 14. Non-disposable items are to be disinfected after each patient use... 1. An observation for cleaning and disinfection of the dialysis station was conducted on 1/23/24 at 2:55 PM at station 6 with Employee Identifier (EI) # 3, Certified Clinical Hemodialysis Technician. EI # 3 failed to clean and disinfect the television arms and control knobs. An interview was conducted on 1/25/24 at 2:29 PM with EI # 1, Facility Administrator, who confirmed the dialysis station was not cleaned/disinfected per facility policy.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 41624 Based on review of medical records (MR), facility policy, and interview with facility staff, it was determined the facility failed to ensure the initial Plan of Care (POC) was completed within 30 days or 13 treatments for one of one records reviewed for newly admitted patients. This affected Patient Identifier (PI) # 2 and had the potential to negatively affect all patients newly admitted to this facility. Findings include: Facility Policy: Interdisciplinary Team (IDT) Patient Assessment and Plan Of Care Policy Number: 1-14-01 Revision Date: July 2023 Policy: Plan of Care: 8. The facility’s IDT will develop and implement a written, individualized comprehensive POC that specifies the services necessary... ...10. An initial POC...will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment... 1. PI # 2 was admitted to the facility on 8/10/23 with a diagnosis of ESRD (End Stage Renal Disease). Review of the MR revealed the initial POC was signed and dated by each IDT member on 9/13/23, which was 34 days after admission. The IDT failed to complete and develop the POC for PI # 2 within 30 calendar days of admission. An interview was conducted on 1/25/24 at 2:20 PM with Employee Identifier # 1, Facility Administrator, who confirmed the POC was not developed within 30 calendar days of the first outpatient dialysis treatment per facility policy.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 41624 Based on review of medical records (MR), facility policy and staff interview, it was determined the facility failed to ensure the Interdisciplinary Team (IDT) completed at least monthly re-assessments and care plan updates for Patient Identifier (PI) # 3, one of one unstable MR’s reviewed. This had the potential to negatively affect all patients served by the facility. Findings include: Facility Policy: IDT Patient Assessment and Plan Of Care Policy Number: 1-14-01 Revision Date: July 2023 Policy: Assessment: ...2. The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. ...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: - At least monthly for unstable patients ... 1. PI # 3 was admitted to the facility on 12/16/2020 with a diagnosis of End Stage Renal Disease. Review of the MR revealed PI # 3 was deemed unstable by the IDT on 7/17/23. Further review of the MR revealed an IDT monthly review/revision of the Plan of Care (POC) was performed 8/23/23 and 9/20/23, in which PI # 3 remained unstable. The next POC review/revision was dated 11/2/23, which was 43 days after the 9/20/23 assessment. There was no documented POC review/revision for the month of October. The POC review/revision was not performed monthly per policy for an unstable patient. An interview was conducted 1/25/24 at 2:14 PM with Employee Identifier # 1, Facility Administrator, who confirmed there was no POC dated for the month of October and facility policy was to perform them at least monthly.”

“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: 41624 Based on review of medical records (MR), facility policy and interviews with the staff, it was determined the facility failed to ensure post treatment weights greater than one kilogram (kg) from the prescribed target weight were reported to the physician. This deficient practice affected four of five hemodialysis MR’s reviewed and did affect Patient Identifier (PI) # 2, PI # 3, PI # 4, and PI # 5 and had the potential to negatively affect all 45 hemodialysis patients dialyzing at this facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy Number: 1-03-08 Revision Date: October 2023 Purpose: To obtain and document baseline and ongoing information before, during and after dialysis treatment... Policy: 1. Patient data will be obtained and documented... a. Data collection includes... iv. Patient weight... Intradialytic Data Collection/Assessment ...11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). Post Treatment Data Collection/Assessment 15. The PCT (Patient Care Technician) or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. ...17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if ... notification of physician...is necessary prior to discharge of the patient from the facility. Abnormal Findings Fluid Status: Post-treatment: If patient is above or below 1 kg from the target weight. 1. PI # 2 was admitted to the facility on 8/10/23 with a diagnosis of ESRD (End Stage Renal Disease). Review of the ICHD (In-center Hemodialysis) Prescription with order start date 1/13/24 revealed PI # 2 had a prescribed target weight of 73 kg. Review of the Treatment Details Report (TDR) dated 1/17/24 revealed PI # 2 had a post treatment weight of 75.4 kg, which was 2.4 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was greater than (>) one kg over the target weight. Review of the TDR dated 1/19/24 revealed PI # 2 had a post treatment weight of 75.2 kg, which was 2.2 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. Review of the TDR dated 1/22/24 revealed PI # 2 had a post treatment weight of 75.0 kg, which was 2.0 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. An interview was conducted on 1/25/24 at 2:20 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed staff failed to follow facility policy and notify the physician for a post treatment weight > one kg above the target weight. 2. PI # 3 was admitted to the facility on 12/16/2020 with a diagnosis of ESRD. Review of the ICHD Prescription with order start date 12/14/23 revealed PI # 3 had a prescribed target weight of 82 kg. Review of the TDR dated 1/8/24 revealed PI # 3 had a post treatment weight of 83.4 kg, which was 1.4 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. An interview was conducted on 1/25/24 at 2:14 PM with EI # 1 who confirmed staff failed to follow facility policy and notify the physician for a post treatment weight > one kg above the target weight. 3. PI # 4 was admitted to the facility on 5/18/22 with a diagnosis of ESRD. Review of the ICHD Prescription with order start date 1/6/24 revealed PI # 4 had a prescribed target weight of 80.5 kg. Review of the TDR dated 1/8/24 revealed PI # 2 had a post treatment weight of 83.0 kg, which was 2.5 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. An interview was conducted on 1/25/24 at 2:08 PM with EI # 1 who confirmed staff failed to follow facility policy and notify the physician for a post treatment weight > one kg above the target weight. 4. PI # 5 was admitted to the facility on 10/2/23 with a diagnosis of Acute Kidney Injury. Review of the ICHD Prescription with order start date 12/22/23 revealed PI # 5 had a prescribed target weight of 78.5 kg. Review of the TDR dated 1/10/24 revealed PI # 5 had a post treatment weight of 80.2 kg, which was 1.7 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. Review of the TDR dated 1/12/24 revealed PI # 5 had a post treatment weight of 80.2 kg, which was 1.7 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. Review of the TDR dated 1/22/24 revealed PI # 5 had a post treatment weight of 80.2 kg, which was 1.7 kg over the prescribed target weight. There was no documentation the physician was notified the post weight was > one kg over the target weight. An interview was conducted on 1/25/24 at 1:51 PM with EI # 1 who confirmed staff failed to follow facility policy and notify the physician for a post treatment weight > one kg above the target weight.”

“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: 41624 Based on review of Medical Records (MR), policies and staff interviews, it was determined the facility failed to ensure the staff followed the physician’s orders for Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR). This deficient practice affected two of five in-center hemodialysis (ICHD) records reviewed and did affect Patient Identifer (PI) # 2 and PI # 4, and had the potential to negatively affect all 45 ICHD patients who dialyzed at this facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Revision Date: 10/2023 Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment... Policy: ...3. Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment with the exception of BFR which is verified and documented when the ordered rate is obtained after onset of treatment... Intradialytic Data Collection/Assessment: ...9. ...b. At a minimum, obtain and document the following: ...iii. Blood and dialysate flows... ...10. If the dialysis prescription is not being met (including DFR or change to/inability to obtain prescribed BFR) the reason will be documented... 1. PI # 2 was admitted to the facility on 8/10/23 with a diagnosis of ESRD (End Stage Renal Disease). Review of the ICHD (In-center Hemodialysis) Prescription with order start date 12/18/23 revealed PI # 2 had an ordered DFR of 600 ml/min (milliliters per minute). Review of the Treatment Details Report (TDR) dated 1/12/24 revealed the DFR ran at 500 from the beginning of treatment 2:03 PM until the end of treatment 5:30 PM. There was no reason documented why the DFR was 500 and not 600 as ordered. Review of the TDR dated 1/17/24 revealed the DFR ran at 500 from the beginning of treatment 11:02 AM until the end of treatment 2:05 PM. There was no reason documented why the DFR was 500 and not 600 as ordered. Review of the TDR dated 1/22/24 revealed the DFR ran at 500 from the beginning of treatment 1:26 PM until the end of treatment 5:03 PM. There was no reason documented why the DFR was 500 and not 600 as ordered. An interview was conducted on 1/25/24 at 2:20 PM with Employee Identifier (EI) # 1, Facility Administrator (FA), who confirmed the staff failed to follow policy and document why the DFR was not run at the ordered rate. 2. PI # 4 was admitted to the facility on 5/18/22 with a diagnosis of ESRD. Review of the ICHD Prescription with order start date 1/6/24 revealed PI # 4 had a prescribed BFR of 350 ml/min. Review of the TDR dated 1/12/24 revealed the BFR was decreased to 250 at 10:31 AM until the end of treatment at 11:16 AM. There was no reason documented why the BFR was 250 and not 350 as ordered. An interview was conducted on 1/25/24 at 2:08 PM with EI # 1 who confirmed the staff failed to follow policy and document why the BFR was not run at the ordered rate.”

“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: 41624 Based on observations, review of facility procedure and interview, it was determined the facility failed to ensure staff performed AVF/AVG (arteriovenous fistula/graft) site preparation per facility procedure in one of two observations conducted for AVF/AVG access and initiation of dialysis for an unsampled patient. This had the potential to negatively affect all patients who dialyze with an AVF/AVG at this facility. Findings include: Facility Procedure Number: 1-04-01E Facility Procedure: AV (Arteriovenous) Fistula or Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose. Revision Date: October 2022 ...Materials required: 70 % alcohol preps ...Skin antiseptic... Notes: Check for patient sensitivity to preferred antiseptic/skin disinfectant listed in table below. Use Isopropyl Alcohol 70 % as the single skin antiseptic ONLY when the patient has documented allergies to other skin antiseptics. Notes: ...Skin Antiseptic Povidone Iodine...Effective Contact Time 30 seconds, Air Drying Time 2 minutes ...Isopropyl Alcohol 70 %...Effective Contact Time 60 seconds, Air Drying Time 15 seconds Procedure: ...10. While maintain(ing) aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic... 1. An observation of care for access of AVF/AVG for initiation of dialysis was conducted on 1/23/24 at 11:35 AM with Employee Identifier (EI) # 3, Certified Clinical Hemodialysis Technician (CCHT), at station 2 for an unsampled patient. Using an alcohol pad, EI # 3 performed antisepsis to each site of the AVF/AVG for five seconds, and after dry time, performed antisepsis with a povidone iodine pad for three seconds to each site. EI # 3 failed to perform antisepsis to each access site for the minimal effective contact time per facility procedure. An interview was conducted on 1/25/24 at 2:29 PM with EI # 1, Facility Administrator, who confirmed staff failed to perform access site antisepsis of the cannulation sites per facility procedure.”