Davita Limestone 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: 47295 Based on observations, facility policy, and interview, it was determined the facility failed to ensure staff followed the facility policy for hand hygiene. This deficient practice affected one of two observations of Cleaning and Disinfection of the Dialysis Station and one of two observations of Discontinuation of Dialysis and Post Dialysis Access Care for Arteriovenous Fistula or Graft (AVF/AVG) and had the potential to negatively affect all 27 in-center hemodialysis (ICHD) patients who dialyzed 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): ...b. prior to gloving and immediately after removal of gloves... 1. An observation of cleaning and disinfection of the dialysis station by Employee Identifier (EI) # 2, Certified Clinical Hemodialysis Technician (CCHT), was conducted at station 4 on 1/7/25 at 9:54 AM. Upon completing the station cleaning, EI # 2 removed his/her gloves and did not immediately perform HH. 2. An observation of discontinuation of dialysis and post dialysis access care for AVF/AVG by EI # 2 was conducted at station 7 on 1/7/25 at 10:20 AM for Patient Identifier (PI) # 5. EI # 2 donned gloves without performing HH. EI # 2 then moved the red biohazard sharps box closer to the station with a gloved hand and without performing HH, removed PI # 5’s second needle. An interview was conducted on 1/9/25 at 2:00 PM with EI # 1, Manager of Clinical Services, who confirmed EI # 2 failed to perform HH per policy.”

“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: 47295 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 two of two observations of dialysis station disinfection. This deficient practice had the potential to negatively affect all 27 in-center hemodialysis (ICHD) 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: 12...b. Use an appropriate disinfectant...for routine disinfection of environmental surfaces. ...ii. Sufficient disinfectant should be applied so that surfaces are visibly wet. ...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, blood pressure cuffs....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 1/7/25 at 9:54 AM at station 4 with Employee Identifier (EI) # 2, Certified Clinical Hemodialysis Technician (CCHT). EI # 2 failed to clean all the hooks on the Intravenous (IV) pole, and failed to clean and disinfect the blue emergency bag hanging on the pole. EI # 2 also failed to clean the wire basket on the side of the dialysis machine and after cleaning the chair, the dirty blood pressure cuff and tubing were placed on the clean chair. 2. An observation for cleaning and disinfection of the dialysis station was conducted on 1/7/25 at 10:06 AM with EI # 2 at Station 10. During the observation, EI # 2 failed to clean all the hooks on the IV pole and failed to clean and disinfect the blue emergency bag hanging on the pole. EI # 2 also failed to clean the wire basket on the side of the dialysis machine and after cleaning the chair, the dirty blood pressure cuff and tubing were placed on the clean chair. An interview was conducted on 1/9/25 at 2:00 PM with EI # 1, Manager of Clinical Services, who confirmed the dialysis station was not cleaned/disinfected per facility policy.”

“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: 47295 Based on review of medical records (MR), facility policy and staff interview, it was determined the facility failed to ensure: 1. Blood pressure (BP), pulse rate and safety checks were performed and documented every 30 minutes per policy. 2. Post treatment Estimated Dry Weight (EDW) was reported to the physician if less than or greater than one kilogram (kg) from prescribed EDW. This deficient practice affected Patient Identifier (PI) # 1 and PI # 2 in two of three in-center MRs reviewed and had the potential to negatively affect all 27 in-center hemodialyisis (ICHD) patients dialyzed at the facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Revision Date: April 2024 ...Purpose: To obtain and document baseline and ongoing information... Policy: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. ...Intradialytic Data Collection/Assessment: ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs (VS) and treatment monitoring ...iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate ...iv. Fluid removal and/or replacement... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately... 12. The licensed nurse notifies the physician...as needed of changes in patient status. Abnormal Findings: Post-treatment: If patient is above or below 1 kg from the target weight. 1. PI # 1 was admitted to the facility on 4/8/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Dialysis Prescription dated 12/31/24 revealed an ordered EDW of 132 kg. Review of the Treatment Details Report (TDR) dated 12/31/24 revealed a post-treatment EDW of 133.5. There was no documentation the physician was notified of the post-treatment weight, which was 1.5 kg above the EDW. Review of the TDR dated 1/7/25 revealed a post-treatment EDW of 136.5 kg. There was no documentation the physician was notified of the post-treatment weight, which was 4.5 kg above the EDW. An interview was conducted on 1/9/25 at 3:15 PM with Employee Identifier (EI) # 1, Manager of Clinical Services, who confirmed staff failed to notify the physician when the patient’s post-treatment weight was greater than 1 kg from the ordered EDW. 2. PI # 2 was admitted to the facility on 8/30/21 with a diagnosis of ESRD. Review of the TDR dated 12/23/24 revealed a VS and safety check at 1:47 PM. The next VS and safety check was at 2:43 PM, which was 56 minutes later, and not every 30 minutes per policy. Review of the TDR dated 12/28/24 revealed a VS and safety check at 1:48 PM. The next VS and safety check was at 2:30 PM, which was 42 minutes later, and not every 30 minutes per policy. Review of the TDR dated 1/3/25 revealed a VS and safety check at 1:12 PM. The next VS and safety check was at 2:12 PM, which was 60 minutes later, and not every 30 minutes per policy. An interview was conducted on 1/9/25 at 2:45 PM with EI # 1, who confirmed staff failed to document VS and safety checks per 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: 47295 Based on review of medical records (MR), facility policy and staff interview, it was determined the facility failed to ensure: 1. The staff followed the physician’s orders for Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR). 2. The staff had patients sign the Early Termination of Treatment Against Medical Advice (AMA) Form when treatment was terminated early. This deficient practice affected two of three in-center hemodialysis (ICHD) records reviewed, including Patient Identifier (PI) # 1 and PI # 3, and had the potential to negatively affect all 27 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: April 2024 ...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 and the licensed nurse informed. Facility Policy: Prescribed Treatment Time Not Met Policy Number: 1-01-09 Revision Date: April 2024 Purpose: Provide requirements for teammates to follow when a patient’s treatment is terminated early... Policy: A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time... B. Prescribed Treatment Time Not Met 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs... 1. PI # 1 was admitted to the facility on 4/8/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Dialysis Prescription revealed ICHD treatment orders dated 12/17/24 with a BFR of 500 and a DFR of 800. Review of the Treatment Details Report (TDR) dated 12/17/24 revealed the DFR ran at 500 from 8:45 AM to 11:58 AM. There was no documentation why the DFR was not at the ordered rate of 800. Review of the TDR dated 12/27/24 revealed the BFR ran at 450 from 8:41 AM to 11:47 AM. There was no documentation why the BFR was not at the ordered rate of 500. Review of the TDR dated 12/31/24 revealed a prescribed treatment time of three hours 30 minutes and completed treatment time of two hours 27 minutes. There was no documentation that an AMA form was signed or that the physician was notified of an early termination of treatment time exceeding 30 minutes. Review of the TDR dated 1/4/25 revealed the BFR ran at 400 from 10:14 AM to 10:30 AM and at 240 from 10:36 AM to 10:44 AM. There was no documentation why the BFR was not at the ordered rate of 500. Further review of the TDR dated 1/4/25 revealed a prescribed treatment time of three hours 30 minutes and completed treatment time of two hours 9 minutes. There was no documentation an AMA form was signed or that the physician was notified of an early termination of treatment time exceeding 30 minutes. Review of the TDR dated 1/7/25 revealed a prescribed treatment time of three hours 30 minutes and completed treatment time of two hours 37 minutes. There was no documentation an AMA form was signed or that the physician was notified of an early termination of treatment time exceeding 30 minutes. An interview was conducted on 1/9/25 at 3:15 PM with Employee Identifier (EI) # 1, Manager of Clinical Services who confirmed staff failed to follow orders for BFR and DFR and failed to follow facility policy for early treatment termination. 2. PI # 3 was admitted to the facility on 5/15/24 with a diagnosis of ESRD. Review of the Dialysis Prescription revealed ICHD treatment orders dated 12/23/24 with a BFR of 400. Review of the TDR dated 12/23/24 revealed the BFR rate was 200 from 11:20 AM to 11:46 AM and at 350 from 12:16 PM to 2:49 PM. There was no documentation why the BFR was not at the ordered rate of 400. Review of the TDR dated 12/26/24 revealed the BFR rate was 390 from 12:18 PM to 2:38 PM. There was no documentation why the BFR was not at the ordered rate of 400. An interview was conducted on 1/9/25 at 3:00 PM with EI # 1, who confirmed staff failed to follow orders for BFR.”