Dialysis Services of Decatur, LLC

“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: 28297 Based on observation, interview, Centers for Medicare and Medicaid Services ESRD Core Survey Version 1.6 Infection Control Observation forms, and policy review, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood.) for one of two observations. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 54 in-center patients. Findings include: Observation on 06/24/25 at 10:30 AM, revealed Patient (P) 8 at Station 7 applied pressure to the left lower access site until bleeding had stopped. When the patient was finished, he/she walked to the scale to retrieve weight with Certified Clinical Hemodialysis Technician (CCHT) 2 however the patient did not wash or sanitize hands before leaving the facility and CCHT2 did not instruct or encourage patient to wash or sanitize hands. During an interview on 06/24/25 at 10:40 AM, CCHT2 confirmed P8 did not wash or sanitize hands, and he/she did not instruct or encouraged them to wash hands to prevent cross contamination. During an interview on 06/25/25 at 1:20 PM, the Nurse Manager stated patients should wash or sanitize their hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. Review of the facility’s policy titled, “Hand Hygiene” revised 01/09/2018 revealed no information specific to patient hand hygiene. Review of the “Centers for Medicare and Medicaid Services ESRD Core Survey Version 1.6 Infection Control Observation” undated, document “Discontinuation of Dialysis and Post Treatment Access Care for AV Fistula or Graft indicated the following as the last step on the checklist was “Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene.)”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 28297 Based on observation, interview, and review of facility policy, the facility failed to ensure there was always a supply of paper towels available at three of six handwashing sinks for one of three survey days. The failure to have paper towels readily available may hinder a patient’s or staff’s ability to wash hands as required and this could affect 54 in-center patients. Findings include: Observation on 06/23/25 at 11:20 AM revealed the two sinks across from Station 15, and Station 16 and the sink at the medication preparation area did not have any paper towels available for staff or patient use. During an interview on 06/23/25 at 11:25 AM Registered Nurse (RN) 2 confirmed there were no paper towels at the medication preparation area or at the two sinks across from Station 15 and 16. RN2 stated the housekeepers usually kept them stocked but they had not been stocked for the past week. RN2 stated the Biomedical Technician had a key for the paper towel dispenser however nursing did not have a key to open the paper towel dispensers to refill. During an interview on 06/25/25 at 1:20 PM the Nurse Manager stated all sinks should always have paper towels available and he/she was not sure why housekeeping had not refilled the paper towel dispensers. Review of the facility policy “Hand Hygiene,” revised 01/09/18 indicated, “ ...Disposable paper towels should be kept in a dispenser located in close proximity to all hand washing sinks. The dispenser should not have the opening at the top, allowing water droplets to fall onto clean papertowels ...””

“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: 28297 Based on interview, medical record review and review of facility policy the facility failed to complete an unstable assessment for one of seven sampled patients (Patient (P) 7). The failure to complete an unstable assessment had the potential to missed opportunities for improvement and this could affect 54 in-center patients. Findings include: Review of the medical record for P7 revealed the patient was admitted on 05/21/15 with diagnosis including end stage renal disease (ESRD). Review of the last Assessment and Plan of Care for P7 revealed the facility completed it on 10/16/24 and identified the patient as stable. Review of the hospitalizations reported provided by the facility revealed the patient was hospitalized from 04/04/25-04/30/25 with diagnosis of Acute on chronic hypercapnia/ hypoxic respiratory failure due to multifocal pneumonia. There was no unstable Assessment and Plan of Care completed for P7 due to the extended hospitalization. Review of the hospital progress note dated 04/29/25 for P7 revealed the following: “Subjective: patient has no major complaints he/she seems to be doing better his/her breathing is all a bit better he/she is less agitated I discussed about going home today and he/she says he/she wants to give it one more day, but he/she also doesn’t want to go to rehab.” During an interview with the Nurse Manager on 06/25/25 at 11:30 AM he/she indicated the Interdisciplinary Team decided not to do an unstable Assessment and Plan of Care for P7 because the patient was only in the hospital for extended period because they were looking to send the patient to rehab. Once a rehab facility was located the patient refused to be discharged to that facility and was discharged home. Review of facility’s undated policy titled, “Care Plan,” indicated, “ ...Patients are considered unstable using the following criteria: Greater than 15 extended hospital stay ...””

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 28297 Based on interview, facility document review, and review of “Facility Risk Management Guide”, the facility failed to complete an adverse event report as required. The failure to complete the adverse event had to potential for staff to not track and trend adverse events for facility improvement and this could affect 54 in-center patients. Findings include: Review of the “Water System Log DCI” from 04/01/25 through 06/01/25 revealed on 05/17/25 the facility did not check the water for chlorine until 7:16 PM, almost 2 hours later than the normal start time. Review of the adverse event reports from November 2024 until June 2025 revealed no adverse event was reported for the water system malfunction. During an interview on 06/23/25 at 1:10 PM the Nurse Manager stated on Saturday 05/17/25 there was a Reverse Osmosis (RO) alarm, and the facility had to call the Biomedical Technician to come to the clinic to evaluate. The Nurse Manager stated it was a problem with the Booster Pump and Biomedical Technician only had to turn the RO off and back on to reset the Booster. He/she confirmed that patient treatments did not start until 7:38 AM with normal start up as 6:00 AM. The Nurse Manager stated two patients did not complete their full treatment and signed off Against Medical Advice per the patient request. He/she acknowledged it should have been documented as an adverse event and that he/she just forgot because it was on a Saturday. Review of the document “Dialysis Clinic, Inc Risk Management Guide” revised 05/06/22 indicated, “The reporting of adverse occurrences and near misses is the responsibility of all employees .... Facility Related Occurrences- those events that can affect the operation of the facility in general or specifically, which may or may not affect patients or employees and may or may not result in injury ... This includes but not limited to ...Water System (malfunction, contamination) ...The Administrator, Nurse Manager, or their designee will enter occurrences ...Enter occurrence as soon as possible but no later than 24 hours after the event. Limiting the time between when the event occurred and when it is reported improves the quality and accuracy of the information about the occurrence ...””