Davita Majestic 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: 41624 Based on observations, facility policy, and interviews, it was determined the facility failed to ensure staff followed the facility policy for cleaning and disinfection of the dialysis station between patients. This affected two of three observations of dialysis station cleaning/disinfection and had the potential to affect all 49 patients who 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 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 (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g.,...countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses... ...b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution. 1. An observation of cleaning and disinfection of station 4 by Employee Identifier (EI) # 4, Patient Care Technician, was conducted on 11/14/23 at 12:05 PM. EI # 4 failed to lift the cover over the Hansen Connectors to clean and disinfect underneath while cleaning the dialysis machine, and failed to clean the counter around the dialysis station. An interview was conducted on 11/16/23 at 2:00 PM with EI # 1, Facility Administrator (FA), who confirmed the dialysis station was not cleaned and disinfected per facility policy. 2. An observation of cleaning and disinfection of station 1 by EI # 3, Registered Nurse, was conducted on 11/15/23 at 8:44 AM. While cleaning the dialysis machine, EI # 3 failed to clean the wire basket attached, and did not lift the cover over the Hansen Connectors to clean and disinfect underneath. EI # 3 cleaned the blood pressure cuff and television remote, then placed them in the uncleaned wire basket. Further observation revealed EI # 3 failed to remove two blood line clamps for disinfection that were hanging on the IV (intravenous) pole attached to the dialysis machine, and failed to clean the counter around the dialysis station. An interview was conducted on 11/16/23 at 2:00 PM with EI # 1, FA, who confirmed the dialysis station was not cleaned and disinfected per facility policy.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 41624 Based on observations, review of facility policy, Potter - Perry Fundamentals of Nursing, and interviews, it was determined the facility staff failed to ensure all intravenous (IV) medications were secured and stored according to facility policy. This had the potential to negatively affect all patients served by this facility. Findings include: Facility Policy: Medication Policy Policy Number: 1-06-01 Revision Date: October 2023 Policy: ...11...Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day or if not under supervision by the licensed teammate... Potter - Perry Fundamentals of Nursing 6th edition copyright date 2001 Chapter 34 Unit VI Medication Administration page 907 Bullets 11 and 12 The six rights of medication administration are the right medication, right dose, right client, right route, right time, and right documentation. Nurses administer only medications they prepare and prepared medications are never left unattended. 1. During observations of care in the treatment area on 11/15/23 at 7:25 AM, two unattended 5 cc (cubic centimeter) syringes filled with medications were observed laying on the chair table at station 11, which was vacant. One syringe was labeled Heparin 1200 units, and had the date, time, and patient name, Patient Identifier (PI) # 17 on the label. The second syringe was labeled Heparin 2000 units, and had the date, time, and PI # 17’s name on the label. PI # 17 came to station 11 at 7:42 AM for dialysis treatment. Employee Identifier (EI) # 3, Registered Nurse, administered the two syringes of Heparin that had been left unattended to PI # 17 at 7:55 AM. In an interview on 11/15/23 at 8:30 AM, EI # 1, Facility Administrator, confirmed the medications were not stored per policy.”

“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: 41624 Based on observations, facility procedure, and interview, it was determined the facility failed to ensure staff performed Central Venous Catheter (CVC) care per facility policy. This affected one of two observations for CVC exit site care, including Patient Identifier (PI) # 2, one of two observations of discontinuation of dialysis with a CVC, including PI # 6, and had the potential to negatively affect all patients with CVC’s who dialyze at the facility. Findings include: Facility Policy: CVC With Clearguard HD (Hemodialysis) Antimicrobial End Caps Procedure Policy Number: 1-04-02 B Revised Date: October 2023 Notes: ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines... ... Device Disinfectant and Skin Antiseptic...2 % (percent) Chlorhexidine Gluconate/70 % Isopropyl Alcohol...Effective Contact Time...30 seconds back and forth motion...CVC Hubs...Effective Contact Time...15 second scrub... Procedure ...8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2 % Chlorhexidine Gluconate/70 % Isopropyl Alcohol swab for a minimum of 30 seconds... Upon Completion of Dialysis: ...33...disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads, and end of hub thoroughly with friction for 15 seconds.... 1. An observation was conducted on 11/14/23 at 11:00 AM at station 3 with Employee Identifier (EI) # 2, Registered Nurse (RN), to observe CVC exit site care provided to PI # 2. During the observation, EI # 2 cleansed the CVC exit site with a 2 % Chlorhexidine Gluconate/70 % Isopropyl Alcohol swabstick for 15 seconds. EI # 2 failed to cleanse the CVC exit site for 30 seconds per the facility procedure. An interview was conducted on 11/16/23 at 2:00 PM with EI # 1, Facility Administrator (FA), who confirmed EI # 2 failed to cleanse the CVC exit site for 30 seconds per the facility procedure. 2. An observation was conducted on 11/14/23 at 1:38 PM at station 10 with EI # 2 to observe discontinuation of dialysis with a CVC provided to PI # 6. During the observation, EI # 2 scrubbed both CVC hubs with an alcohol prep pad for one second each, and not 15 seconds per facility procedure. An interview was conducted on 11/16/23 at 2:00 PM with EI # 1 who confirmed EI # 2 failed to scrub the CVC hubs for 15 seconds per the facility procedure.”

“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 interviews, it was determined the facility failed to ensure: 1. Vital signs (VS) were completed at least every thirty minutes. 2. The physician was notified when the post treatment weight was > (greater than) one kilogram (kg) above the ordered target weight. This deficient practice affected two of five in-center hemodialysis records reviewed and did affect Patient Identifier (PI) # 3, and PI # 4, and had the potential to negatively affect all 49 in-center patients who dialyze at this facility. Findings include: Facility Policy: Intradialytic Data Collection/Assessment Policy Number: 1-03-08 Revised Date: 10/2023 Intradialytic Data Collection/Assessment: ...9. Intradialytic treatment monitoring and data collection...includes: a. Vital signs and treatment monitoring...completed at least every thirty minutes. ...b. At a minimum, obtain and document the following: i. Blood pressure (BP) ii. Heart or pulse rate... Post Treatment Data Collection Assesment: ...16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse... 17. Licensed nurse will use their clinical judgement...to determine if any clinical interventions or 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 # 3 was admitted to the facility on 4/24/17 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Treatment Details Report (TDR) dated 10/10/23 revealed a BP and pulse documented at 8:31 AM. The next BP and pulse was documented at 10:08 AM, which was 97 minutes later. Further review of the TDR dated 10/10/23 revealed a BP and pulse documented at 10:33 AM. The next BP and pulse was documented at 11:24 AM, which was 51 minutes later. An interview was conducted on 11/16/23 at 1:34 PM with Employee Identifier (EI) # 1, Facility Administrator (FA), who confirmed staff failed to document VS within the timeframe per policy. 41624 2. PI # 4 was admitted to the facility on 10/19/22 with a diagnosis of ESRD. Review of the IDT (Inter-Disciplinary Team) Rounding Worksheet Active Treatment Orders with start date 8/9/23 revealed orders for a target weight post treatment of 123 kg. Review of the TDR dated 11/6/23 revealed PI # 4’s pre treatment weight was 127.5 kg. The post treatment weight was 125.3 kg, which was a 2.3 kg difference from the target weight of 123 kg. There was no documentation the physician was notified the post treatment weight was > one kg above the target weight. Review of the TDR dated 11/8/23 revealed PI # 4’s pre treatment weight was 128.8 kg. The post treatment weight was 125.3 kg, a 2.3 kg difference from the target weight of 123 kg. There was no documentation the physician was notified the post treatment weight was > one kg above the target weight. An interview was conducted on 11/16/23 at 1:14 PM with EI # 1 who confirmed per policy the physician was to be notified for a post weight > or < (less than) one kg from the target weight, and there was no documentation the physician was notified when PI # 4 exceeded his/her target weight > one kg.”