Davita Central Little Rock Dialysis

“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: 52740 Based on review of policy and procedure, surveyor observation, and interview with staff, it was determined that facility staff failed to ensure that clean supplies were not handled or stored in the same or an area adjacent to where blood samples are handled. This failed practice placed patients at risk for infection due to cross contamination and had the potential to affect all 74 in-center hemodialysis patients. Findings follow: A. Review of Policy 1-05-01 “Infection Control for Dialysis Facilities” (rev. date April 2023) showed, 1) Supplies will be stored in a manner that maintains their integrity. Anytime the integrity of a package with or without an expiration date is in question, i.e., torn ripped, wet or contaminated, the package and its contents must be disposed of and not used. 2) 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. B. During tour of facility on 08/19/2025 with FA, surveyor observed: 1) The cleam CVC (Central Venous Catheter) “kits” sitting on counter in “dirty” lab area less than three feet from centrifuge. FA and RN #9 confirmed that this is the area that the CVC “kits” are assembled for later use. 2) Clean boxes of gloves stored on chase wall behind station 3. C. During post tour interview on 08/19/2025, FA confirmed that clean CVC supplies should not be stored or prepared in a “dirty” area.”

“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: 52740 0122 Based on review of policy and procedure, surveyor observation, and interview with staff, it was determined that facility staff failed to clean and disinfect environmental surfaces; in-center hemodialysis (ICHD) facility staff failed to ensure that medical equipment and dialysis stations (including chase walls, chairs, and wall boxes) were disinfected between patients; and home program, peritoneal dialysis and home hemodialysis, staff failed to ensure that wall boxes in five of five treatment rooms were disinfected between patients. This failed practice had the potential to place all in-center hemodialysis, peritoneal dialysis, and home hemodialysis patients at risk for infection due to cross contamination. Findings follow: A. Review of Policy 1-05-01 “Infection Control for Dialysis Facilities” (rev. date April 2023) showed: 1) Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials and prior to returning to clean/designated area or removal from treatment area. a) Prior to routine disinfection remove all visible blood i) For visible blood or gross blood spills, a 1:10 bleach solution must be utilized. ii) After all visible blood is cleaned with the 1:10 bleach solution, teammates are to use a new disposable towel soaked with 1:10 bleach solution and clean area a second time iii) Cleaning of visible blood should be performed when first observed. b) Use an appropriate disinfectant such as 1:100 bleach solution for routine disinfection of environmental surfaces. i) Disinfection should be completed by using a wiping motion with friction ii) Sufficient disinfectant should be applied so that surfaces are visibly wet. 2) At the end of each treatment, the dialysis station will be cleaned and disinfected. 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., control panel; tip, front and sides of dialysis machine; touchscreens; countertops). The wall box, drain and water supply lines are considered part of the dialysis delivery system ...Teammates will monitor, and address wall box residue/ build up and patency issues. 3) Non-disposable items are to be disinfected after each patient use, prior to removal from treatment are/ station and if contaminated between uses. If item cannot be cleaned and disinfected, it will be dedicated for use on a single patient. 4) 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. B. During tour of facility on 08/19/2025 with FA, surveyor observed the following; 1) Dark brown colored stains on wall in lobby bathroom under the hand dryer. 2) Large stickers on floor of lobby with exposed adhesive collecting dirt and debris 3) Tape residue on multiple windows, area dividers, and walls. 4) Seven IV (intravenous) pumps/poles were stored in “clean” area. Three of seven had electrical cords hanging onto the floor. Four of seven had visible residue from liquid medications on top and sides. Dirty IV pump sitting on top of refrigerator in med prep area. 5) Tape residue was found on 20 of 20 treatment chair tables. 6) Ether net cables taped into wall connections between stations 2 and 3, 12 and 13, and 17 and 18 with large amounts of plastic tape. 7) Dried blood on light switch at stations 5 and 17, chase wall at station 9, wall between stations 9 and 10 above the sharps container, countertop in northeast corner, wall at station 14, plexiglass walls outside of iso room. 8) Springs, wheel casters, screws, and rails on 20 of 20 treatment chairs covered in rust 9) Dried blood inside chair arms on chairs at stations 2, 5, and 6. 10) Dried bicarbonate on wall boxes at 19 of 20 stations. 11) Dried red brown residue on wall boxes in five of five home department treatment rooms. C. During post tour interview on 08/19/2025, FA confirmed findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 52740 Based on facility policy, surveyor observation and interview with staff, it was determined that facility staff failed to provide a safe environment free of risks for trips and falls and free from areas that pose infection control risks. These failed practices had the potental to affect and placed all facility patients at risk for physical injury and infection. Findings follow: A. Review of Policy 3-01-07A “Patient’s Rights” showed, “8. To receive adequate, safe, sanitary, and efficient dialysis treatment and respectful care by competent personnel in a comofrtable environment.” B. During facility tour on 08/19/2025 at 10:35AM with FA, surveyor observed: 1) Lobby walls were scuffed and gouged leaving the drywall exposed. 2) Tiles in the patient bathroom under the sink were splitting from seams allowing the tile edges to rise and accumulate a buildup of black grime. 3) An approximately 7 inch metal trim piece was bent and sticking out from the vinyl floor base trim where it meets the wall. 4) Vinyl base trim was coming loose from wall surrounding the treatment floor allowing for water and debris intrusion. 5) Holes were noted in the drywall behind station #1 in the in-center treatment area. 6) Electrical outlet behind station #1 showed blackened area on top outlet. 7) Particle board under dirty sink across from station 6 had water damage causing board to expand and crack. 8) A build up of white substance was around dirty sink faucet and handles across from station 6. 9) Floor grate/drain outside of water room was full of trash and slimy black substance. 10) Water room floor had missing and flaking pieces of paint and chipped concrete leaving exposed concrete that cannot be disinfected. 11) Noted black, gritty substance on top of all water treatment system components, pipes, and on walls in water room. 12) Corrosion noted on pipes leading to hot water tanks. 13) Large gaps were visible in the weather stripping around the storage room outside door allowing for insect/ pest entry. 14) Noted thin layer of dust and rust on shelving and casters of shelving in storage room. 15) Floor in home department hallway had a patched and uneven area that creates a trip hazard for patients. 16) Vinyl flooring in treatment room 3 had gouges that cannot be disinfected. 17) Scuffs and marks on walls in home department hallway left drywall exposed and cannot be disinfected. 18) Wood trim around viewing windows was gouged and unsealed in areas and cannot be disinfected. C. During post tour interview on 08/19/2025, FA confirmed findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 52740 Based on review of facility policies, review of clinical records, and staff interviews, it was determined that facility staff failed to assess and re-assess pre/intra/post and interdialytic blood pressures for 6 (#1, #3, #4, #5, #6, #7) of 7 and fluid management for 2 (#3, #5 of 7 in-center hemodialysis (ICHD) patients reviewed. These failed practices had the potential to affect all 74 ICHD patients on census. Findings follow: A. Review of Policy 1-03-08 “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment (Rev. Date April 2024) showed: 1) Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician or non-physician practitioner (NPP) will be notified of any concerns that may preclude the initiation of dialysis. 2) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a) Vital signs and treatment monitoring of non-nocturnal treatments are completed at least every thirty minutes. b) At a minimum, obtain and document the following: blood pressure, heart or pulse rate, blood and dialysate flows, arterial and venous pressures, fluid removal and/or replacement, vascular access visible and line connections intact, and patient subjective statements 3) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 4) The licensed nurse notifies the physician or NPP as needed of changes in patient status. 5) All findings, interventions and patient response will be documented in the patient’s medical record. 6) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 7) Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician or NPP is necessary prior to discharge of the patient from the facility. 8) Unless other abnormal parameters are established by the facility Governing Body (GB) and documented in the GB Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. a) Pre-treatment: any weight loss from last post weight b) Post treatment: if patient is above or below 1kg (kilogram) from the target weight c) Blood pressure: pre-dialysis: i) Systolic greater (>) than 180 millimeters of Mercury (mm/Hg) or less than 90 mm/Hg ii) Diastolic > or equal to 100mm/Hg or less than 50mm/Hg d) Blood pressure: intradialytic: i) Systolic > 180 mm/Hg or less than 90 mm/Hg ii) Diastolic > or equal to 100mm/Hg or less than 50mm/Hg iii) Signs/symptoms of hypotension may include nausea and vomiting, cold and clammy skin, restlessness, rapid/shallow respirations, excessive yawning, diaphoretic e) Blood pressure post treatment: i) If the patient can stand: Standing systolic BP >140 mm/Hg or < 90 mm/Hg or standing diastolic BP > than 90 mm/Hg or < 50mm/Hg ii) If patient is not able to stand, document reason and sitting BP iii) Sitting BP for patients that cannot stand: Sitting systolic BP > 140 mm/Hg or <90 mm/Hg or sitting diastolic BP > 90mm/Hg or < 50mm/Hg B. Review of patient clinical records showed: 1) Patient #1’s treatment sheets showed: a) On 08/06/2025, blood pressure (BP) dropped from 171/88 at 1:32 PM to 147/91 at 2:02 PM. Facility provided no evidence of registered nurse (RN) notification. Chart record by patient care technician (PCT) #1 stated, “Late entry on break PCT #2 responsible.” b) On 08/08/2025, BP dropped from 143/66 at 12:31 PM to 122/61 at 1:00 PM. Facility provided no evidence of RN notification and no evidence that patient subjective findings were documented until 1:39 PM. c) On 08/11/2025, BP dropped from 174/82 at 11:02 AM to 139/84 at 11:32 AM. Facility provided no evidence of RN notification. d) On 08/13/2025, BP dropped from 135/96 at 12:01 PM to 112/88 at 12:31 PM. Facility provided no evidence of RN notification. BP dropped from 143/81 at 1:31 PM to 115/81 at 2:01 PM. Facility provided no evidence of RN notification. Documentation at 1:31 by PCT #1 stated, “late entry.” Facility did not provide evidence that patient’s subjective findings were being monitored at that time. e) On 08/15/2025, BP dropped from 136/54 at 2:09 PM to 106/57 at 2:39 PM. Facility did not provide evidence of RN notification. f) On 08/18/2025, BP dropped from 146/92 at 11:12 AM to 112/80 at 12:05PM. Facility did not provide evidence that RN was notified of BP drop. Facility did not provide evidence of patient monitoring for 53 minutes from 11:12 AM to 12:05 PM. 2) Patient #3’s treatment sheets showed: a) On 07/18/2025, Patient’s post treatment weight was 2.2 kilograms (Kg) over target weight (TW). Facility provided no evidence of RN assessment of weight or physician notification. b) On 08/06/2025, Patient’s post treatment weight was 1.1Kg under TW. Facility provided no evidence of RN assessment of weight or physician notification. c) On 08/06/2025, BP 172/152 at 7:35 AM. No evidence of RN notification of hypertension provided. BP 142/86 at 8:05 AM. No evidence of RN notification of BP drop >20 points provided. 3) Patient #4’s treatment sheets showed: a) On 08/06/2025 at 8:31 AM, patient’s BP was 154/78. At 9:01 AM, BP dropped to 129/71. Facility provided no evidence of RN notification. b) On 08/13/2025, BP was 132/56 at 7:01 AM. BP dropped 27 points to 105/66 at 7:31 AM. Facility provided no evidence of RN notification or intervention until 8:00 AM. 4) Patient #5’s treatment sheets showed: a) On 08/04/2025, Patient’s post treatment weight was 2.5 Kg over TW. Facility provided no evidence of RN assessment of weight or physician notification. b) On 08/08/2025, BP was documented 165/89 at 7:01 PM and dropped to 144/72 at 7:31 PM. Facility provided no evidence of RN notification by PCT. c) On 08/11/2025, Patient’s post treatment weight was 2.9kg> TW. Facility provided no evidence of RN assessment of weight or MD notification. d) On 08/12/2025, Patient’s post treatment weight was 1.3Kg> TW. Facility provided no evidence of RN assessment or weight or MD notification. No evidence was provided of post treatment standing blood pressure collection or documentation of why blood pressure not recorded. Facility provided no evidence of monitoring vital signs and intradialytic data from 11:18 AM to 11:41 AM. e) On 08/15/2025, Patient’s post treatment weight was 1.5kg> TW. Facility provided no evidence of RN assessment of weight or MD notification. 5) Patient #6’s treatment sheets showed: a) On 08/05/2025, facility provided no evidence showing that blood pressure and intradialytic data were monitored between 10:57 AM and 12:04 PM, between 1:05 PM and 2:05 PM, and between 2:05 PM and 2:47 PM. b) On 08/14/2025, Patient’s post treatment weight was 1.8 Kg>TW. Facility did not provide evidence of RN assessment or physician notification. Patient’s BP at 2:03 PM was 90/51. Facility failed to provide evidence of RN notification by PCT. 6) Patient #7’s treatment sheets showed: a) On 07/11/2025, Patient’s post treatment weight was 2.4Kg > TW. Facility did not provide evidence of RN assessment or physician notification. b) On 07/14/2025, Patient’s post treatment weight was 2.5 Kg> TW. Facility did not provide evidence of RN assessment or physician notification. Patient’s blood pressure dropped from 133/90 at 12:05 PM to 109/57 at 12:33 PM. Facility provided no evidence of RN notification. c) On 07/21/2025, Patient’s post treatment weight was 2.1Kg >TW. Facility did not provide evidence of RN assessment or physician notification. Patient’s blood pressure dropped from 137/61 at 11:45 AM to 115/54 at 12:03 PM. Facility provided no evidence of RN notification. d) On 07/23/2025, Patient’s blood pressure dropped from 142/76 at 11:32 AM to 104/53 at 12:03 PM. Facility provided no evidence of RN notification. e) On 08/16/2025, Patient presented for treatment 9 KG under TW. Facility provided no evidence of MD notification. Patient’s blood pressure was 86/46 at 10:32 AM. Facility provided no evidence of RN notification. Patient’s blood pressure was 92/45 at 11:32 AM. Facility provided no evidence of RN notification. C. Findings confirmed with FA during exit interview on 08/20/2025 at 3:45PM”

“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: 52740 0544 Based upon review of policy, review of clinic records, and staff interviews, it was determined that facility staff failed to ensure that patients understand dialysis adequacy and the consequences of skimming dialysis treatments or cutting treatments short for 4 (#1, #3, #6, and #7) of 7 in-center hemodialysis (ICHD) patients reviewed. This failed practice has the potential to affect all 74 ICHD patient on census. Findings follow: A. Review of Policy 1-01-09 “Prescribed Treatment Time Not Met” showed: 1) The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment/ Against Medical Advise (AMA) form any time the patient requests to terminate their treatment earlier than the prescribed run time. 2)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. B. Review of Policy 1-01-10 “Refusal of Care/ Treatment Against Medical Advise” showed: 1) If a patient refuses care/ treatment against medical advice (AMA), the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention, including what additional medical orders may be necessary to address the patient’s specific needs. 2) If a patient refuses care/ treatment, the RN will document the event in the patient’s medical record. Documentation will include, as appropriate, the following: i) A description of the care/ treatment that was refused by the patient ii) The patient’s stated reason for refusing care/ treatment iii) The date and time that the patient’s attending nephrologist was notified about the refusal of care/ treatment iv) A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any) v) A description of all other interventions planned to address the patient’s refusal of care/ treatment, including recommendations to the patient vi) A copy of the Refusal of Care/ Treatment AMA form signed by the patient 3) The facility’s FA will verify that all patient refusals of care/ treatment are recorded and trended, and the FA shall verify that such trends are reviewed and discussed at the Facility Health Meetings 4) The RN will verify that a patient signs the Refusal of Care/ Treatment AMA form if a patient: Refuses their entire dialysis treatment, refuses prescribed medications/ antibiotics, refuses recommended hospitalization, refuses pre/ post treatment data collection, especially vital signs, refuses to remain in the facility when the RN has assessed the patient and has indicated to the patient that they are not well enough to leave. In this situation, the RN will immediately notify the Medical Director and the patient’s attending nephrologist. 5) The RN will obtain the patient’s signature on the Refusal of Care/ Treatment AMA form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 6) A RN must countersign all Refusal of Care/ Treatment AMA forms. A witness signature is required only if the patient refuses to sign the form. C. Review of patient clinical records showed: 1) On 08/18/2025, patient #1 terminated treatment 26 minutes early. Discharge status at 2:46 PM was documented as Discharge to home (Routine Discharge).” Facility was unable to provide evidence that patient had signed an AMA form or been educated on risks associated with ending treatment early. 2) On 8/11/2025, patient #3 terminated treatment 95 minutes early. Facility was unable to provide evidence that patient had signed an AMA form. 3) On 08/09/2025, patient # 6 terminated treatment 18 minutes early. Discharge status at 2:56 PM was documented as “Discharge to Home (Routine Discharge).” Facility was unable to provide evidence that patient had signed an AMA form or been educated on risks associated with ending treatment early. On 08/12/2025, patient #6 signed terminated 86 minutes early. Close treatment reason at 1:50 PM was documented as “Vascular Access Issue”, and discharge status was “Discharge to Home (Routine Discharge).” Facility was unable to provide evidence that efforts were made to correct vascular access issue, that patient signed an AMA form, or that patient was educated on risks associated with ending treatment early. On 08/14/2025, patient #6 terminated treatment 45 minutes early. Discharge status at 2:40 PM was documented as “Discharge to home (Routine Discharge).” Facility was unable to provide evidence that patient had signed an AMA form or been educated on risks associated with ending treatment early. 4) On 07/14/2025, patient #7 terminated treatment 85 minutes early. Close treatment reason at 2:10 PM was documented as “Patient Choice (AMA, feels unwell/ cramping, patient behavioral issue)”, and discharge status was documented as “Discharge to home (Routine Discharge).” Facility was unable to provide evidence that patient had signed an AMA form or been educated on risks associated with ending treatment early. On 08/16/2025, patient #7 terminated treatment 43 minutes early. Close treatment reason at 12:20 PM was documented as “Patient Choice (AMA, feels unwell/ cramping, patient behavioral issue)”, and discharge status was documented as “Discharge to home (Routine Discharge).” Facility was unable to provide evidence that patient had signed an AMA form or been educated on risks associated with ending treatment early. D. Findings confirmed with FA during exit interview on 08/20/2025 at 3:45PM”