Davita Tucson East 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: 37489 Based on observation, document review, and interview, it was determined that the facility failed to ensure staff changed gloves and performed hand hygiene between glove changes, between clean and dirty tasks when providing patient care. Failure to follow established standard and infection control precautions poses an increased risk of infections for immunocompromised patients through contact transmission and cross contamination. Findings include: Observation on 04/02/2025 at approximately 1133 revealed staff not adhering to standard infection control guidelines as follows related to hand hygiene and wearing gloves. Employee #6 assessed a patient at Station #21 and placed oxygen tubing on the patient. Employee #6 left the station, removed her gloves, did not wash her hands or use hand sanitizer (perform hand hygiene), then walked to the CWOW charting cart/computer and documented in a patient’s chart. Employee #6 finished typing on the computer keyboard, then donned a pair of gloves without performing hand hygiene and provided direct patient care to the patient dialyzing at station #3. Employee #6 charted on a patient at station #8, left the station, walked to station #6 and obtained a pair of gloves. Employee #6 held the pair of gloves in her left hand, walked to the nurses desk, obtained a folder and flipped through several pages, stopped put on the right hand glove, continued to look through papers contained in the folder with one gloved and one un-gloved hand, retrieved a pen from the desk top next to a computer keyboard, wrote something on paper, then donned the left hand glove and walked to station #4 and provided patient care. Employee #6 removed her gloves after providing patient care and returned to the nurse’s station without performing hand hygiene. Employee #6 documented on the desk top computer, turned to retrieve a pair of gloves, donned one glove obtained a stethoscope to assess a patient at station #5, then donned the second glove at the patient station without performing hand hygiene. Employee #6 provided care for the patient dialyzing at station #3, left without performing hand hygiene, and walked to station #21 to talk to another staff member, then returned to the nursing station to document on the computer. Employee #10 donned gloves without performing hand hygiene prior to providing care to a patient # station #7. Employee #10 donned gloves then reached up to retrieve her face shield that was on top of her head, did not remove the dirty gloves, and proceeded to remove a fistula needle from the patient’s arm at station #8. The facility policy titled “Infection Control for Dialysis Facilities” requires: “ ...HAND HYGIENE ...All teammates ...will perform hand hygiene ...prior to gloving and immediately after removal of gloves ...after patient and dialysis delivery system contact ...between patients even if the contact is casual ...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ...Use of an alcohol-based hand rub may be substituted for handwashing ....” Employee #2 confirmed on 04/02/2025, that staff did not perform hand hygiene as required.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 37489 Based on observation, document review, and interview, it was determined that the facility failed to ensure staff cleaned and disinfected their stethoscope after use which has the potential for cross contamination and increased infection. Findings include: Observation on 04/02/2025 at approximately 1415 revealed staff not adhering to standard infection control guidelines as follows related to cleaning and disinfecting of non-disposable equipment taken into the dialysis station. Employee #6 used her stethoscope to assess the patient at station #3. Employee #6 used an alcohol prep pad to disinfect the diaphragm on the bell of the stethoscope and the ear pieces. The tubing was not disinfected. Employee #6 used her stethoscope to assess the patient at station #7 and when finished hung the stethoscope on a hanger without cleaning and disinfecting the stethoscope. Employee #6 then documented on a computer at the nurse’s station. Employee #6 finished documenting at the computer, retrieved the same stethoscope, and used it to assess the patient at station #11. Employee #6 finished the assessment, walked to station #7, set the stethoscope on the chairside computer cart, documented in the computer, and eventually left the station and hung the stethoscope on a hook at the nursing station without cleaning and disinfecting the stethoscope. The facility policy titled “Infection Control for Dialysis Facilities” requires: “ ...DISINFECTION ...Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station ...Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution ....” Employee #2 confirmed on 04/02/2025, that staff did not clean and disinfect their stethoscope as required.”

“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: 37489 Based on observation, document review, and interview, it was determined the facility failed to ensure hemodialysis treatment stations were properly disinfected between patient treatments. This deficient practice poses a potential risk for infection due to cross contamination between patients. Findings include: Observation on 04/02/2025 at approximately 1515 revealed staff not adhering to standard infection control guidelines related to cleaning and disinfection of the dialysis station. Employee #10 did not clean/disinfect the IV pole, IV pole hangers, or the blood pressure cuff blue tubing while cleaning and disinfecting station #6. Employee #10 did not clean/disinfect the IV pole/pole hangers, blood pressure cuff tubing, the left side of the dialysis machine, the base of the dialysis machine, part of the front of the machine, or the television and emergency take off kit while cleaning and disinfecting station #8. Employee #10 did not clean/disinfect the IV pole/pole hangers, blood pressure cuff tubing, the left side of the dialysis machine, the base of the dialysis machine, part of the front of the machine, or the television and emergency take off kit while cleaning and disinfecting station #10. Employee #10 did not clean/disinfect the IV pole/pole hangers, blood pressure cuff tubing, the left side of the dialysis machine, the base of the dialysis machine, part of the front of the machine, or the television and emergency take off kit while cleaning and disinfecting station #14. Employee #14 did not clean/disinfect the emergency take off bag on the back of the television when cleaning and disinfecting station #1. Employee #4 did not clean/disinfect the emergency take off bag on the back of the television or disinfect the Hansen hoses on the dialysis machine during cleaning and disinfection at station #18. The facility policy titled “Infection Control for Dialysis Facilities” requires: “ ...DISINFECTION ...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; top, front and sides of dialysis machine; touchscreens; countertops ...Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station ...Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution ....” Employee #2 confirmed on 04/02/2025, that staff did not clean and disinfect the dialysis station as required.”

“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: 49430 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff performed hand hygiene between glove changes and wore gloves appropriately while providing patient care. Failure to follow established standard and infection control precautions poses an increased risk of infections for immunocompromised patients through contact transmission and cross contamination of potentially pathogenic organisms. Findings include: The facility policy titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” requires: “...Hand Hygiene...All teammates...will perform hand hygiene...prior to gloving and immediately after removal of gloves...after contamination with blood or other infectious material...after patient and dialysis delivery system contact...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...Use of an alcohol-based hand rub may be substituted for handwashing....” Observation on 12/06/2023 revealed Provider #31 failed to change gloves in between patients. The provider used a gloved hand to reach into shirt chest pocket underneath his/her gown and retrieve a cell phone, answer and speak on phone, and then return the phone to his/her shirt pocket without changing gloves. Provider #31 was observed going from station to station rounding on patients without changing his/her gloves and/or performing hand hygiene. Employee #1 confirmed, on 12/06/2023, the policy requires all team members to change gloves between patient contacts and policy was not followed.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49430 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff cleaned and disinfected their stethoscope between and after use on multiple patients which poses a potential risk of increased infection for patients through contact transmission and cross contamination of pathogenic organisms that may be harbored on the dirty stethoscope. Findings include: The facility policy titled “Cleaning and Disinfecting the Dialysis Station” requires: “...The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between used...Also, the nature of dialysis treatments with frequent exposure to blood and body fluids, close proximity of patients and staff, and the immunocompromised status of dialysis patients make dialysis a high-risk area for spreading infectious disease...Dialysis station...Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment...General Cleaning...After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station....” The facility policy titled “Access Assessment and Cannulation” requires: “...Assessment of Vascular Access...LISTEN...Bruit high pitch/whistle...Document in treatment record...Staff...who have been trained to auscultate vascular accesses should listen to the entire length of the access for changes in the sound of the bruit...Clean stethoscope after assessing a patient....” Observation on 12/06/2023 revealed Employee #14 auscultate patients’ vascular access at station #8 with stethoscope then return stethoscope to clean area without cleaning and disinfecting stethoscope. Observation on 12/06/2023 revealed Employee #15 auscultate a patient’s vascular access at station #24 with stethoscope then return stethoscope to clean area without cleaning and disinfecting stethoscope. Employee #2 confirmed on 12/06/2023 that staff did not clean and disinfect their stethoscopes after use at the dialysis station as required by 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: 49430 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff appropriately labeled multi-dose medication vials when opened. Failure to label medication vials when opened with an appropriate expiration date prevents staff from knowing when to discard the vial which increases the risk a patient will receive a medication that is no longer stable, and that may be contaminated due to reduction of preservative efficacy as well as an increased exposure to pathogens from accessing a vial multiple times. Findings include: The facility policy titled “Medication Policy” requires: “...Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer...Each vial is labeled with the initials of the person opening the vial and the expiration date....” Observation on 12/06/2023 revealed two open, multidose vial of Heparin Sodium 30 ml labeled with an expiration date of 01/16/2023. There were no staff initials to identify the individual that labeled the vials with the expiration date. Employee #2 confirmed on 12/06/2023, that the vials were mislabeled with the year and dated with an expiration date that exceeded the maximum open time of 28 days.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 49430 Based on document review, observation, and interview, it was determined that the facility failed to ensure medications in the treatment area were locked and secured to prevent unauthorized access. Failure to secure medications when not in use may result in unauthorized access to medication not prescribed to an individual and the potential for tampering or other compromise to the integrity of medications administered. Findings Include: The facility policy titled “Medication Policy” requires: “...Non-refrigerated medications are to be stored in cabinets(s) and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations....” Observation on 12/06/2023 revealed an unsupervised, unlocked drawer at the technician/nurses’ station containing a (25) count box of Heparin Sodium 30 ml multi dose vials, (2) open, multi dose vials of Heparin Sodium, and (4) pre-drawn syringes of Heparin. Employee #2 confirmed on 12/07/2023 that the medications were left unlocked and not secured as required by facility policy.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49430 Based on document review, observation, and interview, the facility failed to ensure vascular access sites and bloodline connections were visible by staff at all times during dialysis treatments for two patients which has the potential risk for exsanguination (a severe loss of blood). Findings include: The facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” requires: “...The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment....” Observation on 12/06/2023 at 1056 revealed patients dialyzing at Stations #14 and 18 central venous catheters and bloodline connections were covered with clothing and blankets. Employees #1 and 2 confirmed on 12/06/2023 that staff did not ensure patient’s CVCs were uncovered and visible as required by policy.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure compliance with the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) by keeping clear a means of exit from the facility which has the potential risk of harm to patients if unable to evacuate from the facility in the event of a fire. Findings include: Observation on 12/7/2023 revealed egress from the facility was impeded by multiple, empty cardboard boxes stacked in a pile directly outside and blocking the emergency exit doors leading off of the treatment floor. The document titled “2012 edition of NFPA 101, Life Safety Code” requires: “...Means of Egress - General...Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11...20.2.1, 21.2.1, 7.1.10.1...Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency....” Employee #1 and 38 confirmed on 12/06/2023 that staff did not dispose of the pile of discarded boxes in the dumpster as required and that the emergency exit was blocked creating a safety hazard.”

“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: 49430 Based on review of facility policy and procedure, medical records, and interview it was determined that the facility failed to ensure RNs and PCTs monitored, assessed, and documented abnormal findings for patient #4 during treatment. This deficient practice limits the interdisciplinary team (IDT) in addressing blood pressure, heart rate, and fluid management issues in the patient’s plan of care if treatment data is not documented, assessed, and addressed in the patient’s medical record. Findings include: The facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” requires: “...Patient data will be obtained and documented...Data collection includes...Measurement of Blood Pressure...Intradialytic Data Collection/Assessment...Vital signs and treatment monitoring...At a minimum, obtain and document...Blood pressure...Abnormal findings...will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician...as needed of changes in patient status...Abnormal Findings...Blood pressure: Pre-dialysis ...Systolic greater than 180 mm Hg ...Diastolic greater than or equal to 100 mm Hg ...Blood Pressure-Intradialytic...Difference of 20 mm/Hg increase or decrease from patient’s last intradialytic treatment BP reading ...Post Treatment ...Standing systolic BP greater than 140 mm Hg ...Standing diastolic BP greater than 90 mm Hg ...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute....” Review of Patient Treatment Sheets reveals: Patient #4; 11/24/2023 13:01 Blood Pressure (BP) 178/100. No RN notification for hypertension, or RN assessment and follow up. 13:31 BP 141/75. No RN notification of BP decrease more than 20mm/Hg, or RN assessment and follow up. 13:49 BP 163/91. No RN notification for increase in excess of 20mm/Hg, or RN assessment and follow up. 11/29/2023; 10:38 Heart Rate (HR) 58. No RN notification for bradycardia, or RN assessment and follow up. 10:43 HR 59. No RN notification for bradycardia, or RN assessment and follow up. 11:30 HR 58. No RN notification for bradycardia, or RN assessment and follow up 12:00 HR 58. No RN notification for bradycardia, or RN assessment and follow up. 12:30 HR 59. No RN notification for bradycardia, or RN assessment and follow up. 12/01/2023 10:38 HR 58. No RN notification for bradycardia, or RN assessment and follow up 11:01 HR 59. No RN notification for bradycardia, or RN assessment and follow up. 11:31 HR 58. No RN notification for bradycardia, or RN assessment and follow up. 12:02 HR 57. No RN notification for bradycardia, or RN assessment and follow up 12:31 HR 59. No RN notification for bradycardia, or RN assessment and follow up. 13:35 HR 59. No RN notification for bradycardia, or RN assessment and follow up. Employee #1 confirmed on 12/7/2023 that RNs and PCTs failed monitored, assessed, and documented abnormal findings per facility policy.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 49430 Based on facility policy review, record review and interviews, the facility’s interdisciplinary team failed to develop and implement an initial plan within 30 days of admit for a newly admitted patient (Patient #7). Finding includes: Policy Titled “Interdisciplinary Team (IDT) Patient Assessment And Plan of Care” requires “...10. An initial Plan of Care...will be completed on all new patients...within 30 calendar days...” Patient admitted 09/18/2023. Initial Care Plan dated 11/01/2023. Employee #1, on 11/29/2023, confirmed the plan of care did not meet the 30-day requirement.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 49430 Based on review of facility policy, medical records and interview, it was determined that the facility failed to ensure: 1. That there was a documented discharge summary within 30 days of the patient’s discharge for (1) of (3) patients (Patient #9), which poses the potential risk of lack of coordination and continuity of care; 2. AMAs (against medical advice) forms were not completed for treatment times not met for (4) of (4) patients with early termination of treatment (Patients #1, 2, 3, and 4) which has the potential risk of adverse events related to inadequate dialysis. Findings Include: 1. Policy Titled “Medical Record Quality Assurance” requires “...8. A discharge note is to be entered into the medical record within 30 days of the patient’s discharge date...”. Employee #1 confirmed on 12/06/2023 that Patient #9’s discharge summary was not completed within 30 days of the patient’s discharge as required by facility policy. 2. The facility policy titled “Prescribed Treatment Time Not Met” requires: “...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....4. A copy of the Early termination of Treatment Against Medical Advice form signed by the patient, if shortened voluntarily by the patient, will be kept in the patient’s health record....” Patient #1 Treatment records dated 10/30/2023 revealed treatment was terminated early. The medical record did not contain AMA documentation of the early terminated treatment. Patient #2 Treatment records dated 11/06/2023 through 12/04/2023 revealed (11) of (11) treatments were terminated early. The medical record did not contain AMA documentation for (8) of the (11) early terminated treatments. Patient #3 Treatment records dated 11/08/2023 through 12/04/2023 revealed (4) of (12) treatments were terminated early. The medical record did not contain AMA documentation for (3) of the (4) early terminated treatments. Patient #4 Treatment records dated 11/27/2023 through 12/01/2023 revealed (3) of (3) treatments were terminated early. The medical record did not contain AMA documentation for (3) of the (3) early terminated treatments. Employee #1 and 2 confirmed on 12/06/2023 that AMA forms were not completed for the aforementioned patients as required by facility policy.”