Davita Kayenta 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: 28297 Based on observation, interview, 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 three survey days. 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 05/05/25 at 11:20 AM revealed patient (P) 4 at Station 9 applied pressure to the left upper arm access site until bleeding had stopped. When finished the patient walked to the scale to retrieve his/her weight. Patient Care Technician (PCT) 1 accepted the patients’ weight on a piece of paper. The patient then gathered belongings and left the facility without washing or sanitizing hands. During an interview on 05/05/25 at 12:00 PM PCT 1 acknowledged the patient did not wash or sanitize hands after holding access site as required. Observation on 05/05/25 at 11:20 AM revealed P6 at Station 2 applied pressure to the left upper arm access site until bleeding had stopped. When it finished the patient walked to the scale to retrieve his/her weight. PCT2 accepted the patients’ weight on a piece of paper. The patient then gathered belongings and left the facility without washing or sanitizing hands. During an interview on 05/05/25 at 12:10 PM PCT2 acknowledged the patient did not wash or sanitize hands after holding access site as required. During an interview on 05/07/25 at 10:25 AM the Registered Nurse Clinic Coordinator stated patients should wash or sanitize 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, “Infection Control for Dialysis Facilities,” revised April 2023 indicated, “ ...Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to initiation of dialysis. Perform hand hygiene after treatment before leaving the treatment area ...””

“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 one of five handwashing sinks for three of three survey days. The failure to have paper towels readily available may hinder a patient’s ability to wash hands as required and this could affect 54 in-center patients. Findings include: Observation on 05/05/25 at 11:40 AM revealed the handwashing sink at the patient scale did not have any paper towels available for staff or patient use. Observation on 05/06/25 at 10:30 AM revealed the handwashing sink at the patient scale did not have any paper towels available for staff or patient use. Observation on 05/07/25 at 9:00 AM revealed the handwashing sink at the patient scale did not have any paper towels available for staff or patient use. During an interview on 05/07/25 at 10:25 AM the Registered Nurse Clinic Coordinator stated that they were undergoing renovations, and they had not installed the paper towel dispenser yet. He/she stated there should be paper towels available at the patient scale and handwashing sinks for patients to use when entering the unit and washing their access and for hand hygiene after treatment. Review of the facility policy “Infection Control for Dialysis Facilities,” revised April 2023 indicated, “ ...Sinks should be easily accessible and readily available in the treatment area and in other appropriate areas ...Soap and a supply of paper towels protected from contamination must be available at each clean sink ...””

“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: 28297 Based on observation, interview, and policy review, the facility failed to ensure expired medications were disposed of and not available for use during one of three survey days. Failure to remove expired medical supplies had the potential to affect 54 in-center patients receiving dialysis treatments at the facility. Findings include: During an observation of the medication refrigerator on 05/07/25 at 10:05 AM, one vial of Purified Protein Derivative (PPD) testing solution (used to test patients for Tuberculosis, a highly contagious respiratory disease) was opened and marked expired 04/14/25. During an interview on 05/07/25 at 10:10 AM, Registered Nurse (RN) Clinic Coordinator confirmed the medication was opened and expired on 04/14/25. He/she stated they did not do monthly audits to ensure medication were removed if expired. Review of the facility policy titled, “Medication Policy,” revised October 2023 indicated, “ ...Medications with a preservative must be discarded 28 days after opening or accessed (e.g. needle punctured) ...””

“RO-CHEMICAL ANALYSIS-FREQUENCY CFR(s): 494.40(a) 6.2.7 Reverse osmosis: Chemical analysis: frequency Chemical analysis for the contaminants listed in 4.1.1 (Table 1) should be done when the RO system is installed, when membranes are replaced, and at not less than annual intervals thereafter to ensure that the limits specified in 4.1.1 are met (see Table 1). Chemical analyses should be done when seasonal variations in source water suggest worsening quality or when rejection rates fall below 90 %. This Standard is not met as evidenced by: 28297 Based on interview, facility document review, and policy review the facility failed to provide evidence that the annual AAMI (Association for the Advancement of Medical Instrumentation) (an organization that establishes requirements for the quality of water) waster analysis was obtained, reviewed, approved and signed off by the Medical Director since July 2022. In addition, the facility failed to ensure the AAMI water analysis was maintained on file at the facility per facility policy, since July 2022. Findings include: Review of the Water and Dialysate water review revealed the facility was unable to find the annual AAMI water analysis results since July 19, 2022. During an interview on 05/06/25 at 9:00 PM Biomedical Technician 2 stated they completed the AAMI water analysis in July 2023 and 2024 however they were unable to pull the results from the computer program that was now obsolete. During an interview on 05/06/25 at 9:30 AM the Facility Administrator from Chinle unit and Surveyor Educator confirmed the results should have printed out and signed off by the Medical Director however they were unable to locate the results. During an interview on 05/07/25 at 11:00 AM the Medical Director stated he/she was unsure of what I was referring too but would look into the issue. Review of the facility’s policy titled, “International Organization of Standardization (ISO)/Association for the Advancement of Medical Instrumentation (AAMI)/ American National Standards Institution (ANSI) Water Analysis for Inorganic Contaminates” revised April 2019 indicated, “1. Analysis to determine the levels of chemical contaminants specified in the ISO/AAMVANSI Standards of Dialysate for hemodialysis (excluding chlorine and chloramine) is performed and documented annually on the dialysis quality water or as required per state or local regulations. 2. The dialysis quality waler test sample is collected from a sample tap or valve. The sample tap or valve will be located on the water treatment distribution loop (purified) water line at the point where the RO product supply returns into the holding tank (indirect system) or the point the RO product returns back to the RO (direct system). 3. The intent of the analysis is to verify that the dialysis quality water meets the requirements for maximum allowable chemical contaminant levels specified in ISO/AAMVANSI Standards “Dialysate for hemodialysis”. If these standards are not met, the facility will redraw dialysis quality water sample and send by end of first business day following receipt of the unacceptable test result. 4. Analysis to determine the level of chemical contaminants will also be performed: . At system installation . When RO membranes are replaced. When seasonal variations in source water suggest worsening quality . When RO rejection rate falls below 90% \ 5. The Facility Administrator or designee is responsible for verifying the results are obtained, reviewed approved and signed off by the Medical Director and necessary actions taken, as applicable. The results will be maintained on file by the facility.””