Davita Palm Brook Dialysis Center

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 45999 Based on a review of facility procedure, observation, and staff interview, the Department determined that the facility failed to ensure that the AV fistula or graft cannulation procedure was performed according to the facility policy for one of the patients observed, which has the potential risk of development of a bloodstream infection and hospitalization. Findings include: The policy titled “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” dated 10/2022, requires: “...Check for patient sensitivity to preferred skin antiseptic/skin disinfectant listed in the table below (povidone-iodine, hypochlorite ExSept Plus). Use Isopropyl Alcohol 70% as the single-skin antiseptic ONLY when the patient has documented allergies to other skin antiseptics...Isopropyl Alcohol 70%...At least 4 prep pads per site...Effective Contact Time...60 seconds....” Observation on June 12, 2024 at station #6 revealed Employee # 20 cleansing and disinfecting patient # 13 ‘s vascular access in preparation for cannulation. Employee #20 started cleaning the access with PAWS cleaning pad and then used one alcohol prep pad to cleanse the arterial cannulation site for a 5-second contact time. Employee #20 repeated the same process for the venous site with a contact time of 4 seconds. Employee #1 confirmed during an interview on June 12, 2024, that Employee #20 should have used at least (4) alcohol prep pads per cannulation site for skin asepsis prior to cannulation when alcohol is used as the single skin antiseptic for patient # 13, with a contact cleaning time of 60 seconds per site as required by facility policy.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50568 Based on observation, review of facility documentation, policy and procedures, and interviews with staff, the Department determined the facility failed to ensure medication was administered to a patient only as prescribed by not ensuring that loading doses, or bolus doses, of heparin were given within the apprioriate timeframe prior to the intitiation of treatment. This deficient practice poses a health risk to patients including the potential risk of insufficient anticoagulation, blood loss, and hospitalization. Findings Include: Facility policy titled, “ AV fistula or graft cannulation with nipro or medisystems safety fistula needles (SFN) and administration of heparin loading dose” states that, “ ...Procedure: After a minimum of three (3) to five (5) minutes, initiate the dialysis per procedure ...” Review of patient treatment sheets revealed the following: Patient #10 05/31/24 The patient’s treatment was initiated at 1510 and the documented time heparin bolus time was 1522. 05/24/24 The patient’s treatment was initiated at 1626 and the documented time heparin bolus time was 1627. During an interview on June 13, 2024, Employee #1 confirmed that the loading doses of heparin were not administered to the patient per the required timeframes within facility policy.”