Davita Gilbert 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: 49430 Based on a review of policy and procedure, observation, and staff interview, it was determined that the facility failed to ensure: The staff appropriately cleansed the patient’s (Patient #10 and patient #11 ‘s) vascular access prior to cannulation with fistula needles. Failure to practice appropriate safe aseptic technique when cleansing and disinfecting a patient’s vascular access increases the risk for vascular access and bloodstream infection if bacteria are not sufficiently reduced at the cannulation sites prior to needle insertion. Findings include: 1. The policy titled “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” 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 and dry time of 15 seconds ... Povidone Iodine at least 1 prep pad per site or 1 saturated sterile gauze pas per site ...for 30 seconds effective contact time and air-dry time of two minutes ....” Patient #10 Observation on April 1, 2024, revealed Employee #14 cleansing and disinfecting the patient #10 ‘s vascular access in preparation of cannulation. Employee #14 used saturated gauze with ExSept to cleanse the arterial cannulation site for a 57-second contact time. Employee #14 repeated the same process for the venous site with a contact time of 60 seconds. Employee #1 confirmed on April 2, 2024, that Employee #14 should have cleansed the cannulation site for two m”

“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 medical record review, review of facility policy and procedure, and interview, it was determined the facility failed to ensure that vital signs were monitored every 30 minutes while receiving dialysis by a personnel member for 3(three) out of 5(five) patients reviewed, Patients #10, # 11, and # 12. Failure to ensure patients are monitored by a personnel member every 30 minutes while on dialysis can result in a patient having an adverse event. Findings include: Facility policy titled, “...Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment....” revised April 2021, revealed, “...The Nursing assessment will be performed and documented by a licensed nurse...The assessment includes...Verification that patient access is visible and face is not covered...Vital signs and treatment monitoring...For non-nocturnal treatments is completed at least every thirty (30) minutes....” “ ...Post Treatment ....” sheets revealed: Patient #8 March 18, 2024 11:10 to 11:40 March 27, 2024 09:31 to 10:02 Patient #10 March 20, 2024 06:43 to 07:14 08:55 to 09:28 10:42 to 11:37 March 25, 2024 11:53 to 12:28 March 27, 2024 08:25 to 09:04 Patient #11 March 22, 2024 10:25 to 10:56 11:26 to 10:57 March 25, 2024 10:25 to 10:56 12:56 to 13:27 March 29, 2024 12:00 to 12:31 Patient #12 March 18, 2024 10:45 to 11:19 March 20, 2024 10:48 to 11:19 11:42 to 12:13 March 22, 2024 10:43 to 11:14 11:14 to 11:45 March 25, 2024 10:55 to 11:27 March 27, 2024 11:10 to 11:41 13:07 to 13:38 March 29, 2024”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 49430 Based on policy review, medical record review and staff interview, it was determined by the Department that the facility failed to require a History and Physical (H&P) be done annually for 3 of 5 current patients reviewed (Patients 10, # 11 and #12). Findings include: Policy titled “Dialysis Services and Patient History and Physical Examination” requires “The patient’s nephrologist...preforms a medical history and physical examination on the patient at least once every 12 months from the date of the patient’s admission...”. Patients’ #10, #11, #12 H&P’s were not completed within the 12 months required. During an interview conducted April 2, 2024, Employee #1, confirmed the intervals between the H&P’s in the patient’s chart is greater than one (1) year.”