Davita Central Mesa 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 review of policy/procedure, observation, and staff interview, it was determined by the department that the facility administrator failed to ensure staff appropriately cleansed (2) of (2) patients’ (Patient’s #) vascular access prior to cannulation with fistula needles. Failure to practice safe aseptic technique when cleansing and disinfecting a patient’s vascular access increases the risk for vascular access and blood stream infection. The facility policy titled “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” requires “...cleanse the site by applying skin antiseptic using a circular motion, moving from the center out and allow to dry. (for contact and dry time refer to the table...) ...Iodine...30 second contact time...Alcohol...60 second contact time...”. Observation on 02/27/24 revealed Employee #5 access a patient’s (Patient #1) fistula site at chair #12. Employee #5 scrubbed the entire site for 6 seconds with and alcohol pad then scrubbed each individual site for 24sec with iodine pads then preceded to cannulate both, red and blue needle sites. Observation on 02/27/24, revealed Employee #6 prepared to cannulate Patient #’15’s vascular access. Employee #6 used an alcohol pad to disinfect the arterial cannulation site for 5 seconds prior to cannulating the site. Employee #6 used an alcohol pad to disinfect the venous cannulation site for 5 seconds prior to cannulating the site. Employee #1 confirmed on 02/27/2024 and that this practice was not following facility policy.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 49430 Based on document review and interview, it was determined that the administrator failed to ensure: 1. staff administered treatment medication for hypertension as ordered by the patient’s nephrologist for (2) of (6) patient (Patient #1 and #5) which has the potential risk to patients for adverse outcomes related to untreated hypertension 2. Staff administered heparin infusions per physician order during treatment for (5) of (6) patients (Patients #1, #2, #3, #5 and #6). Findings include: 1. The facility document “SKI/DaVita PRN Panel” requires: “...Medication...Clonidine...0.1 mg PO...0.10 mg for systolic BP (greater than or equal to) 180 and/or diastolic (greater than or equal to)110 after 60 minutes on treatment. May repeat X 1 after one hour if BP remains (greater than or equal to)180 and/or diastolic (greater than or equal to) 110....” 2. Facility policy titled “Anticoagulation” requires “ ...Heparin is administered per physician’s order ....stop/discontinuation time ...” 2. Physician , for all patients receiving heaparin infusions during treatment, reads, “Stop time for hourly does before end of treatment: 60 minutes”. 1. Patient treatment sheets revealed systolic BP (greater than or equal to) 180 and/or diastolic (greater than or equal to)110 after 60 minutes on treatment without assessment or interventions documented. 2. Patient treatment sheets revealed heparin infusions were not discontinued 60 minutes prior to end of treatment. Employee #1 confirmed in an interview on 02/28/2024, that this practice of not administering Clonidine for hypertension and not discontinuing heparin infusion 60 minutes prior to end of treatment was not following physician orders.”

“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: 49430 Based on review of facility policy, medical records and interview, it was determined that the facility failed to ensure that staff followed the attending physicians prescribed hemodialysis (HD) order for blood flow rate and/or temperature setting for (5) of (6) patients. Failure to follow physician orders poses the potential risk of inadequate dialysis, decreased clearances and hospitalizations. Findings Include: Facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” requires ...”prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment....”. Review of patient treatment sheets revealed (5) of (6) patients had documented blood flow rates or machine temperatures (greater than .5 degree from physician order) documented across multiple treatment sheets. Employee #1 confirmed in an interview 02/28/2024 that this practice was not following facility policy or physician orders.”

“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 a review of facility policy, medical records, and staff interviews, it was determined that the facility failed to require clinical staff to notify the nurse and the nurse provide a documented intervention for 6 out of 6 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) was out of range and/or vital signs were not preformed within a 30 minute interval per the facility policy, which poses the potential risk of cardiovascular compromise and hospitalization. Findings include: Facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” requires “...Vital signs and treatment monitoring...completed at least every thirty (30) minutes...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Post-treatment: If patient is above or below 1 kg from the target weight...Pre-dialysis: Systolic greater the 180 mm Hg or less than 90 mm Hg...Diastolic greater than or equal to 100 mm Hg...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 or less than 90 mm Hg...Standing diastolic BP greater than 90 mm Hg or less than 50 mm HG...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute...”. Facility document titled “SKI/Da Vita PRN Medication Panel” requires “...Clonidine...0.10 mg for systolic BP>180 and/or diastolic >110 after 60 minutes on treatment. May repeat X 1 after one hour if BP remains >180 and/or diastolic >110...”. Medical record review of 6 patient’s treatment sheets revealed all (6/6) patients had multiple occurrences of blood pressures, heart rates, vital signs greater than 30-minute intervals and weights 1 kg off from their prescribed target weight without documentation of the licensed nurse being notified or the licensed nurse assessing the occurrence. Employee #1 confirmed in an interview on 02/28/2024 that this practice was not following facility policy.”