Davita Ocotillo Dialysis

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 49430 Based on review of facility policies and procedures, observations and staff interviews, it was determined that the facility failed to require staff dispose of expired supplies and medications, which has the potential risk of infection by using outdated items that may have lost their intended effectiveness for patients receiving hemodialysis treatments. Findings include: Facility policy, “Expiration Dates of Sterile Supplies” revealed: “...Sterile items will be checked before use to ensure that they have not expired...Appropriately dispose of sterile items that have reached the expiration date...” Observation on 05/23/2024 revealed the following expired supplies were found in the patient care area: Fifty-three (53) BD Microtainer Contact Activated lancets- Expired 04/30/2024 Fifty-four (54) BD 10ml Syringe- Expired 02/29/2024 Twenty-nine (29) BD 3ml Syringe- Expired 02/28/2023 One hundred thirty-two (132) BD PrecisionGlide Needle 21g X 1- Expired 09/30/2023 Fifty-five (55) VioNex toweletts- Expired 02/01/2023 Six (6) Cobas PCR Media Uni Swab Sample Packets- Expired 04/30/2024 Eleven (11) BD Safety-Lok 3 ml syringe with needle- Expired 07/31/2023 Twenty-four (24) UltiCare low dead space disposiable syringe 3ml- Expired 10/31/2023 One (1) blue top saline 0.85% solution for swab collection- Expired 01/2024 One (1) Posi-Grip Sterile Thumb Forceps- Expired 07/2019 Employee #1 confirmed the expiration dates of supplies and that policy was not followed in the removal and disposal of these items.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 49430 Based on observation and staff interview it was determined that the facility failed to ensure that preventative maintenance (PM) was completed on patient care equipment yearly. This lack of validation of equipment may lead to malfunctions during use of equipment, base hemodialysis therapy on inaccurate information causing harm, hospitalizations and possible death to patients. Finding include: PM tag on patient scale, used to weight all patients pre and post treatment, dated t have PM completed by 04/25/2024. PM tag on automated external defiblator (AED) dated to have PM completed by 04/25/2024. PM tag on suction machine, that is placed on top of code cart, dated to have PM completed by 04/25/2024. PM tag on two (2) centrifuge machines, in the lab room, dated to have PM completed by 04/25/2024. PM tag on two (2) oxygen concentrators, in the patient care area, dated to have PM completed by 04/24/2024. During interview conducted 05/23/2024, Employee #1 confirmed the PM for all the listed equipment was past due at the time of survey and did not follow 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 document review and staff interview, it was determined that the facility did not require staff to complete plans of care within thirty (30) days of a patient’s admit date. Absent Plans of Care may contribute to uncoordinated care between all disciplines participating in the interdisciplinary care team, leading to missed oversight of changing conditions leading to complications, hospitalizations and/or death. Findings include: Facility policy titled “Interdisciplinary Team (IDT) Assessment and Plan of Care” requires “New Patient ...within 30 days of admission to facility ... or 13 treatments ...” Plan of Care requested for patient #2, whom has an admit date of 04/08/2024, on 05/23/2024. None were provided by staff. During staff interview on 05/24/2024, Employee #1 confirmed the Plans of Care were not completed per facility policy.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 49430 Based on document review and staff interview, it was determined that the facility did not require staff to update unstable plans of care within thirty (30) days of a patient’s original designation of unstable. Delinquent Plans of Care for unstable patients may contribute to uncoordinated care between all disciplines participating in the interdisciplinary care team, leading to missed oversight of changing conditions leading to complications, hospitalizations and/or death. Findings include: Facility policy titled “Interdisciplinary Team (IDT) Assessment and Plan of Care” requires “Monthly (unstable patients) ... assessment to be done monthly until patient is determined to be stable by the interdisciplinary team” Plan of Care for dates ranging from 10/2023 through 05/23/2024 requested for patient #4. An unstable plan of care was produced with a signature/start date of 04/08/2024. No other plans of care were provided. During staff interview on 05/24/2024, Employee #1 confirmed there was not an updated plan of care completed, within 30 days of unstable designation, for patient #4.”