Davita Tulare Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47734 Based on observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, “Infection Control for Dialysis Facilities” when one used mechanical lift was stored by the nurses’ station. This failure had the potential to result in contamination of a clean area and potentially spread germs within the facility. Findings: During an observation on 8/6/25 at 9:40 a.m. on the treatment floor, there was a mechanical lift blocking the clean supply cabinets and drawers at the nurses’ station. During an interview on 8/6/25 at 12:16 p.m. with Registered Nurse (RN) 2, RN 2 stated the mechanical lift was used by a patient who had already left the facility. RN 2 stated the mechanical lift should not be stored by the nurses’ station. During a review of the facility’s P&P titled, “Infection Control for Dialysis Facilities,” dated April 2023, the P&P indicated, “Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.””

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47734 Based on observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, “Termination of Dialysis Utilizing [brand] Dialysis Delivery Systems and [brand] or [brand] Blood Lines,” when: 1. One of one sampled patient care technician (PCT) 1 did not wear eye protection when terminating dialysis treatment (returning patient’s blood and removing dialysis needles) for Patient 1. 2. One of one PCT ( PCT 2) wore unapproved eye protection when terminating dialysis treatment for Patient 8. These failures had the potential for PCT 1 and PCT 2’s eyes to be splattered with blood during termination of dialysis treatment for Patient 1 and Patient 8, and potentially cause infection. Findings: 1. During an observation on 8/6/25 at 9:36 a.m. at Station 16, PCT 1 was terminating dialysis treatment for Patient 1, PCT 1 had no face shield or eye protection on. During an interview on 8/6/25 at 10:29 a.m. with PCT 1, PCT 1 stated she should have put on her goggles while terminating dialysis treatment for Patient 1. During a review of the facility’s policy and procedure (P&P) titled, “Termination of Dialysis Utilizing [brand] Dialysis Delivery Systems and [brand] or [brand] Blood Lines,” dated October 2022, the P&P indicated, “PPE-personal protective equipment [used to protect employees] (face protection, gloves, fluid resistant/fluid impervious barrier garment). . .1. . .Put on PPE. . .PPE is worn for teammate protection.” 2. During an observation on 8/6/25 at 11:11 a.m. at Station 1, PCT 2 was terminating dialysis treatment for Patient 2. PCT 2 was wearing eye protection that looked like eyeglasses with a covering on the sides and top. During an interview on 8/6/25 at 11:14 a.m. with PCT 2, PCT 2 stated the eye protection she was wearing had about half an inch gap between her forehead and the top cover. PCT 2 stated the eye protection did not fit her snugly. During an interview on 8/20/25 at 3:08 p.m. with Facility Administrator (FA), FA stated the goggles worn by PCT 2 did not have a manufacturer’s guide for use since it was not a [facility] item provided to staff. During a review of the facility’s P&P titled, “Infection Control for Dialysis Facilities” dated April 2023, the P&P indicated, “PPE (i.e., gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces.” During a review of U.S. Centers for Disease Control and Prevention (CDC) article titled, “Eye Protection for Infection Control,” dated 2/11/25, the article indicated, “Eye protection must be comfortable, provide good peripheral vision, and fit securely. . .goggles must fit snugly around the eyes and brow.” During a review of U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) article titled, “Eye and Face Protection,” dated 3/25/16, the article indicated, “1910.133(a) General requirements. 1910.133(a)(1) The employer shall ensure that each affected employee uses appropriate eye or face protection when exposed to eye or face hazards. . .1910.133(a)(4) Eye and face PPE shall be distinctly marked to facilitate identification of the manufacturer.””

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 47734 Based on observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, “Facility Emergency Management Plan” when a privacy curtain divider was left in front of one of one exit door. This failure resulted in the exit door being blocked and the potential for unsafe evacuation in case of a fire or emergency. Findings: During an observation on 8/6/25 at 9:35 a.m. on the treatment floor, there was a privacy curtain divider in front of a door with an exit sign. The divider was blocking the exit door. During an interview on 8/6/25 at 11:22 a.m. with Registered Nurse (RN) 1, RN 1 stated the privacy curtain should not be blocking the exit door. During a review of the facility’s P&P titled, “Facility Emergency Management Plan,” dated October 2024, the P&P indicated, “5. Evacuation routes shall be, as per local fire code:. . .e. The egress area (exit to the outside of the building) must remain clear at all times.””