Davita Murrieta Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 44505 Based on observation, interview, and record review, the facility failed to ensure four Patient Care Technicians (PCT) performed hand hygiene before and after removing gloves. This failure had the potential to increase the risk for cross-contamination and the spread of infections, affecting a census of 25 patients. Findings: 1. On November 18, 2024, PCT 1 was observed not peforming hand hygiene on multiple occasions: - At 12:13 p.m., PCT 1 assisted a patient at Station 19 during discharge. After removing the patient’s needles, PCT 1 donned new gloves without performing hand hygiene. - At 12:30 p.m., with gloves on, PCT 1 approached the clean supply cabinet, removed the gloves, and retrieved needles from the cabinet. PCT 1 held the used gloves in one hand and clean supplies in the other, without performing hand hygiene after glove removal. - At 12:47 p.m., before assisting a patient at station 21, PCT 1 donned clean gloves without prior hand hygiene. On November 18, 2024, at 1:50 p.m., PCT 1 stated she should have performed hand hygiene before donning clean gloves and after removing used gloves to prevent disease transmission and ensure infection control. 2. On November 18, 2024, PCT 2 was observed not performing hand hygiene on multiple occasions: - At 12:16 p.m., at station 12, PCT 2 removed a patient’s needles. After removing gloves, PCT donned new gloves without performing hand hygiene between glove changes. This sequence occurred three times, including when PCT 2 moved to Station 10 to mute the alarm. - At 12:35 p.m., PCT 2 assisted a patient at Station 10, donning gloves without performing hand hygiene. 3. On November 18, 2024, PCT 3 was observed not performing hand hygiene on two occasions: - At 12:20 p.m., at station 16, PCT 3 removed a patient’s needles and applied tape. PCT 3 donned new gloves without performing hand hygiene between glove changes. - At 12:50 p.m., PCT 3 cleaned and disinfected the machine at station 16. After removing soiled gloves, PCT 3 donned new gloves without performing hand hygiene prior to gloving. 4. On November 18, 2024, at 12:40 p.m., at Station 23, PCT 4 removed a patient’s needles, discarded the soiled gloves, and proceeded to the computer to chart without performing hand hygiene after glove removal. On November 18, 2024, at 3:09 p.m., PCT 4 was interviewed. PCT 4 stated, hand hygiene should be performed before gloving and after removal of gloves. On November 18 at 2:08 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated, hand hygiene should be performed before and after gloving to maintain infection control. A review of the facility policy and procedure, titled, “Infection Control for Dialysis Facilities” dated, September 2007, indicated, “ ...all teammates, physicians and non-physician will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves ...””

“IC-SINGLE USE VIALS CFR(s): 494.30(a)(1)(i) Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. This Standard is not met as evidenced by: 44505 Based on observation, interview, and record review, the facility failed to ensure pre-drawn medication syringes were labeled indicating preparation time and the preparer’s initials. This failure had the potential for medication error and compromise patient safety. Findings: On November 18, 2024, at 1:38 p.m., during a concurrent observation and interview with Registered Nurse (RN) 2, four unlabeled syringes filled with black liquid were found inside a drawer at the nurse’s station. RN 2 stated he had drawn the liquid but without labels, it was unclear what the liquid was or when it was prepared. RN 2 further stated, syringes should be labeled with the medication name, date, time, and the preparer’s initials. On November 18, 2024, at 3:19 p.m. an interview was conducted with the Clinical Coordinator, (CC). The CC stated the staff were expected to label drawn medications with the medication name, date, time and initial, to prevent errors. A review of the facility’s policy titled, “Medication policy,” dated, September 2017, indicated, “ ...if the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient’s name, name of medication, date, time prepared, dose and initials of teammate preparing the medication ...””

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 44505 Based on observation, interview, and record review, the facility failed to ensure the dialysate (fluid used to remove unwanted waste products from the blood during dialysis [a procedure that removes waste products and excess fluid from blood when the kidneys are no longer functioning properly]) conductivity (test to confirm a desired proportion of components in the dialysate) was tested before initiating hemodialysis (a type of dialysis) treatment. This failure had the potential to result in an unsafe provision of care of one out of three sampled patients (Patient 1) receiving hemodialysis. Findings: A review for Patient 1’s Face sheet, indicated, Patient 1 was admitted to the facility on December 4, 2017, with diagnoses which included, end stage renal disease (ESRD - a terminal illness in which a person’s kidneys no longer work properly). Further review of Patient 1’s medical record, indicated Patient 1 has a Central Venous Catheter (CVC-a soft plastic tube that is inserted into a vein to provide access to the central veins for hemodialysis) as her dialysis access, and scheduled to dialyze (to undergo dialysis: a process that uses a special machine for removing harmful waste substance from the blood of people whose kidneys are not working properly) three times a week (Monday, Wednesday, Friday), for 3 hours and 30 minutes. On November 18, 2024, at 11:24 a.m., an interview was conducted with the Clinical Coordinator (CC). The CC stated that 24 patients were receiving hemodialysis during the current shift. On November 18, 2024, at 1:00 p.m., an observation was conducted with Registered Nurse (RN) 2. RN 2 did not perform a pH check and dialysate conductivity test prior to initiating treatment to Patient 1. On November 18, 2024, at 1:15 p.m., an interview was conducted with RN 2. RN 2 stated that he did not check the pH and conductivity for Patient 1’s machine prior to initiating treatment. RN 2 stated he assumed someone else checked it. On November 18, 2024, at 3:19 p.m. an interview was conducted with the CC. The CC stated the staff were expected to check pH and conductivity using (name of conductivity meters and pH instruments) before starting dialysis treatment to prevent errors. A review of the operator’s manual titled, “[Brand and Model A] Hemodialysis Machine Operator’s Manual”, undated, indicated, “Warning! Always verify the conductivity and approximate pH of the dialysate solution through independent means (e.g., using a conductivity meter or pH paper or meter, as applicable) before initiating each dialysis treatment ... Verify that the conductivity is reasonably close to the theoretical conductivity value (TCD) and the pH is between 6.9 and 7.6. If conductivity and pH are not within limits, do not initiate dialysis ...””