Davita Boulder Dialysis Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §494.30 Infection Control was out of compliance. V113 - 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. Based on observations, interviews, and document reviews, the facility failed to ensure staff performed hand hygiene between each patient or station in five of ten observations conducted of staff activities on the dialysis treatment floor.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §494.60 Physical Environment was out of compliance. V407 - Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). Based on interviews and document reviews, patient care staff failed to document if hemodialysis patients’ access sites were visualized during their hemodialysis treatments in three of four medical records reviewed. (Patients #1, #2, and #4)”

“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: 45020 Based on observations, interviews, and document reviews, the facility failed to ensure staff performed hand hygiene between each patient or station in five of ten observations conducted of staff activities on the dialysis treatment floor. Findings include: Facility policy: The Infection Control for Dialysis Facilities policy read, the purpose of this policy is to minimize the spread of infections or blood borne pathogens in the dialysis facility environment. All teammates, physicians and non-physicians will perform hand hygiene prior to gloving and immediately after removal of gloves. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. Gloves should be changed after touching one patient or their dialysis delivery system and before arriving to care for another patient or touching another patient’s dialysis delivery system. 1. The facility failed to ensure staff performed hand hygiene between each patient, workstation, or task when gloves were put on and removed. A. Observations i. On 6/23/25 at 7:53 a.m., an observation was conducted on the dialysis treatment floor. Observations revealed patient care technician (PCT) #1 did not perform hand hygiene prior to putting on gloves. PCT #1 touched the dialysis machine at station #5, where the patient was receiving treatment. PCT #1 then removed their gloves and did not perform hand hygiene. PCT #1 further walked to the patient at station #3 and touched the patient’s blanket with an ungloved hand. PCT #1 then walked to the nurses station without performing hand hygiene. ii. On 6/23/25 at 7:55 a.m. observations of PCT #1 revealed hand hygiene was not performed prior to putting on gloves. PCT #1 touched the dialysis machine at station #10, where a patient was receiving treatment. PCT #1 removed their gloves and did not perform hand hygiene. iii. On 6/25/25 at 7:08 a.m., observations of PCT #1 revealed hand hygiene was not performed prior to putting on gloves. PCT #1 touched the dialysis machine at station #11, where a patient was receiving treatment. PCT #1 removed their gloves and did not perform hand hygiene. iv. On 6/25/25 at 10:09 a.m., observations of medical doctor (MD) #2 revealed hand hygiene was not performed and gloves were not put on prior to touching a patient at station #4. MD #2 proceeded to touch the patient receiving treatment at station #5 without performing hand hygiene or wearing gloves. v. On 6/25/25 at 10:40 a.m., MD #2 was observed at patient station #6. MD #2 touched the patient without wearing gloves, and hand hygiene was not performed before or after. These observations were in contrast to the Infection Control for Dialysis Facilities policy which stated, to minimize the spread of infections or blood borne pathogens, hand hygiene should have been performed prior to gloving and after the removal of gloves. Gloves were to be worn when patient care was performed. B. Interviews i. On 6/25/25 at 12:24 p.m., an interview was conducted with PCT #3. PCT #3 stated hand hygiene was to be performed before gloves were put on and after gloves were removed. PCT #3 stated gloves were to be worn when the patient or dialysis equipment was touched. PCT #3 stated gloves were worn to minimize the risk of infection which could cause death. ii. On 6/25/25 at 12:48 p.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated hand hygiene was expected to be completed before gloves were put on and taken off. RN #4 stated it was important to wear gloves for patient care, and to perform hand hygiene according to facility policy, to minimize the risk of infection and cross contamination between patients. iii. On 6/25/25 an interview was conducted with MD #2. MD #2 stated hand hygiene performed between patients could be improved. MD #2 stated they performed hand hygiene before the treatment floor was entered and exited. MD #2 stated hand hygiene was important because there was a risk for infection to be transferred between patients. MD #2 stated dialysis patients were at a higher risk for infection because most were immunocompromised (impaired immune system).”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 45020 Based on interviews and document reviews, patient care staff failed to document if hemodialysis patients’ access sites were visualized during their hemodialysis treatments in three of four medical records reviewed. (Patients #1, #2, and #4) Findings include: Facility policy: The Pre-Intra-Post Treatment Collection, Monitoring and Nursing Assessment policy read, during intradialytic (the period during hemodialysis) treatment, treatment monitoring will be at least every 30 minutes, including vital signs. At a minimum, Registered Nurses (RNs) or Patient Care Technicians (PCTs) obtain and document the following: blood pressure, heart or pulse rate, blood and dialysate flows, arterial and venous pressures, fluid removal and/or replacement, vascular access visible and line connections intact. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. All findings, interventions and patient response will be documented in the patient’s medical record. 1. The facility failed to ensure patients were monitored during their dialysis treatments according to facility policy. Specifically, staff did not visualize patients’ access sites every 30 minutes. A. Document Review i. Review of medical records revealed access site checks were not documented as performed during intradialytic treatment. a. Review of Patient #1’s treatment sheet, dated 6/20/25, revealed the patient’s access site was not visualized and documented every 30 minutes. The patient’s treatment started at 5:57 a.m., and ended at 9:40 a.m. There was no documentation of access site visualization between 8:32 a.m. and 9:32 a.m. b. Review of Patient #2’s treatment sheet, dated 6/20/25, revealed the patient’s access site was not visualized and documented every 30 minutes. The patient’s treatment started at 2:50 p.m., and ended at 5:34 p.m. There was no documentation of access site visualization between 3:04 p.m. and 4:04 p.m. Similar findings were discovered during Patient #2’s treatments on 6/18/25, 6/16/25, 6/13/25 and 6/9/25. c. Review of Patient #4’s treatment sheet, dated 6/11/25, revealed the patient’s access site was not visualized and documented every 30 minutes. The patient’s treatment started at 7:26 a.m., and ended at 10:24 a.m. There was no documentation of access site visualization after 9:03 a.m. This was in contrast to the Pre-Intra-Post Treatment Collection, Monitoring and Nursing Assessment policy, which stated patient access sites should have been visualized and documented every 30 minutes. B. Interviews i. On 6/25/25 at 12:24 p.m., an interview was conducted with PCT #3. PCT #3 stated patients’ access sites were to be visualized and documented every 30 minutes during treatment. PCT #3 stated it was important to visualize patient access sites to ensure the lines to the machine were intact and the access site was not bleeding. PCT #3 also stated there was a risk of death if access sites bled. ii. On 6/25/25 at 12:48 p.m., an interview was conducted with RN #4. RN #4 stated vital signs, including visualization of the patient’s access site was to be performed and documented every 30 minutes during treatment. RN #4 stated if the patient’s access was not visualized every 30 minutes during treatment, there was a risk the patient could bleed out if the needle became dislodged from the patient’s access site.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 45020 Based on observations and interviews, the facility failed to ensure staff assessed arteriovenous (AV) fistulas (surgically created dialysis access sites) prior to inserting dialysis access needles into the access sites. This failure was identified in two of five patients observed undergoing initiation of dialysis treatment. Findings include: Facility policies: The Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care policy read, the purpose of this policy is to reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize the lifetime of each access. Inspection of the AVF or AVG access includes the following: Presence/absence of thrill (a vibration which can be felt) and/or bruit (a loud, rushing sound caused by blood flow moving through the surgical dialysis access). 1. The facility failed to ensure AV fistulas were assessed for a bruit before dialysis access needles were inserted into the access sites. A. Observations i. On 6/23/25 at 10:49 a.m., an observation was conducted at patient dialysis station #10. Patient care technician (PCT) #5 was observed as they inserted needles into an AVF. PCT #5 did not assess the AVF for a bruit with a stethoscope. Both needles were inserted, secured in place with tape, and treatment was started. ii. On 6/25/25 at 10:47 a.m., an observation was conducted at patient dialysis station #14. PCT #5 was observed as they inserted needles into an AVF. PCT #5 did not assess the AVF for a bruit with a stethoscope. Both needles were inserted, secured in place with tape, and treatment was started. This was in contrast to the AVF and AVG Vascular Access Care policy which stated, inspection of the access included the presence of a bruit. B. Interviews i. On 6/25/25 at 12:24 p.m., an interview was conducted with PCT #3. PCT #3 stated a patient’s access was to be auscultated (listened to) with a stethoscope for a bruit and felt with their hand for a thrill, before needles were inserted to ensure the access was functional. PCT #3 stated if there was an absence of a bruit or thrill, they would immediately notify the nurse. PCT #3 stated there was a risk the patient’s access could be clotted, and if a needle were to be inserted, the clot could dislodge to the patient’s heart or lungs, which could cause chest pain or shortness of breath. ii. On 6/25/25 at 12:48 p.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated a stethoscope was to be used to listen for the bruit, as well as felt with the staff member’s hand before the needles were inserted. RN #4 stated there was a risk of a clot within the patient’s access which could cause damage to the AVF. RN #4 stated if the access was clotted or damaged, the patient would not be able to receive their hemodialysis treatment, and they would be transferred to the hospital.”