Davita North Colorado Springs Dialysis

“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 for Coverage §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 review, the facility failed to ensure five of five patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. Additionally, the facility failed to ensure patient care staff performed hand hygiene and changed gloves when a central venous catheter (CVC) (a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) dressing change procedure was performed in two of two CVC dressing changes observed. V122 - [Standard: Procedures for infection control. The facility must demonstrate that it follows standard infection control precautions by implementing-] [Maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-](ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. Based on observations, interviews, and document review, the facility failed to ensure patient care staff cleaned and disinfected the patient treatment station chair per facility policy in three of four observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned.”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 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 for Coverage §494.80 Patient Assessment, was out of compliance. V511 - (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). Based on observations, interviews, and document review, the facility failed to ensure heparin was administered according to facility policy in two of four dialysis initiations observed and in four of five in-center patient medical records reviewed. (Patients #1, #2, #4 and #5)”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 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 for Coverage §494.90 Patient Plan of Care, was out of compliance. V544 - Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. Based on document review and interviews, the facility failed to follow the individualized dialysis prescription for blood flow rate (BFR) as determined by the medical provider in four of five in-center patient medical records reviewed. (Patient #1, #2, #4 and #5)”

“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 review, the facility failed to ensure five of five patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. Additionally, the facility failed to ensure patient care staff performed hand hygiene and changed gloves when a central venous catheter (CVC) (a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) dressing change procedure was performed in two of two CVC dressing changes observed. Findings include: Facility policies: The Infection Control for Dialysis Facilities policy read, the purpose of this policy is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area. The CVC with Clearguard Hemodialysis (HD) Antimicrobial End Caps Procedure read, perform hand hygiene per procedure, remove old dressing and discard. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. The Infection Control policy read, all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, and after patient and dialysis delivery system contact. Gloves should be changed when soiled, when going from a “dirty” area or task to a “clean” area or task, and when moving from a contaminated body site to a clean body site of the same patient. 1. The facility failed to ensure patients were asked to perform hand hygiene after treatment, before leaving the treatment floor, according to facility policy. A. Observations i. On 9/2/25 at 10:18 a.m., an observation was conducted at station #11. The patient was observed holding pressure to their own access sites with a gloved right hand following the removal of the needles used for treatment. At 10:38 a.m., after stabilization of the sites, patient care technician (PCT) #2 applied a gauze dressing to the sites. The patient then removed the soiled glove and without performing hand hygiene, ambulated to the scale and obtained their weight by pressing a button on the scale with their right hand. The patient exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. ii. On 9/2/25 at 10:23 a.m., an observation was conducted at station #8. The patient received dialysis treatment through a CVC. Registered nurse (RN) #5 secured the CVC, the patient gathered their belongings, touched the scale button to obtain their weight and exited the facility. Staff did not educate or request the patient to perform hand hygiene before the patient left the treatment floor. iii. On 9/2/25 at 10:44 a.m., an observation was conducted at station #6. The patient was observed holding pressure to their own access sites with a gloved right hand. At 10:47 a.m., after stabilization of the sites, PCT #1 applied a dressing to the sites. The patient then removed the soiled glove and without performing hand hygiene, ambulated to the scale and obtained their weight by pressing a button with their right hand. The patient touched the automatic door opening button and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. iv. On 9/3/25 at 8:53 a.m., an observation was conducted at station #5. The patient was observed holding pressure to their own access sites with a gloved left hand following the removal of the needles used for treatment. PCT #6 applied a gauze dressing to the sites. The patient ambulated to the scale with the soiled glove on their left hand. The patient removed the glove at the scale, and without performing hand hygiene, obtained their weight and ambulated back to station #5. The patient gathered their belongings and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. v. On 9/3/25 at 9:14 a.m., an observation was conducted at station #8. The patient was observed holding pressure to their own access sites with a gloved right hand following the removal of the needles used for treatment. At 9:41 a.m., after stabilization of the sites, PCT #3 applied a gauze dressing. The patient then removed the soiled glove and without performing hand hygiene, gathered their belongings, ambulated to the scale and obtained their weight. The patient exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. This was in contrast to the Infection Control for Dialysis Facilities policy which stated, patients would be encouraged to perform hand hygiene after treatment, before leaving the treatment area, to minimize the spread of infections or blood borne pathogens in the dialysis facility environment. B. Interviews i. On 9/3/25 at 1:13 p.m., an interview was conducted with PCT #3. PCT #3 stated patients were to perform hand hygiene before and after dialysis treatments. PCT #3 stated hand sanitizer was to be offered to patients because there was a risk of infections, such as MRSA (Methicillin-resistant Staphylococcus aureus) (bacteria that cause infections), flu, and coronavirus disease (COVID). ii. On 9/3/25 at 2:00 p.m., an interview was conducted with RN #4. RN #4 stated patients were to perform hand hygiene before leaving the facility because the treatment floor was a shared environment. RN #4 stated there was a high risk of contamination because patients all touched the scale and door when leaving the facility. RN #4 stated if a patient did not perform hand hygiene after treatment, there was a risk of infection, which could lead to MRSA, flu, COVID, and hospitalization. 2. The facility failed to ensure patient care staff performed hand hygiene and glove changes after the dressing was removed from the CVC access site according to facility policy. A. Observations i. On 9/2/25 at 11:04 a.m., an observation was conducted of a CVC dressing change at station #9. PCT #2 performed hand hygiene, donned gloves and removed the dressing covering the patient’s CVC access site. PCT #2 discarded the old dressing, and without changing gloves, swabbed the CVC exit site with a Chlorhexidine swab, then used an alcohol pad to clean the CVC limbs. ii. On 9/2/25 at 11:47 a.m., an observation was conducted of a CVC dressing change at station #5. PCT #2 performed hand hygiene, donned gloves and removed the dressing covering the patient’s CVC access site. PCT #2 discarded the old dressing, and without changing gloves, swabbed the CVC exit site with a Chlorhexidine swab, then used an alcohol pad to clean the CVC limbs. These observations were in contrast to the CVC Procedure which stated, staff should have removed and discarded their gloves, performed hand hygiene, and re-gloved after the old dressing had been removed and discarded. These observations were also in contrast to the Infection Control policy which stated, gloves should have been changed when soiled, when going from a “dirty” area or task to a “clean” area or task, and when moving from a contaminated body site to a clean body site of the same patient. B. Interviews i. On 9/3/25 at 1:13 p.m., an interview was conducted with PCT #3. PCT #3 stated after the dressing was removed from the patient’s CVC access site, hand hygiene was to be performed and new gloves were to be applied. PCT #3 stated it was important to perform hand hygiene after removing the old dressing because patients were at risk for infection. PCT #3 stated infections could cause hospitalization, the need for antibiotics or replacement of the CVC, and death. ii. On 9/3/25 at 2:00 p.m., an interview was conducted with RN #4. RN #4 stated after the dressing was removed, hand hygiene was to be performed and new gloves were to be applied because the old dressing was considered dirty. RN #4 stated it was important to perform hand hygiene when initiating treatment because the CVC was a straight line to the patient’s heart. RN #4 stated a lack of hand hygiene could cause infections, a blood stream infection, hospitalization, and death.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document review, the facility failed to ensure patient care staff cleaned and disinfected the patient treatment station chair per facility policy in three of four observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned. 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. At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings (e.g., dialysis chair). Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. Disinfection should be completed by using a wiping motion with friction. Sufficient disinfectant should be applied so that surfaces are visibly wet. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time. 1. The facility failed to ensure dialysis chairs were cleaned and disinfected between patient treatments according to facility policy. Dialysis chairs were not placed into the fully reclined position to ensure all surfaces of the chair were cleaned. A. Observations i. On 9/2/25 at 9:30 a.m., patient care technician (PCT) #1 was observed as they disinfected the dialysis chair at station #4. PCT #1 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. ii. On 9/2/25 at 9:55 a.m., PCT #2 was observed as they disinfected the dialysis chair at station #5. PCT #1 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. iii. On 9.2.25 at 10:32 a.m., PCT #2 was observed as they disinfected the dialysis chair at station #9. PCT #2 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. These observations were in contrast to the Infection Control for Dialysis Facilities policy which stated, staff should have disinfected all surfaces in contact with the patient to minimize the spread of infections or blood borne pathogens in the dialysis facility environment. B. Interviews i. On 9/3/25 at 1:13 p.m., an interview was conducted with PCT #3. PCT #3 stated the process for a dialysis chair to be cleaned was to pull the lever on the back of the chair to completely recline it. PCT #3 stated it was important to clean dialysis chairs thoroughly between patients because there was a risk of infection, including Hepatitis C (a liver disease spread primarily through blood), MRSA (Methicillin-resistant Staphylococcus aureus) (a bacteria that causes infections), and hospitalization. ii. On 9/3/25 at 2:00 p.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated dialysis chairs were to be cleaned after each use. RN #4 stated chairs were to be fully reclined to ensure the crevices were fully disinfected. RN #4 stated if dialysis chairs were not cleaned appropriately, there was a risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred with harmful effect). RN #4 stated cross contamination increased the risk of infections, such as blood stream infections, C-diff (Clostridium Difficile, a contagious bacterial infection causing diarrhea and inflammation of the colon) and MRSA, which could cause hospitalization and death. These interviews were in contrast to the observations which revealed dialysis chairs were not fully reclined when cleaned.”

“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, interviews, and document review, the facility failed to ensure heparin was administered according to facility policy in two of four dialysis initiations observed and in four of five in-center patient medical records reviewed. (Patients #1, #2, #4 and #5) Findings include: Facility policy: The Anticoagulation policy read, heparin is the primary anticoagulant used to prevent clotting. The purpose of this policy is to deliver anticoagulation therapy that reduces clotting within the extracorporeal circuit and prevents complications such as blood loss, optimizes dialyzer efficiency and adequacy of dialysis, and prevents bleeding secondary to over-anticoagulation during the hemodialysis treatment. To anticoagulate the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least three to five minutes prior to the initiation of the hemodialysis treatment. 1. The facility failed to ensure patient care staff waited three to five minutes after heparin was administered before starting dialysis treatment. A. Observations i. On 9/2/25 at 11:04 a.m., an observation was conducted at station #9. Patient care technician (PCT) #2 prepared the patient’s CVC for dialysis treatment. Heparin was administered into the CVC at 11:16 a.m., the dialysis lines were connected and treatment was started at 11:18 a.m., two minutes later. ii. On 9/2/25 at 11:19., an observation was conducted at station #4. PCT #1 prepared the patient’s arteriovenous fistula (AVF)(a surgically created connection between an artery and a vein) for dialysis treatment. Heparin was administered into the venous line at 11:34 a.m., the dialysis lines were connected to the patient and treatment was started at 11:35 a.m., one minute later. During the observation, PCT #1 stated they were unsure if there was a wait time to start treatment after heparin was administered, however, they stated they thought it was one to two minutes. These observations and PCT #1’s statement was in contrast to the Anticoagulation policy which stated, the initial loading dose of heparin should have been administered at least three to five minutes prior to the initiation of the hemodialysis treatment. B. Document Review i. Review of the medical record for Patient #1 revealed on 8/20/25, dialysis treatment was initiated at 11:33 a.m., and heparin 800 units (U) was administered at 11:36 a.m., three minutes after the dialysis treatment had been initiated. On 8/22/25, heparin 800 U was administered at 11:06 a.m., and dialysis treatment was initiated at 11:06 a.m. ii. Review of the medical record for Patient #2 revealed on 8/28/25, heparin 1000 U was administered at 11:34 a.m., and dialysis treatment was started at 11:34 a.m. On 8/30/25, heparin 1000 U was administered at 12:06 p.m., and dialysis treatment was initiated at 12:06 p.m. iii. Review of the medical record for Patient #4 revealed on 8/21/25, dialysis treatment was initiated at 10:35 a.m., and heparin 1600 U was administered at 10:37 a.m., two minutes after the dialysis treatment had been initiated. On 8/26/25, heparin 1600 U was administered at 11:48 a.m., and dialysis treatment was initiated at 11:48 a.m. iv. Review of the medical record for Patient #5 revealed on 8/22/25, dialysis treatment was initiated at 12:21 p.m., and heparin 1000 U was administered at 12:22 p.m., one minute after the dialysis treatment had been initiated. These medical record reviews were in contrast to the Anticoagulation policy which stated, the initial loading dose of heparin should have been administered at least three to five minutes prior to the initiation of the hemodialysis treatment. C. Interviews i. On 9/3/25 at 1:13 p.m., an interview was conducted with PCT #3. PCT #3 stated heparin was a medication administered to prevent blood from clotting during dialysis treatment. PCT #3 stated after heparin was administered, there was a three to five minute wait time before dialysis treatment was started because the medication needed time to circulate throughout the body. PCT #3 stated if a patient’s blood clotted during dialysis treatment, there was a risk of blood loss and the patient’s red blood cells (cells in blood essential for carrying oxygen to the body’s tissues) could be decreased. ii. On 9/3/25 at 2:00 p.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated heparin was administered to ensure the patient’s blood did not clot during dialysis treatment. RN #4 stated there was a three to five minute wait time after heparin was administered before dialysis treatment was started to ensure the medication circulated throughout the patient’s body. RN #4 stated there was a risk of blood clots in the dialysis system, blood loss, and hypovolemia (a decreased volume of blood in the body) if staff did not wait three to five minutes after heparin was administered before dialysis treatment was started.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45020 Based on document review and interviews, the facility failed to follow the individualized dialysis prescription for blood flow rate (BFR) as determined by the medical provider in four of five in-center patient medical records reviewed. (Patient #1, #2, #4 and #5) Findings include: Facility policy: The Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment policy read, the purpose of this policy is to obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse includes at a minimum, obtain and document the following: Blood pressure, heart rate, blood and dialysate flows, arterial and venous pressures, fluid removal, vascular access visible. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate), the reason will be documented and the licensed nurse informed. 1. The facility failed to ensure patient care staff followed individualized dialysis prescriptions for BFR to ensure the effectiveness of patients’ prescribed dialysis treatments. A. Document Review i. A review of Patient #1’s treatment sheet from 8/22/25 revealed a prescribed BFR of 350 milliliters (mL)/minute (min). Patient #1’s treatment started at 11:06 a.m. The BFR remained at 250 ml/min until treatment ended at 2:29 p.m.There was no documented rationale for the changes to the prescribed BFR. ii. A review of Patient #2’s treatment sheet from 8/21/25 revealed a prescribed BFR of 350 ml/min. Patient #2’s treatment started at 11:37 a.m., with the BFR at 350 ml/min. At 12:30 p.m., the BFR was decreased to 300 ml/min. At 1:30 p.m., the BFR was decreased to 280 ml/min. At 2:00 p.m., the BFR was decreased to 260 ml/min. The BFR remained at 260 ml/min until treatment ended at 3:43 p.m. On 8/28/25, Patient #2’s treatment sheet revealed treatment started at 11:34 p.m., at the prescribed BFR of 350 ml/min. At 12:29 p.m., the BFR was decreased to 320 ml/min, where it remained until treatment ended at 3:33 p.m. There was no documented rationale for the changes to the prescribed BFRs on 8/21/25 or on 8/28/25. iii. A review of Patient #4’s treatment sheet from 8/29/25 revealed a prescribed BFR of 350 ml/min. Patient #4’s treatment started at 5:40 a.m., with the BFR at 350 ml/min. At 7:31 a.m., the BFR was decreased to 280 ml/min. At 8:00 a.m., the BFR was decreased to 250 ml/min, where it remained until treatment ended at 8:30 a.m. There was no documented rationale for the changes to the prescribed BFR. iv. A review of Patient #5’s treatment sheet from 8/18/25 revealed a prescribed BFR of 400 ml/min. Patient #5’s treatment started at 12:27 p.m., with the BFR at 400 ml/min. At 2:37 p.m., the BFR was decreased to 350 ml/min, where it remained until treatment ended at 4:07 p.m. On 8/20/25, Patient #5’s treatment sheet revealed treatment started at 12:20 p.m., at the prescribed BFR of 400 ml/min. At 12:59 p.m., the BFR was decreased to 350 ml/min, and at 1:59 p.m., the BFR was decreased to 300 ml/min, where it remained until treatment ended at 3:54 p.m. On 8/22/25, Patient #5’s treatment sheet revealed treatment started at 12:21 p.m., at the prescribed BFR of 400 ml/min. At 2:59 p.m., the BFR was decreased to 350 ml/min, where it remained until treatment ended at 3:44 p.m. On 8/29/25, Patient #5’s treatment sheet revealed treatment started at 10:05 a.m., at the prescribed BFR of 400 ml/min. At 11:00 a.m., the BFR was decreased to 380 ml/min. At 12:00 p.m., the BFR was decreased to 300 ml/min. At 12:30 p.m., the BFR was decreased to 280 ml/min. At 1:00 p.m., the BFR was decreased to 250 ml/min, where it remained until treatment ended at 1:42 p.m. There was no documented rationale for the changes to the prescribed BFRs on 8/18/25, 8/20/25, 8/22/25, or 8/29/25. This was in contrast to the Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment policy which stated, if the prescribed BFR was not met the reason should have been documented and the licensed nurse informed. B. Interviews i. On 9/3/25 at 1:13 p.m., an interview was conducted with PCT #3. PCT #3 stated it was important to follow the physician’s orders to ensure the patients received adequate treatment. PCT #3 stated BFR was a prescription and if the BFR was decreased, it was to be documented and the nurse was to be notified. PCT #3 stated if the BFR was decreased, there was a risk the patient would not get adequate dialysis which could decrease the length of their life. ii. On 9/3/25 at 2:00 p.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated the BFR was the rate the patient’s blood went through the dialysis machine, and providers prescribed a BFR to ensure proper clearance of waste products from the bloodstream during dialysis. RN #4 stated it was their expectation to be notified by the PCT if the BFR was decreased. RN #4 stated the BFR decrease and the reason was to be documented. RN #4 stated if the BFR was decreased the patient’s blood would not be cleaned as well, which could cause the patient to get sick and possibly hospitalized. These interviews were in contrast to the treatment sheet reviews which revealed patients’ BFRs had been decreased without a documented reason.”