Davita Greeley Dialysis

“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 the dialysis station bleach cleaning solution containers were labeled with expiration dates according to facility policy to ensure its efficacy in one of three observations of the patient care area. Findings include: Facility policies: The Preparation of One to One Hundred (1:100) Bleach Solution policy read, with indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only. The Preparation of One to One Hundred (1:10) Bleach Solution policy read, with indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only. 1. The facility failed to ensure patient care staff prepared bleach solution used to clean patient chairs, dialysis machines and supplies used in patient care according to facility policy. Specifically, the bleach containers were not labeled with the expiration dates, times and staffs’ initials. A. Observation i. On 7/14/25 at 9:55 a.m., the patient care area was observed. Three containers filled with a solution were observed on the countertop in front of patient treatment station #6. The containers had labels on them, indicating they were filled with a bleach solution, however, there was no documentation of the date and time of when the bleach solutions expired, or initials to indicate which staff member had mixed the solution. During the observation, a staff member stated the bleach solutions had been prepared that morning, but could not provide evidence. This was in contrast to the Preparation of 1:100 and 1:10 Bleach Solution policies which read, containers should have been labeled with the expiration date, time and initials. B. Interviews i. On 7/16/25 at 7:40 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated 1:100 bleach solutions were used to clean patient chairs and dialysis machines after each use, and 1:10 bleach solution was used if blood was visible. PCT #1 stated it was important for a label to be placed on the containers with the date and time it was prepared because the bleach solutions were not as effective after 24 hours. PCT #1 also stated expired bleach solutions might not have cleaned surfaces effectively, which could increase the risk of patient infections. ii. On 7/16/25 at 8:30 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated bleach solution containers were to be labeled with the date, time and staff initials at the time they were prepared. RN #2 stated bleach containers were labeled because bleach could lose effectiveness over time. RN #2 also stated patients were at risk for infections such as hepatitis (an inflammation of the liver) if expired bleach solutions were used to clean equipment and supplies.”

“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 ensure hemodialysis patients’ access sites were visualized during their hemodialysis treatments in three of five in-center hemodialysis patients’ medical records reviewed. (Patients #1, #2, and #6) Findings include: Facility policy: The Pre-Intra-Post Treatment Collection, Monitoring and Nursing Assessment policy read, during intradialytic 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 7/9/25, revealed the patient’s access site was not visualized and documented every 30 minutes. Patient #1’s treatment started at 11:00 a.m. and ended at 2:43 p.m. There was no documentation of access site visualization between 12:31 p.m., and 1:31 p.m. b. Review of Patient #2’s treatment sheet, dated 7/10/25, revealed the patient’s access site was not visualized and documented every 30 minutes. Patient #2’s treatment started at 11:21 a.m. and ended at 1:52 p.m. There was no documentation of access site visualization between 12:31 p.m., and when treatment ended at 1:52 p.m. c. Review of Patient #6’s treatment sheet, dated 7/8/25, revealed the patient’s access site was not visualized and documented every 30 minutes. Patient #6’s treatment started at 9:33 a.m. and ended at 1:01 p.m. There was no documentation of access site visualization between 9:33 a.m., and 10:21 a.m. Similar findings were discovered during Patient #6’s treatment on 7/12/25. 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 7/16/25 at 7:40 a.m., an interview was conducted with PCT #1. PCT #1 stated patients’ access sites were to be visualized and documented every 30 minutes during treatment. PCT #1 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, which could cause cardiac arrest and death. ii. On 7/16/25 at 8:30 a.m., an interview was conducted with RN #2. RN #2 stated vital signs, including visualization of the patient’s access site was to be performed and documented every 30 minutes during treatment. RN #2 stated if the patient’s access was not visualized every 30 minutes during treatment, there was a risk the patient could lose blood and stop breathing if the needle became dislodged from the access site.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 45020 Based on document reviews and interviews, the facility failed to ensure the social worker (SW) completed a Kidney Disease Quality of Life (KDQOL, a standardized mental and physical assessment) within the required timeframe. This failure was identified in one of five in-center hemodialysis patient records reviewed (Patient #3) and one of two home peritoneal dialysis patient records reviewed (Patient #5). Findings include: Facility policy: The Quality of Life Assessment Survey policy read, the purpose of this policy is to provide guidance on administering the Quality of Life (QOL) assessment survey to patients. The QOL assessment survey is to be administered by the social worker to patients within four months of initiating treatment, and on an as needed basis, and repeated at least annually thereafter. If a patient refuses to complete the KDQOL at any time, the social worker needs to document the refusal in the KDQOL Psychosocial condition in the electronic medical record. Reference: The Social Worker Job Description read, essential duties and responsibilities, the SW independently performs psychosocial-related assessments and provides recommendations for patients. The SW completes Centers for Medicare and Medicaid Services (CMS) mandated and social work-specific tasks, and identifies, assesses, and documents psychosocial evaluations as required by CMS, state and/or facility policy. 1. The facility failed to ensure the SW completed the required KDQOL assessments. A. Document Review i. Review of Patient #3’s medical record revealed the patient was admitted to the facility on 5/23/24 for inpatient hemodialysis. There was no evidence the patient had received, or refused, a KDQOL assessment. ii. Review of Patient #5’s medical record revealed the patient was admitted to the facility on 2/28/25 for home peritoneal dialysis. There was no evidence the patient had received, or refused, a KDQOL assessment. This was in contrast to the Quality of Life Assessment Survey policy, which instructed the SW to administer the KDQOL assessment within four months of initiating treatment and on an annual basis. B. Interviews i. On 7/16/25 at 9:00 a.m., an interview was conducted with SW #3. SW #3 stated a KDQOL assessment was to be completed by the SW within 90 days of admission to the facility and on an annual basis. SW #3 stated a KDQOL determined how the patient perceived they were doing and determined if the patient’s needs were met. SW #3 stated if a patient refused a KDQOL assessment, it was to be documented in the medical record that the patient had refused. SW #3 stated there was a risk a patient’s needs could be missed if a KDQOL was not performed. ii. On 7/16/25 at 11:40 a.m., an interview was conducted with the division SW manager (Manager) #4. Manager #4 stated a patient’s KDQOL was to be completed by the SW within 120 days of admission to the facility. Manager #4 stated it was their expectation for KDQOLs to be performed, and SWs should have documented if the patient had refused. Manager #4 stated the facility was required to offer patients the KDQOL assessment, and the results were discussed with the care team at patient care conferences.”