Davita Milford 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: 47491 Based on observations, interview, and review of clinical records for six (6) of eight (8) patients reviewed for hand hygiene, the facility failed to ensure a patient was offered hand hygiene prior to leaving the treatment floor. The findings included: 1. On 11/1/24 at 9:58 AM, Patient #9 was observed holding his/her hemodialysis access site with his/her gloved left hand, the patient removed the glove at 10:00 AM and did not perform hand hygiene, walked to the weigh station, pressed a button at the weight station with his/her left hand twice to have his/her weight printed on a ticket, and then pressed the auto door opener with his/her left hand at 10:03 AM without performing hand hygiene prior to exiting the building. 2. On 11/1/24 at 10:04 AM, Patient #10 was observed holding his/her hemodialysis access sites with his/her gloved right hand, the patient removed the glove at 10:12 AM and did not perform hand hygiene, walked to the weight station and was followed by Staff Person #1, who did not offer the patient hand sanitizer, weighed him/herself and pressed a button at the weigh station with his/her right hand, gave Staff Person #1 his weight ticket, and then pressed the auto door opener with his/her right hand to exit the clinic without performing hand hygiene. 3. On 11/1/24 at 10:05 AM, Patient #12 was observed holding his/her hemodialysis access with his/her gloved left hand, the patient removed his/her glove at 10:07 AM and did not perform hand hygiene, walked to the weigh station, and pressed a button at the weigh station with his/her left hand to print a weight ticket, gave it to Staff Person #2, then proceeded back to his/her station to pick up his/her items and exited the clinic by pressing the automatic door opener with his/her left hand without performing hand hygiene prior to exiting the clinic. 4. On 11/1/24 at 10:08 AM, Patient #2 was observed holding his/her hemodialysis access with his/her gloved right hand, the glove was removed by Staff Person #2, the patient was not offered hand sanitizer, was brought to the weigh station in a wheelchair, stood on the scale while holding the handrail with both hands, and exited the clinic without performing hand hygiene. 5. On 11/1/24 at 10:15 AM, Patient #13 was observed holding his/her hemodialysis access following treatment with a gloved right hand, the patient removed his/her glove at 10:18 AM and did not perform hand hygiene, walked to the weigh station, pressed a button at the weight station with his/her right hand to print a weight ticket, and then proceeded to the bathroom prior to exiting the clinic. 6. On 11/4/24 at 10:33 AM, Patient #9 was observed holding his/her access following treatment with a gloved left hand, the patient removed his/her glove at 10:34 AM and did not perform hand hygiene, went to the weigh station, pressed the button to print a weight ticket, returned to his dialysis station to gather items, proceeded to the clinic exit and pressed the automatic door opener button without performing hand hygiene prior to exiting the clinic. 7. On 11/5/24 at 9:33 AM, Staff Person #1 was observed taking a patient off of treatment. Staff Person #1 was observed adjusting a patient’s blanket with gloved hands, pushing down on the patient’s recliner when assisting the patient into a seated position, and proceeded to disconnect both the venous and arterial bloodlines from the patient’s access Staff Person #1 changed gloves, however, failed to perform hand hygiene in between removing and applying new gloves. Staff Person #1 further failed to perform hand hygiene after removing his/her gloves following the removal of the patient’s blood pressure cuff and before going to the supply cart for a clamp. Interview with the Facility Administrator on 11/4/24 at 11:31 AM identified patients who hold their site(s) following treatment should perform hand hygiene following glove removal with hand sanitizer, Further, staff should perform hand hygiene in between glove changes. Review of the Infection Control for Dialysis Facilities policy directed patients will be encouraged to perform hand hygiene after treatment, before leaving the treatment area. The policy further directs staff to perform hand hygiene prior to gloving and immediately after removal of gloves and after patient and dialysis system contact.”

“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: 47491 Based on observation and review of facility policy, the facility failed to clean and disinfect the hemodialysis station after hemodialysis treatment in accordance with facility policy. The finding included: a. Observation conducted on 11/1/24 at 10:40 AM identified Staff Person #2 cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #2 cleaned the black tubing leading to the wall box and the wall box, however had then cleaned the wall surrounding the wall box with the same cloth. b. Observation conducted on 11/5/24 at 9:40 AM identified Staff Person #3 cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #3 failed to clean and disinfect the drain lines leading from the hemodialysis machine to the wall box, the IV pole, stethoscope, Hansen hoses, and right side of the dialysis machine. c. Observation conducted on 11/5/24 at 10:22 AM identified Staff Person #2 was cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #2 failed to clean the IV pole and right side of the machine. d. Observation conducted on 11/5/24 at 10:29 AM identified Staff Person #3 was cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #3 failed to clean the IV pole, stethoscope, and left side of the machine. Review of the infection control for dialysis facilities policy directed at the end of each treatment, the dialysis station will be cleaned and disinfected. It directed the wall box, drain and watery supply lines are considered part of the dialysis delivery system. It further directed to disinfect all surfaces in touch with the patient or their belongings and surfaces frequently contacted by healthcare personnel.”

“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: 32738 Based on observation during tour on 11/05/24 at 12:30 PM, the surveyor, accompanied by the Facility Administrator, the Regional Bio Med Technician and the facilities Bio Med Technician observed conditions not meeting the requirements. The findings include the following: a) All the dirty sinks throughout the treatment floor were stained with residue and deteriorating, not providing a cleanable surface as required.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 32738 Based on information gathered during a documentation review on 11/05/24 at 10:00 AM, the surveyor was not provided documentation to show the facility is meeting fire and life safety requirements, the findings include the following: a. The surveyor was not provided with paperwork from the Facility Administrator, the Regional Bio Med Technician or the facilities Bio Med Technician to show that the fire alarm system was being maintained as required by section 21.3.4 of NFPA 101 Life Safety Code 2012 Edition. I.e., There was no documentation of a semiannual inspection completed within the past 12 months. b. The surveyor was not provided with paperwork from the Facility Administrator, the Regional Bio Med Technician or the facilities Bio Med Technician to show that the sprinkler system was being maintained as required by table 13.1.1.2 of NFPA 25, 2011 Edition. I.e., There was no documentation of a partial trip of the dry system. c. The surveyor was not provided with paperwork from the Facility Administrator, the Regional Bio Med Technician or the facilities Bio Med Technician to show that the sprinkler system was being maintained as required by section 8.3.4.4 of NFPA 25, 2011 Edition. I.e., There is no indication within the annual fire pump inspection report, that an alignment of the fire pump was completed as required. 2. Based on observation during tour on 11/05/24 at 12:30 PM, the surveyor, accompanied by the Facility Administrator, the Regional Bio Med Technician and the facilities Bio Med Technician observed conditions not meeting the requirements. The findings include the following: a) The facility did not maintain the sprinkler system as required by table 5.1.1.2 of NFPA 25, 2011 Edition. I.e, The sprinkler system gauges were stamped 2015 and 2016. b) FD #7 was being held open by a miniature refrigerator, not allowing the door to operate as designed and not meeting the requirements of section 7.2.1.8.1 of NFPA 101, 2012 Edition. c) FD #6 was being held open by a wedge, not allowing the door to operate as designed and not meeting the requirements of section 7.2.1.8.1 of NFPA 101, 2012 Edition.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 44675 47491 Based on a review of clinical records, interview, and policy review for one (1) of four (4) hemodialysis patients (Patients #4) reviewed for blood pressures, the facility failed to ensure an ambulating patient had a post treatment standing blood pressure in accordance with facility policy, and for two (2) of ten (10) patients (Patient #2 and Patient #3) failed to ensure a post-treatment weight was in excess of one (1) kilogram was addressed. The findings included the following: 1. Patient #4 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for four (4) hours, at a blood flow rate (BFR) of 400, dialysate flow rate (DFR) of 600, using a central venous catheter. Review of Patient #4’s treatment flowsheets dated 10/21/24 and 10/23/24 identified Patient #4 ambulated with a device (walker), however did not have a post-treatment standing blood pressure documented and/or the reason the post treatment standing blood pressure was not obtained documented for the dates reviewed. Interview with the Manager of Clinical Services on 11/5/24 at 2:18 PM identified staff was to obtain a post-treatment standing blood pressure for ambulatory patients, and if the patient refused, staff was to document the reason for refusal. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed to document the reason a post treatment blood pressure was not obtainable. 2. Patient #2 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes, at a blood flow rate (BFR) of 400, dialysate flow rate of 600, using a left upper arm arteriovenous fistula. Review of Patient #2’s treatment sheets identified elevated post-treatment weight of greater than one (1) kilogram on 11/1/24 (2.6 kg), 10/30/24 (2.3 kg), 10/28/24 (2.4 kg), 10/23/24 (2.4 kg), 10/21/24 (4.1 kg), 10/18/24 (2.9 kg), 10/16/24 (2.5 kg), and 10/14/24 (2.5 kg) without identifying or noting the physician was informed. 3. Patient #3 was admitted to the facility with diagnoses that included end stage renal disease. Patient #3’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 51.5 kg and blood flow rate of 450. Review of Patient #3’s care plan dated 6/27/24 identified Patient #3’s goal was to maintain post weight compared to target weight. Review of Patient #3’s hemodialysis flowsheets identified on 10/16/24 Patient #3’s post treatment weight was 1.2 kg above the prescribed target weight. Patient #3’s nursing assessment identified trace edema to Patient #3’s right and left legs. On 10/18/24 Patient #3’s post treatment weight was 1.5 kg above the prescribed target weight. Patient #3’s nursing assessment identified generalized edema and facial edema. On 11/1/24 Patient #3’s post treatment weight was 6.1 kg above the prescribed target weight. Patient #3’s nursing assessment identified generalized edema and facial edema. The treatment flowsheets failed to identify Patient #9’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. Review of Patient #3’s progress notes (for the treatment dates of 10/16/24, 10/18/24 and 11/1/24) failed to identify Patient #3’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. Interview with the Facility Administrator on 11/5/24 at 12:00 PM identified facility practice was for the nurse to inform the physician when a patient’s weight was more than one (1) kilogram over target weight after receiving treatment. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that if an abnormal finding(s) or concern is identified post treatment, it needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. The licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician is necessary prior to discharge of the patient from the facility. An abnormal fluid status post treatment was defined as when a patient is above or below 1 kg from their target weight.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of five (5) hemodialysis patients reviewed for physician visits, (Patient #1), the facility failed to ensure the patient was seen by the practitioner monthly and had a documented progress note completed in the medical record. The findings include the following: Patient #1 was admitted to the facility with diagnoses that included end stage renal disease. Patient #1’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 72 kg and blood flow rate of 400. Review of Patient #1’s treatment calendar identified Patient #1 received hemodialysis treatment in the facility on 9/2/24, 9/9/24, 9/14/24, 9/18/24, 9/23/24 and 9/30/24. Review of the progress notes for September 2024 failed to identify physician progress notes during the month of September 2024. Interview with the Clinical Services Director on 11/4/24 at 12:24 PM identified Patient #1 did not have monthly physician progress note in his/her medical record. She identified patients should be seen and documented by the physician at a minimum of monthly. She identified Patient #1 skipped hemodialysis treatment days on the days the MD and/or APRN came into the facility, but identified the practitioner should have circled back to visit Patient #1 on a day he/she was in the facility. Review of the progress note policy identified the attending nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44675 Based on observation, clinical record review, interview, and review of facility policy the facility failed to disinfect a multidose vial appropriately for medication draws, for one (1) of four (4) Patients (Patient #3), the facility failed to address an irregular vital sign pre-treatment and conduct a nursing assessment per facility policy, and administer dialysis in accordance with physician orders, (Patient #3), and for one (1) of four (4) patients (Patient #1), the facility to ensure the patient completed an against medication advice form for early termination of treatment per facility policy, The finding included: 1. Observation conducted on 11/1/24 identified Staff Person #1 drawing up heparin syringes out a multidose vial. Staff Person #1 disinfected the top of the vial once and then proceeded to draw up heparin nine times with separate syringes without the benefit of disinfecting the top of the heparin vial prior to each medication draw. Interview with the Clinical Services Specialist on 11/5/24 at 2:00 PM identified the multidose heparin vial should be disinfected prior to each medication draw. Review of the anticoagulation policy directed policies and procedures for dialysis precautions, aseptic technique and infection control will be used when administering anticoagulants. It identified aseptic technique must be used for disinfection of the stopper prior to any entry of a vial. 2. Patient #3 was admitted to the facility with diagnoses that included end stage renal disease. Patient #3’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 51.5 kg and blood flow rate of 450. Review of Patient #3’s hemodialysis flowsheet dated 10/9/24 identified Patient #3’s pre-treatment pulse collected by a PCT at 7:16 AM was 110 Beats Per Minute (BPM) while standing and 102 BPM while sitting (normal range is 60 - 100 BPM). Treatment was initiated at 7:24 AM by the PCT and Patient #3’s pulse was 102 BPM. The nursing assessment was conducted at 7:55 AM (after treatment was already initiated). Interview with the FA on 11/5/24 at 2:00 PM identified a pulse greater than 100 BPM would be an abnormal finding. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed any abnormal findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to the abnormal findings). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The abnormal findings section of the policy identified an abnormal heart rate was defined as less than 60 beats per minute or greater than 100 beats per minute. 3. Patient #1 was admitted to the facility with diagnoses that included end stage renal disease. Patient #1’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 72 kg and blood flow rate of 400. Review of Patient #1’s hemodialysis flowsheets identified the following: a. On 10/18/24 Patient #1 received 3 hours and 15 minutes of treatment (15 minutes short of the prescribed treatment time) with no documentation as to why Patient #1’s prescribed treatment time was not met and if the physician was notified. Review of Patient #1’s medical record identified no against medical advice (AMA) form was reviewed and completed. b. On 10/21/24 Patient #1 received 3 hours and 6 minutes of treatment (24 minutes short of the prescribed treatment time) with no documentation as to why Patient #1’s prescribed treatment time was not met and if the physician was notified. Review of Patient #1’s medical record identified no against medical advice form was reviewed and completed. c. On 10/25/24 Patient #1 received 3 hours and 14 minutes of treatment (16 minutes short of the prescribed treatment time) with no documentation as to why Patient #1’s prescribed treatment time was not met and if the physician was notified. Review of Patient #1’s medical record identified no against medical advice form was reviewed and completed. Review of the prescribed treatment time not met policy directed that the RN will verify that a patient signs the early termination of treatment against medical advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. Based on a review of clinical records, interview, and policy review for two (1) out of five (5) patients reviewed for hemodialysis prescriptions (Patient #3), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: 4. Patient #3 was admitted to the facility with diagnoses that included end stage renal disease. Patient #3’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 51.5 kg and blood flow rate of 450. a. Review of the treatment flowsheet dated 10/9/24 identified Patient #3 was cannulated successfully, however for the entirety of the treatment Patient #3’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. b. Observation conducted on 11/4/24 at 10:09 AM identified Patient #3 was receiving hemodialysis treatment at Station #20. Patient #3’s BFR was being administered at 400. Interview with Staff Member #4 identified Patient #3’s venous pressure was running high so the BFR was set to 400, however the flowsheet did not identify that. Review of the treatment flowsheet dated 11/4/24 identified Patient #3 was cannulated successfully, and treatment began at 7:35 AM, however for the entirety of the treatment Patient #3’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met (treatment was terminated at 10:45 AM). Subsequent to surveyor inquiry, Patient #3’s flowsheet was updated at 12:34 PM (after treatment was terminated) and identified Patient #3 had elevated venous pressures despite intervention and the BFR was 400. Interview with the Manager of Clinical Services on 11/5/24 at 2:19 PM identified facility practice was to run a treatment at the prescribed DFR and if not attainable, to document the reason for the modification. Review of the Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment policy directed if the dialysis prescription was not being met (including the dialysis flow rate or change to/inability to obtain the prescribed blood flow rate) the reason would be documented. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that if the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed. 47491”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 44675 Based on review of clinical records, interviews and review of facility documents for two (2) of four (4) patients (Patient #4 and #6) reviewed for treatments, the facility failed to document the patient’s pre-treatment assessment within one hour of treatment initiation .The findings included: 1. Patient #4 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for four (4) hours, at a blood flow rate (BFR) of 400, dialysate flow rate (DFR) of 600, using a central venous catheter. Review of Patient #4’s treatment records identified the following: a. On 10/16/24, Patient #4’s treatment was initiated at 10:00 AM, however the pre-treatment assessment was not documented until 11:27 AM. 2. Patient #6 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for four (4) hours, at a blood flow rate (BFR) of 400, dialysate flow rate of 600, using a left upper arm arteriovenous fistula. Review of Patient #6’s treatment records identified the following: a. On 11/1/24, Patient #6’s treatment was initiated at 10:27 AM, however the pre-treatment assessment was not documented until 12:00 PM. Interview with the Manager of Clinical Services on 11/5/24 at 11:43 AM identified pre-treatment assessments should be entered within one (1) hour of treatment initiation. Review of the Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy directed the prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation with the nursing assessment or as allowable by state law.”