Davita Hamden Dialysis

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 47491 Based on observations made during station disinfection, the facility failed to properly clean/disinfect a treatment station following a blood spill and failed to appropriately disinfect a treatment station between patient treatments. The findings included: 1. Observation of Station #19 on 7/22/25 at 9:22 AM identified that Staff Person #1 was noted to be cleaning up blood that had splattered onto the left side table and left inner chair arm, due to a breakthrough bleeding event, following Patient #14’s treatment. During disinfection of station #19, Staff Person #1 failed to utilize 1:10 bleach solution when cleaning the areas that were splattered with blood. Staff Person #1 further failed to remove blood from the clamps that were placed on Patient #14’s access (used to apply pressure on the access sites following needle removal) with 1:10 bleach solution before placing them into the container of 1:100 bleach solution. 2. Observation of Station #9 disinfection on 7/22/25 at 10:15 AM identified Staff Person #1 failed to clean the Hansen tubing, lines in front of the dialysis machine, remote control cage on the side of the dialysis machine, wall box, television and television arm, back counter, and outside of chair arm were not disinfected. Interview with the Manager of Clinical Services on 7/23/25 at 1:53 PM identified the process of properly disinfecting bloodied clamps was to first remove the blood from the clamps using 1:10 bleach solution, then soaking them in 1:100 bleach solution. Review of the Infection Control for Dialysis Facilities policy identified 1:10 (one to ten) bleach solution was to be used for disinfection of visible blood or gross blood spills and that after all visible blood was cleaned with the 1:10 (one to ten) bleach solution, teammates were to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean the area a second time. The policy further directed the dialysis station to be cleaned and disinfected at the end of each treatment, including all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs), frequently contacted by healthcare personnel (e.g., control panel, top, front, and sides of dialysis machine, touchscreens, and countertops, and that the wall box, drain, and water lines were considered part of the dialysis delivery system.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 44675 Based on observation, review of clinical records, interview, and policy review for two (2) of three (3) hemodialysis patients reviewed for catheter care (Patient #12 and Patient #13), the facility failed to perform catheter care per facility protocol, and administer Heparin in accordance with facility policy. The findings include the following: 1. Patient #12 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right Central Venous Catheter (CVC) and heparin Intravenous (IV) bolus of 1,000 units (blood thinner). Observation conducted on 7/22/25 at 11:12 AM identified Staff Member #3 CVC and treatment initiation at Station #14 with Patient #12. Staff Member #3 took clean gloves out of the box and placed them on the chairside table. She then put on gloves without the benefit of performing hand hygiene. She then removed and discarded the old catheter exit site dressing and proceeded to clean the catheter exit site without the benefit of removing her gloves and performing hand hygiene. She then removed her gloves and put on new gloves from the chairside table without the benefit of performing hand hygiene. She then applied a new catheter exit site dressing. She then picked up the trash from the chairside table and on the floor and removed her gloves and put on new gloves without the benefit of performing hand hygiene. She proceeded with the catheter initiation process and at 11:17 AM administered the heparin IV bolus and proceeded to initiated treatment at 11:18 AM without the benefit of waiting for the heparin to dwell for 3 - 5 minutes. 2. Patient #13 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a right central venous catheter (CVC). Observation was conducted on 7/22/25 at 11:35 AM identified Staff Member #4 performing CVC care and treatment initiation of Station #12 with Patient #13. Staff Person #4 cleaned the CVC exit site with a chlorhexidine swab. She then proceeded to apply a new catheter exit site dressing without the benefit of removing her gloves and performing hand hygiene. Review of the central venous catheter (CVC) policy directed, in part, to clean the CVC exit site with a chlorhexidine swab for a minimum of thirty seconds. Then clean each CVC limb/cap with a new large alcohol prep pad starting close to the exit site and finishing with the cap. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Place a sterile 2x2 gauze over the catheter exit site and seal the edges of gauze with tape. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Attach sterile 10 ml syringes to the arterial and venous limbs and aspirate about 5 ml from each limb. The procedure further directed to attach heparin loading dose to the venous limn, as applicable. Unclamp and gently flush back and forth 3-5 times into the catheter. It directed not to initiate dialysis for a minute of 3-5 minutes after heparin administration to allow heparin to circulate systemically. Review of the infection control for dialysis facilities policy directed all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves.”

“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 Based on clinical record review, interview and review of facility policy for two (2) of eight (8) Patients (Patient #4 and #7), reviewed for treatments, the facility failed to address irregular vital signs recorded before, during and after treatment per facility policy. The findings included: 1. Patient #4 was admitted to the facility with diagnoses that included end stage renal disease. Patient #4’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and forty-five (45) minutes, 2.0 K 3 Ca dialysate, estimated dry weight (EDW) of 98.5 kg and blood flow rate of 400. Review of Patient #4’s physician orders identified Patient #4 had no physician parameters in place for acceptable blood pressures pre/during and/or post treatment. The annual stable care plan dated 1/17/25 identified Patient #4’s goal was to maintain post weight compared to target weight and blood pressure within range. A sample review of Patient #4’s hemodialysis flowsheets identified: a. On 7/2/25 Patient #4’s treatment was initiated at 2:59 PM with a blood pressure of 91/56 (normal value 120/80). At 3:35 PM Patient #4’s blood pressure was 72/45, at 4:05 PM was 66/42 and at 4:06 PM was 74/37, all signed off by the RN, but was not documented as addressed. At 4:37 PM it was 72/55 and the RN documented that the patient was asymptomatic, alert and responsive. Patient #4’s ultrafiltration rate (fluid removed during treatment) remained on during the entire treatment. The medical record failed to identify what interventions were put into place and if the physician was notified of Patient #4’s abnormal blood pressures. b. On 7/4/25 Patient #4’s treatment was initiated at 3:01 PM with a blood pressure of 92/42. At 3:31 PM Patient #4’s blood pressure was 64/39 and the RN documented “BP monitor”. At 4:04 PM it was 68/39 and at 4:31 PM was 73/60 with no documentation that Patient #4’s blood pressure was addressed. At 6:31 PM it was 58/48, signed off by the PCT, but there was no documentation of if the licensed nurse was notified. Patient #4’s ultrafiltration rate remained on during the entire treatment. The medical record failed to identify what interventions were put into place and if the physician was notified of Patient #4’s abnormal blood pressures. c. On 7/7/25 Patient #4’s treatment was initiated at 3:03 PM with a blood pressure of 69/47 by the LPN and identified the RN was aware. However, there was no documentation that the RN addressed Patient #4’s blood pressure. At 3:32 PM it was 67/34 and at 4:02 PM was 61/37, signed off by the RN, but there was no documentation that Patient #4’s blood pressure were addressed. Patient #4’s ultrafiltration rate remained on during the entire treatment. The medical record failed to identify what interventions were put into place and if the physician was notified of Patient #4’s abnormal blood pressures. d. On 7/9/25 Patient #4’s pre-treatment blood pressure was 87/49. There was no documentation if the RN was notified and assessed the patient prior to treatment initiation. Treatment was initiated at 3:12 PM by the PCT with a blood pressure of 68/21 and failed to identify if the RN was notified. The pre-treatment nursing assessment was completed at 4:00 PM with no documentation that Patient #4’s blood pressure was addressed. Patient #4’s ultrafiltration rate remained on during the entire treatment. Patient #4’s post treatment blood pressure was 90/60 at 7:49 PM and the nursing assessment was completed at 7:50 PM with no documentation that Patient #4’s blood pressure was addressed. The medical record failed to identify if the physician was notified at Patient #4’s abnormal blood pressure post treatment and if he/she was safe for discharge. e. On 7/11/25 Patient #4’s treatment was initiated at 3:10 PM by the PCT with a blood pressure of 72/42. There was no documentation if the RN was notified and assessed the patient. At 3:52 PM the blood pressure was 79/43 by the LPN and identified the RN was aware. However, there was no documentation that the RN addressed Patient #4’s blood pressure. At 4:02 PM it was 81/50 documented by the PCT and failed to identify if the RN was notified. Patient #4’s ultrafiltration rate remained on during the entire treatment. f. On 7/18/25 Patient #4’s treatment was initiated at 3:28 PM by the PCT with a blood pressure of 51/41 and failed to identify if the RN was notified. Review of Patient #7’s nursing progress notes for July 2025, failed to identify that Patient #4’s low blood pressure during treatment and/or post treatment were addressed. Interview and record review with the Clinical Coordinator on 7/22/24 at 11:28 AM identified Patient #4 had baseline low blood pressures. She identified Patient #4 did not have patient specific physician order parameters for acceptable blood pressures during treatment. She identified she had discussed Patient #4’s blood pressures with the physician but did not have any orders in yet for physician approved blood pressures. 2. Patient #7 had diagnoses that included end stage renal disease. Physician’s orders directed to hemodialysis three (3) times weekly for four (4) hours each treatment, at a blood flow rate (BFR) of 450, dialysate flow rate (DFR) of 800, using a 2.0 potassium / 2.5 calcium dialysate and left forearm arteriovenous fistula. Review of Patient #7’s 7/17/25 treatment record identified a seated blood pre-treatment blood pressure of 197/103 and pre-treatment standing blood pressure of 209/109, and failed to identify if Patient #7’s hypertension was addressed and/or if the physician was notified. Interview with the Clinical Coordinator on 7/23/25 at 2:00 PM identified abnormal blood pressures were to be reported to the registered nurse, rechecked, and if abnormal blood pressures continued, the charge nurse and/or physician were to be informed. Review of the pre-intra-post treatment data collection and assessment policy directed pre-treatment any abnormal findings or 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. The nurse will assess the patient prior to discharge. During treatment, abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. All findings, interventions and patient response will be documented in the patient’s medical record. Post treatment, if any abnormal findings or concerns are identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Abnormal findings were for blood pressure were identified as pre-treatment systolic less than 90 and/or diastolic less than 50, during treatment systolic less than 90 and/or diastolic less than 50 and post treatment sitting blood pressure systolic less than 90 and/or diastolic less than 50. 47491”

“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: 47491 Based on review of clinical records, observation, and review of facility documentation and policy for one (1) of three (3) patients (Patient #7) observed during treatment initiation, the facility failed to allow the proper amount of time between pre-treatment heparin administration and treatment initiation in accordance with facility policy, for three (3) of four (4) patient (Patient #7, #15, and #16), the facility failed to ensure cannulation sites (where the needles are inserted into the patient’s access), were cleaned in accordance with facility policy, and during a flash tour, the facility failed to dispose of expired supplies. The findings included: 1. Patient #7 had diagnoses that included end stage renal disease. Review of physician’s orders directed treatments three(3) times weekly for four (4) hours per treatment, utilizing a left forearm Arteriovenous Fistula (AVF). Observation on 7/23/25 at 11:44 AM identified Staff Person #2 infusing 3000 units of heparin (blood thinner) into Patient #7’s venous line (tubing attached to the needle inserted into Patient #7’s access) prior to treatment initiation. At 11:45 AM, Staff Person #2 connected the lines from the dialysis machine to Patient #7’s access, one (1) minute after infusing the heparin bolus, and initiated Patient #7’s treatment. Interview with the Clinical Coordinator on 7/23/25 at 1:59 PM identified staff was to allow five (5) minutes between the time heparin was administered pre-treatment and the time that treatment was initiated. Review of the AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose policy directs to not initiate dialysis treatment for a minimum of three (3) to five (5) minutes after administering the heparin loading dose. 2. Patient #15 had diagnoses that included end stage renal disease. Review of physician’s orders directed treatments three (3) times weekly for three (3) hours and thirty (30) minutes per treatment, utilizing a right upper arm AVF. Observation on 7/23/25 at 11:05 AM identified Staff Person #3 preparing Patient #15’s access for cannulation. Staff Person #3 applied an alcohol prep pad to the patient’s access and while using circular motion, cleansed the access, starting on the actual cannulation site, then moved outward, away from the cannulation site. However, Staff Person #3, while using the same alcohol prep pad, again directly cleansed the access cannulation site, cross contaminating the area. Staff Person #3 utilized the same technique and practice for the second cannulation site as well. 3. Patient #7 had diagnoses that included ESRD. Review of physician’s orders directed treatments three times weekly for four (4) hours per treatment, utilizing a left forearm AVF. Observation on 7/23/25 at 11:41 AM identified Staff Person #2 preparing Patient #7’s access for cannulation. Staff Person #2 applied an alcohol pad and cleansed Patient #7’s access in a vertical motion, wiping the skin on both sides of the patient’s access, then applied a new alcohol prep pad to Patient #7’s access and wiped it vertically for a maximum of five (5) seconds. 4. Patient #16 had diagnoses that included ESRD. Review of physician’s orders directed treatments three (3) times weekly for four (4) hours and fifteen (15) minutes per treatment, utilizing a left upper arm arteriovenous fistula. Observation on 7/23/25 at 11:55 AM identified Staff Person #3 preparing Patient #16’s access for cannulation. Staff Person #3 applied an alcohol prep pad to the patient’s access and while using circular motion, cleansed the access, starting on the actual cannulation site, then moved outward, away from the cannulation site. However, Staff Person #3, while using the same alcohol prep pad, scrubbed the skin on the sides of Patient #16’s access and then directly cleansed the access cannulation site again. Staff Person #3 utilized the same technique and practice for the second cannulation site as well. Interview with the Clinical Coordinator on 7/23/25 at 1:59 PM identified staff was to clean each cannulation site for fifteen (15) seconds utilizing new alcohol prep pads and proper technique on each site. Review of the AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose policy directs the use of at least four (4) alcohol prep pads per site for an effective contact time of sixty (60) seconds, an air drying time of fifteen (15) seconds, and while maintaining aseptic technique to cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and to allow area to dry. 5. During a flash tour of the facility on 7/21/25, the following was identified: a. Twenty-four (24) one (1) milliliter low dead space syringes with an expiration date of 10/31/23. b. Three (3) one (1) milliliter low dead space syringes with an expiration date of 9/30/24. Interview with the Clinical Coordinator on 7/21/25 at 9:18 AM identified expired supplies should be disposed of no later than the expiration date on the package.”