Davita New Britain Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, facility policy and interviews, the facility failed to provide a clean and sanitary environment. The findings include: During the tour of the facility on 7/8/24 at 9:30 AM the following were identified: a. The medication room contained brown dried splatter throughout the wall and cabinets. There was a box of gloves and two boxes of syringes next to sink in the splash zone area. b. In the biomedical office there were cardboard boxes on the floor that contained of laboratory supplies. c. At Station #16, the hemodialysis chair contained a rip in the back of the chair exposing the contents inside. A piece of tape was placed over the rip. d. The clean sink on the treatment floor contained built up brown crusted substance. Interview with the FA and Clinical Director on 7/10/24 at 11:30 AM identified the medication room needed to be cleaned and that there should not be any supplies next the sink. The Clinical Director identified there should not be any supplies stored on the floor and that they would be given a designated storage room. The Clinical Director identified any rips in hemodialysis chairs need to removed from the treatment floor immediately due to the infection control risks. Review of the infection control for dialysis facilities policy directed that the policy’s purpose is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. It identified supplies will be stored in a manner that maintains their integrity. Clean supplies or equipment will not be placed adjacent to a sink unless a splash guard is in place.”

“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 facility policy, the facility failed to ensure that hand hygiene was performed by the patient prior to leaving the treatment floor in accordance with facility policy. The findings included: Observation on 7/9/24 at 10:10 AM identified Staff Person #3 failed to offer Patient #13 hand sanitizer following the removal of his/her glove after holding his/her access site. Patient #13 was further observed leaving his/her dialysis station, proceeding to the weigh station to obtain his/her weight and failed to perform hand hygiene at the weigh station and prior to exiting the clinic. Interview with Staff Person #3 identified patient’s were to perform hand hygiene following glove remove after holding their access. The infection control policy identified hand hygiene is required after glove removal and prior to exiting the treatment floor.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 47491 Based on observations, review of clinical records, and facility policy for one (1) of four (4) patients observed during the initiation of hemodialysis treatment, the facility failed to ensure proper infection control practices were maintained in accordance with facility policy. The findings include: Patient #12 had diagnoses that included end stage renal disease, and a physician’s order for hemodialysis three times weekly, for three (3) hours and thirty (30) minutes per treatment through a Central Venous Catheter (CVC), utilizing a 2.0 potassium/2.0 calcium bath, run at a blood flow rate of 400 milliliters per minute, and a dialysate flow rate of 500 milliliters per minute. Observation on 7/9/24 at 9:47 AM identified Staff Person #2 discontinuing Patient #12’s hemodialysis treatment. During disconnection of the arterial line from the patient’s access, Patient #12’s face mask failed to cover his/her nose and during disconnection of the venous line from the patient’s access, Patient #12’s mask failed to cover both his/her nose and mouth. Interview with Staff Person #2 on 7/9/24 at 10:05 AM identified the face mask should fully cover the patient’s face during disconnection of both arterial and venous lines from the patient’s CVC. Review of the CVC procedure directs the teammate and patient to wear masks covering the nose and mouth throughout the treatment discontinuation process.”

“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 a facility tour on 07/08/24 at 09:30 AM the surveyor, while accompanied by the Bio Med Technician, observed the facility failed to maintain a safe functional environment. The findings include the following: On July 8, 2024, at 9:30 AM, it was observed that the walls in the office and the treatment floor had unfinished drywall and peeling wallpaper, not providing a clean and sanitary surface. On July 8, 2024, at 9:30 AM, it was observed that the cove base molding was damaged and the walls were stained at Station # 20 on the treatment floor, not providing a clean and sanitary surface. On July 8, 2024, at 9:30 AM, it was observed that the cove base at Station #8 on the treatment floor was damaged, not providing a clean and sanitary surface.”

“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 document review on 07/08/24 at 10:00 AM the surveyor was not provided with documentation from the Bio Med Technician to indicate compliance with the Life Safety Code requirements for fire drills. The findings include the following: On July 8, 2024, at 10:00 AM documentation was not provided to indicate fire drills were conducted in the 1st quarter for the 1st, 2nd, and 3rd shift in 2024 and the 4th quarter for the 1st, 2nd, and 3rd shift in 2023.”

“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 a review of clinical records, interview, and policy review for one (3) of five (5) hemodialysis patients reviewed for blood pressure (Patient #1, 4, and 7), the facility failed to ensure an ambulating patient had a standing blood pressure and pulse pre and post hemodialysis treatment per facility policy and for one (1) of three (3) hemodialysis patients reviewed for weights (Patient #6), the facility failed to address the patient not meeting the prescribed target weight in the medical record. The findings include the following: 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, 3 K 3 Ca dialysate and an estimated dry weight (EDW) of 75.5 kilograms (kg). Review of Patient #4’s hemodialysis flowsheets identified on 6/19/24, 6/24/24, 6/26/24, 6/28/24, 7/1/24, 7/3/24, 7/5/24 and 7/8/24 Patient #4 ambulated with a walker and did not have a pre and post standing blood pressure and/or the reason why a standing blood pressure was not obtained. Review of the flowsheet dated 6/21/24 identified Patient #4 ambulated with a walker and did not have a post standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. 2. Patient #1 had diagnoses that included end stage renal disease, an arteriovenous fistula in the left upper arm, and physician’s orders for hemodialysis treatment three times weekly for three hours and forty-five minutes, utilizing a 2.0 potassium/3.0 calcium acid bath, a blood flow rate of 400 milliliters per minute, a dialysate flow rate of 600 milliliters per minute. Review of Patient #1’s dialysis treatment report dated 5/31/24, 6/3/24, 6/17/24, and 6/26/24 failed to identify standing post-treatment blood pressures for a patient who ambulates without assistance. 3. Patient #7 had diagnoses that included end stage renal disease, an arteriovenous fistula in the left upper arm, and physician’s orders for hemodialysis treatment three times weekly for three hours, utilizing a 2.0 potassium/2.0 calcium acid bath, a blood flow rate of 450 milliliters per minute, a dialysate flow rate of 500 milliliters per minute. Review of Patient #1’s dialysis treatment report dated 6/7/24, 6/21/24, and 7/3/24 failed to identify standing post-treatment blood pressures for a patient who ambulates without assistance. Interview with the Clinical Coordinator on 7/9/24 at 12:48 PM identified standing post treatment blood pressures should be obtained for patients that ambulate either with or without a walker, and if the patient refused, the staff was to document the refusal and inform the clinical coordinator so that he/she could address it. Review of the Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy indicated staff would obtain and document basic data (which includes both sitting and standing blood pressures) on each patient and compare to pre-treatment findings. 4. Patient #6 was admitted to the clinic with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right Central Venous Catheter (CVC) and an estimated dry weight (EDW) of 137 kg. The annual stable care plan dated 2/1/24 identified Patient #6’s blood pressure and fluid management goal was to maintain post weight compared to target weight. Review of Patient #6’s hemodialysis treatment sheets identified the following: a. On 6/21/24 Patient #6’s post weight was 140 kg (3 kg above prescribed EDW). The nursing assessment identified Patient #6 had bilateral +1 ankle edema (swelling caused due to excess fluid accumulation in the body tissue). Review of the clinical record failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. b. On 6/24/24 Patient #6’s post weight was 142.9 kg (5.9 kg above prescribed EDW). Review of the nursing notes failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. c. On 6/26/24 Patient #6’s post weight was 141.4 kg (4.4 kg above prescribed EDW). The nursing assessment identified Patient #6 had facial edema. Review of the nursing notes failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. d. On 6/28/24 Patient #6’s post weight was 138.3 kg (1.3 kg above prescribed EDW). The nursing assessment identified Patient #6 had generalized edema. Review of the nursing notes failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. e. On 7/5/24 Patient #6’s post weight was 138.6 kg (1.6 kg above prescribed EDW). The nursing assessment identified Patient #6 had diminished upper left and upper right lung sounds. Review of the nursing notes failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. f. On 7/8/24 Patient #6’s post weight was 139.3 kg (2.3 kg above prescribed EDW). The nursing assessment identified Patient #6 had facial edema and diminished upper and lower left and upper and lower right lung sounds. Review of the nursing notes failed to identify Patient #6’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed if an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. 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. Abnormal findings for fluid status post treatment is if a patient is above 1 kg from the target weight.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 44675 Based on review of clinical records, interview, and policy review for two (2) of five (5) hemodialysis patients reviewed for treatment adherence (Patient #5 and #6), the facility failed to ensure a patient whose albumin was not in range was placed on the Oral Nutrition Supplement (ONS) protocol and given nutritional supplement as appropriate. The findings include the following: 1) Patient #6 was admitted to the facility with diagnoses that included end stage renal disease. Patient #6’s physician orders included hemodialysis treatment three (3) times a week for four (4) hours, 2.0 K 2.5 Ca dialysate, and an estimated dry weight (EDW) of 137 kilograms. Review of Patient #6’s hemodialysis protocols identified Patient #6 was on the ONS protocol from 10/2/23 through 1/27/24 and was then discontinued. Review of Patient #6’s albumin (protein found in blood) labs identified Patient #6’s albumin was 3.5 on 1/19/23 (goal 3.5 and greater) and 3.3 on 2/21/24. A Registered Dietitian note dated 2/26/24 identified Patient #6’s albumin was low at 3.3 and to continue on the ONS protocol (however, Patient #6 was not currently on the ONS protocol). Review of Patient #6’s albumin labs identified on 3/20/24 the albumin was 3.3. A Registered Dietician note dated 3/29/24 identified Patient #6’s albumin was low at 3.3. She identified the ONS protocol was discontinued by mistake and was re-ordered. Review of Patient #6’s hemodialysis protocols identified the ONS protocol was initiated on 3/29/24. The physician’s order dated 4/16/24 directed one serving of ONS every treatment for malnutrition (approximately two months after Patient #6’s albumin decreased below 3.5). Interview with the Dietician on 7/10/24 at 10:40 AM identified she was unaware as to why Patient #6’s ONS protocol was discontinued on 1/27/24. She identified patients with an albumin less than 3.8 qualify for the ONS supplement (unless they refuse). She identified Patient #6 should have been on the ONS protocol and supplement order for the albumin of 3.3 on 2/21/24. 2) Patient #5 was admitted to the facility on 4/11/24 and had diagnoses that included end stage renal disease, an arteriovenous fistula in the left forearm, and physician’s orders for hemodialysis treatment three (3) times weekly for three (3) and a half hours, utilizing a 2.0 potassium/2.5 calcium acid bath, a blood flow rate of 450 milliliters per minute, a dialysate flow rate of 700 milliliters per minute. Review of Patient #5’s monthly labs identified albumin levels of 3.1 on 4/11/24, 3.2 on 5/23/24, and 3.3 on 6/25/24. Review of Patient #5’s clinical record failed to identify any administration of protein supplementation or notation of refusal of protein supplementation from the facility. Interview the Registered Dietician on 7/9/24 at 11:10 AM identified Patient #5 had low albumin levels following admission to the facility to date, and that patients were to be offered protein supplementation from the dialysis facility if their albumin levels fell below 3.8 grams per deciliter. The Registered Dietician further identified the dietician at Patient #5’s skilled nursing facility had informed him/her that Patient #5 was not receptive to taking protein supplements, and because of this, had not approached Patient #5 with protein supplementation options at any time since admission to the facility. Review of the oral nutrition supplement (ONS) protocol identified the optimal goal for albumin is 4.0 or greater and the minimum standard is 3.5 or greater. It further identified the initiation of provision of oral nutrition supplement is determined by the patient meeting an albumin less than 3.8.”

“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, interviews, and facility documentation for one (1) of three (3) patients reviewed for vaccinations, (Resident #5), the facility failed to ensure a resident was screened for tuberculosis in accordance with facility policy, for one (1) of three (3) patients (Patient #1) reviewed for anemia the facility failed to conduct monthly blood work, and the facility failed to ensure multiuse medication bottles were labeled with the date when the bottle was opened and the initials of the staff member who opened the bottle. The findings included: 1. Patient #5 was admitted to the facility on 4/11/24 and had diagnoses that included end stage renal disease, an arteriovenous fistula in the left forearm, and physician’s orders for hemodialysis treatment three times weekly for three (3) and a half hours, utilizing a 2.0 potassium/2.5 calcium acid bath, a blood flow rate of 450 milliliters per minute, a dialysate flow rate of 700 milliliters per minute. Review of Patient #5’s Vaccination Surveillance Report identified the patient was administered his/her first Tuberculine Screen Test (TST) upon admission to the facility (on 4/11/24), but did not have the result of the TST read due to absentism. The Vaccination Surveillance Report further identified the next time Patient #5 was administered his/her TST was on 6/18/24 (68 days after being admitted to the facility.) Review of the Treatment Details Report identified Patient #5 received dialysis treatment at the facility on 5/4/24, 5/7/24, 5/9/24, 5/11/24, 5/14/24, 5/16/24, 5/18/24, 5/21/24, 5/23/24, 5/25/24, 5/28/24, 5/30/24, 6/1/24, 6/4/24, 6/6/24, 6/8/24, 6/11/24, 6/13/24, and 6/15/24. Interview with the Clinical Coordinator on 7/9/24 at 11:44 AM identified the facility missed reading Patient #5’s TST result due to absentism, and was unable to administer another TST during the month of April 2024 due to excessive absentism, and had missed the opportunity to administer and read the TST during May 2024 as Patient #5 had received several dialysis treatments during that month. The Clinical Coordinator further indicated facility policy was to administer the initial TST shortly after a patient is admitted to the facility and then the second TST three weeks after the initial. Review of the Tuberculosis Infection Control policy directed to administer two TST’s upon admission to the facility, the first as soon as possible and the second one to three weeks after the first. 2. Patient #1 had diagnoses that included end stage renal disease, an arteriovenous fistula in the left upper arm, and physician’s orders for hemodialysis treatment three times weekly for three hours and forty-five minutes, utilizing a 2.0 potassium/3.0 calcium acid bath, a blood flow rate of 400 milliliters per minute, a dialysate flow rate of 600 milliliters per minute. Physician’s orders dated March 1, 2024 directed for monthly and bimonthly hemoglobin draws. Review of Patient #1’s monthly lab results indicated a hemoglobin level of 9.6 on 2/21/24, but failed to indicate any hemoglobin results for the month of March 2024. The next hemoglobin result that was 7.1 on 4/5/24 (a 2.5 point drop from results obtained on 2/21/24.) Review of Patient #1’s dialysis treatment report identified attendance and received treatments on 3/1/24, 3/4/24, 3/13/24, and 3/29/24. Interview with the Clinical Coordinator on 7/9/24 at 11:31 AM indicated Patient #1 had hemoglobin labs drawn on 3/29/24, but due to transit issues the specimen became non-viable and the lab was unable to perform the test(s) ordered. The Clinical Coordinator further indicated Patient #1 frequently skips treatment appointments and the facility attempts to have labs drawn when the patient is in attendance, however had missed the opportunity to draw the patient’s labs when he/she was receiving his/her dialysis treatment. The Clinical Coordinator indicated it was facility practice to follow physician’s orders. 4. During the tour of the facility on 7/8/24 at 9:30 AM the following medications were observed open without the date it was opened and staff member who opened the bottles: a. Two bottle of Cinacalcet 60 mg b. One bottle of Cinacalcet 90 mg c. One bottle of Cinacalcet 30 mg d. One bottle of Calcitriol 0.5 mg Interview with the Clinical Director on 7/10/24 at 11:30 AM identified multiuse medication bottles should be dated when opened and initialed by the staff member who opened the bottles.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 47491 Based on observations and interviews for one patient, (Patient #14), during the initial tour of the facility, the facility failed to keep a patient’s personal health information in a secured area. The findings included: Patient #14’s skilled nursing facilities communication book, which included the patient’s name, residence, date of service, vitals, birth date, age, medicaid number, diagnoses, and list current medications, was located on a shelf in the entry way of the isolation room which did not have a door lock. Interview with the Clinical Coordinator on 7/8/24 at 11:45 AM identified the patient had nor been treated at the facility in a few years, further all patient’s personal health information should be maintained in a locked room and not easily accessible. Although the facility was unable to provide a personal health information policy, the Facility Administrator indicated on 7/10/24 at 11:02 AM that staff were educated annually on the importance of keeping patient’s personal health information private and secured.”