Davita Zephyrhills 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: 34768 Based on observation, interview and record review the facility failed to ensure its staff promoted infection control precautions in relation to hand hygiene, donning and doffing of gloves between and after patient care as observed during 15 of 17 observations which included accessing patients with a Central Venous Catheters and as well as arteriovenous fistula (AVF), and equipment contact during one of two days observed, on (11/06/2023). Findings included: During an observation on 11/06/2023 at 10:45 a.m. Staff C, Patient Care Technician (PCT) was observed discontinuing dialysis from an arteriovenous (AV) fistula. She was observed making infection control breaks throughout the procedure which included a lack of hand sanitizing between glove changes. During an observation on 11/06/2023 at 10:50 a.m. Staff B, PCT was observed preparing the hemodialysis machine at station 11. She was observed making infection control breaks throughout the procedure which included the lack of hand sanitizing between glove changes. During an observation on 11/06/2023 at 10:55 a.m. Staff D, PCT was observed performing access of an AV fistula without performing a bruit check (whooshing sound heard through a stethoscope before initiating dialysis). Staff G, Registered Nurse (RN) was observed touching the electronic documentation system without hand sanitizing after removing her gloves post a medication infusion. During an observation on 11/06/2023 at 11:00 a.m. Staff B, PCT was observed cleaning and disinfecting station 11. She was observed to not perform hand sanitizing between glove changes. During an observation on 11/06/2023 at 11:105 a.m. Staff A, Registered Nurse, (RN) was observed, removing her gloves, opening a drawer, and removing tape and replacing her gloves without hand sanitizing. She then performed the initiation of dialysis through a Central Venous Catheter (CVC) and failed to consistently perform hand sanitizing and glove changes per guidelines. During an observation on 11/06/2023 at 11:10 a.m. Staff B, PCT was observed performing an initiation of dialysis through an AV Fistula. She was observed making numerous infection control breaks throughout the procedure including a lack of hand sanitizing between glove changes as well as touching the electronic documentation device without hand sanitizing before and after use and the patient’s personal items. She did not perform a bruit (whooshing sound heard through a stethoscope before initiating dialysis). Staff G, RN was observed infusing a medication while not hand sanitizing before applying gloves. During an observation on 11/06/2023 at 12:05 p.m. Staff A, RN was observed documenting on the electronic documentation system without proper hand sanitizing before and after. During an observation on 11/06/2023 at 12:45 p.m. Staff D, PCT was observed removing her gloves and touching the electronic documentation system without hand sanitizing. During an observation on 11/06/2023 at 12:45 p.m. Staff F, PCT was observed touching his mask with his gloves in place and not removing his gloves, hand sanitizing and applying new gloves before starting a CVC procedure. During an observation on 11/06/2023 at 1:00 p.m. Staff C, PCT was observed performing a discontinuation of dialysis with a CVC. She was observed making numerous infection control breaks throughout the procedure including a lack of hand sanitizing between glove changes as well as touching the electronic documentation device without hand sanitizing before and after use. During an observation on 11/06/2023 at 1:15 p.m. Staff A, RN was observed removing her gloves, and replacing her gloves without hand sanitizing. During an observation on 11/06/2023 at 1:40 p.m. Staff D, PCT was observed walking away from station 8 and moving toward the front of the treatment area after removing her gloves but had not hand sanitized. During an observation on 11/06/2023 at 1:48 p.m. Staff B, PCT was observed performing an initiation of dialysis through a Central Venous Catheter (CVC). She was observed making numerous infection control breaks throughout the procedure including the CVC exit site care. She did not consistently hand sanitize between glove changes nor before and after the use of the electronic documentation system. During an interview on 11/06/2023 at 3:00 p.m. the Director of Nursing (DON) stated that he expected his staff to always hand sanitize between glove changes. He expected them to wash their hands between patients. The staff was to wash their hands before going to another station. He stated a team performed monthly infection control audits, which had been performed by the Infection Control Manager (ICM). He stated they still have to remind the staff from time-to-time about hand sanitizing and following the policies and procedures. He stated they report infection control data at the QA meetings. He was not sure if an IP (Improvement Plan) was being performed regarding infection control or not. The staff was always to perform a bruit and thrill before accessing an AV fistula no matter what the size of the access. He stated that the staff was not to have gloves on when using the electronic documentation system. They were to hand sanitize before and after each use. Review of the facility’s policy, “Infection Control for Dialysis Facilities,” reviewed April 2023 showed to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Hand Hygiene: 1. All teammates will perform hand hygiene: a. upon entering and exiting the patient treatment areas, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis system contact, e. after interacting with wall boxes, f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chair side keyboard/mouse. PPE (Personal Protective Equipment): 7. Gloves should be changed when: ii. when going from a “dirty” area or task to a “clean” area or task, iii. when moving from a contaminated body site to a clean body site of the same patient; and Iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis deliver system. Supplies 11. Electronic thermometers and / or blood glucose meters should not be placed on potentially contaminated equipment such as dialysis delivery system. Disinfection: 12. cleaning and / or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious material and prior to returning to clean / designated area or removal from treatment area. b. Use an appropriate disinfectant such as 1:100 bleach solution for routine disinfection of environmental surfaces. 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel. c. dialysis delivery systems with computers / keyboards mounted on top, the computer and keyboard are considered “dirty” equipment.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 34768 Based on observations, staff interviews and facility policy review, the facility failed to ensure the mechanical lift was cleaned and disinfected before and after use during one of two days observed on (11/06/2023). Findings included: During an observation on 11/06/2023 at approximately 2:00 p.m. Staff B, PCT was observed using the mechanical lift to transfer a patient to his wheelchair. After the transfer she was observed pushing the lift back to where it was stored without cleaning it. At 1:35 p.m. Staff E, RN and another nurse were observed transferring a patient into his wheelchair using the mechanical lift. They had not cleaned it prior to use nor after use, Staff E, RN returned it to the storage area without cleaning it. At 1:50 p.m. Staff F, PCT and Staff H, RN were observed using the mechanical lift to transfer a patient to his wheelchair. After the use of the mechanical lift this time it was cleaned by Staff H, RN. During an interview on 11/06/2023 at 3:00 p.m. the Director of Nursing (DON) stated that two people were to assist during a mechanical lift of a patient. The lift should be cleaned between patients. The staff was also to clean the lift at the end of the day, including all the other equipment. Review of the facility’s policy, “Infection Control for Dialysis Facilities,” reviewed April 2023 showed to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Disinfection: 12. cleaning and / or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious material and prior to returning to clean / designated area or removal from treatment area. b. Use an appropriate disinfectant such as 1:100 bleach solution for routine disinfection of environmental surfaces. 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel. c. dialysis delivery systems with computers / keyboards mounted on top, the computer and keyboard are considered “dirty” equipment.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 28028 Based on review of the medical record and staff interview it was determined the facility failed to ensure staff implemented the individualized patient’s plan of care for prescription of dialysate for one (#4) of twelve patient’s sampled. Findings included: Review of the patient’s plan of care, dated 9/01/2023, revealed the patient’s treatment order for dialysate included potassium 1K. Review of the patient summary report revealed the patient’s treatment orders, dated 10/18/2023, revealed the dialysate for the first 60 minutes of treatment was for potassium 1K and then 2K for the remaining 120 minutes of treatment. Review of the patient’s treatment flowsheet reports, dated 10/24, 10/26, 10/31, and 11/02/2023, revealed no evidence staff administered the dialysate for potassium 1K for the first 60 minutes and then 2K for the remaining 120 minutes of treatment. An interview was conducted with the Manager Clinical Services (MCS) on 11/07/2023 at 12:00 PM. The MCS reviewed and confirmed the above findings.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 34768 Based on observation, staff interviews and facility policy review the facility failed to ensure the Quality Improvement Program included continuous monitoring of underperforming infection control practices, identifying the root causes and placing an action plan in place to evaluate that patient safety and clinical outcomes were at their highest level of importance for 1 of 1 QAPI programs reviewed. Findings included: Review of the facility’s policy, “Continuous Quality Improvement Program,” revised April 2021 showed to improve patient safety and outcomes including the reduction of medical errors in accordance with the Quality Assessment and Performance Improvement (QAPI) requirements in the CMS Conditions for Coverage. Policy: 7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following: Infection Control, including incidence of infection. 8. Continuous monitoring of the above indicators will be reflected in the meeting minute. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained. 9. Each action plan will be evaluated as to priority with Patient Safety and Clinical Outcomes indicators considered for the highest level of priority. During an observation on 11/06/2023 at 10:45 a.m. Staff C, Patient Care Technician (PCT) was observed discontinuing dialysis from an AV(arteriovenous) Fistula. She was observed making infection control breaks throughout the procedure which included a lack of hand sanitizing between glove changes. During an observation on 11/06/2023 at 10:50 a.m. Staff B, PCT was observed preparing the hemodialysis machine at station 11. She was observed making infection control breaks throughout the procedure which included the lack of hand sanitizing between glove changes. During an observation on 11/06/2023 at 10:55 a.m. Staff D, PCT was observed performing access of an AV fistula without performing a bruit check (whooshing sound heard through a stethoscope before initiating dialysis). Staff G, Registered Nurse (RN) was observed touching the electronic documentation system without hand sanitizing after removing her gloves post a medication infusion. During an observation on 11/06/2023 at 11:00 a.m. Staff B, PCT was observed cleaning and disinfecting station 11. She was observed to not perform hand sanitizing between glove changes. During an observation on 11/06/2023 at 11:105 a.m. Staff A, Registered Nurse, (RN) was observed, removing her gloves, opening a drawer, and removing tape and replacing her gloves without hand sanitizing. She then performed the initiation of dialysis through a Central Venous Catheter (CVC) and failed to consistently perform hand sanitizing and glove changes per guidelines. During an observation on 11/06/2023 at 11:10 a.m. Staff B, PCT was observed performing an initiation of dialysis through an AV Fistula. She was observed making numerous infection control breaks throughout the procedure including a lack of hand sanitizing between glove changes as well as touching the electronic documentation device without hand sanitizing before and after use and the patient’s personal items. She did not perform a bruit (whooshing sound heard through a stethoscope before initiating dialysis). Staff G, RN was observed infusing a medication while not hand sanitizing before applying gloves. During an observation on 11/06/2023 at 12:05 p.m. Staff A, RN was observed documenting on the electronic documentation system without proper hand sanitizing before and after. During an observation on 11/06/2023 at 12:45 p.m. Staff D, PCT was observed removing her gloves and touching the electronic documentation system without hand sanitizing. During an observation on 11/06/2023 at 12:45 p.m. Staff F, PCT was observed touching his mask with his gloves in place and not removing his gloves, hand sanitizing and applying new gloves before starting a CVC procedure. During an observation on 11/06/2023 at 1:00 p.m. Staff C, PCT was observed performing a discontinuation of dialysis with a CVC. She was observed making numerous infection control breaks throughout the procedure including a lack of hand sanitizing between glove changes as well as touching the electronic documentation device without hand sanitizing before and after use. During an observation on 11/06/2023 at 1:15 p.m. Staff A, RN was observed removing her gloves, and replacing her gloves without hand sanitizing. During an observation on 11/06/2023 at 1:40 p.m. Staff D, PCT was observed walking away from station 8 and moving toward the front of the treatment area after removing her gloves but had not hand sanitized. During an observation on 11/06/2023 at 1:48 p.m. Staff B, PCT was observed performing an initiation of dialysis through a Central Venous Catheter (CVC). She was observed making numerous infection control breaks throughout the procedure including the CVC exit site care. She did not consistently hand sanitize between glove changes nor before and after the use of the electronic documentation system. During an observation on 11/06/2023 at approximately 2:00 p.m. Staff B, PCT was observed using the mechanical lift to transfer a patient to his wheelchair. After the transfer she was observed pushing the lift back to where it was stored without cleaning it. At 1:35 p.m. Staff E, RN and another nurse were observed transferring a patient into his wheelchair using the mechanical lift. They had not cleaned it prior to use nor after use, Staff E, RN returned it to the storage area without cleaning it. At 1:50 p.m. Staff F, PCT and Staff H, RN were observed using the mechanical lift to transfer a patient to his wheelchair. After the use of the mechanical lift this time it was cleaned by Staff H, RN. During an interview on 11/06/2023 at 3:00 p.m. the Director of Nursing (DON) stated that he expected his staff to always hand sanitize between glove changes. He expected them to wash their hands between patients. The staff was to wash their hands before going to another station. He stated a team performed monthly infection control audits, which had been performed by the Infection Control Manager (ICM). He stated they still have to remind the staff from time-to-time about hand sanitizing and following the policies and procedures. He stated they report infection control data at the Quality Assurance (QA) meetings. He was not sure if an IP (Improvement Plan) was being performed regarding infection control or not. He stated that two people were to assist during a mechanical lift of a patient. The lift should be cleaned between patients. The staff was also to clean the lift at the end of the day, including all the other equipment. The staff was always to perform a bruit and thrill before accessing an AV fistula no matter what the size of the access. He stated that the staff was not to have gloves on when using the electronic documentation system. They were to hand sanitize before and after each use. During an interview on 11/07/2023 at 12:15 p.m. with the Facility Administrator (FA) and the Clinical Manager Specialist (CMS), the FA stated the Infection Control Manager (ICM) was conducting monthly monitoring of IC (Infection Control) activities of the patient care staff members. The FA stated the ICM had delegated to the “team” to conduct monitoring of the patient care staff. The FA stated the IC findings are presented monthly at the Quality Assurance (QA) meetings. The FA stated that an Infection Control IP (Improvement Plan) was initiated in February 2023 and the anticipated completion date was June 2023. Review of the QA summaries revealed the IP was completed and removed. The FA stated the ICM presented the IC audit findings for July, August, September, and October. Review of the audits revealed some improvement, but staff had not met the facility goals of 100%. Review of the QA summaries revealed the facility did not initiate a new IP in July even though the goals had not been met. The FA confirmed they did not perform a “deeper dive” into the IC breaks. The FA stated they implemented IC audits being conducted by team members being responsible for monitoring their peers. Review of the audit tool confirmed the team members were completing the audits but rarely found breaks in IC standards of care. Observations of staff IC practices, at the time of survey, identified multiple breaks in IC standards of care. The FA stated they would educate the team members based on the audit results as well as some one-on-one education. They did not review the audits to ensure they were done accurately nor that all team members were being monitored. He stated that they would monitor IC until the end of the year.”