Davita Temple Terrace 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 the staff followed infection control precautions for four of eight sampled patients (#9, #10, #11, #12) during observation of accessing a Central Venous Catheter (CVC) for initiation of dialysis, during observation of one discontinuing CVC post dialysis and two during access of the AV (Arteriovenous) fistula initiating dialysis. Findings included: 1. On 08/29/2024 at 9:30 a.m. Patient #9 was observed with Staff E, Patient Care Technician (PCT), Staff E was discontinuing her CVC post dialysis. Staff E removed her gloves, applied gloves and opened supplies at bedside. She removed her gloves and replaced her gloves, cleaned the port and flushed the port. Staff E was observed removing her gloves, inputting into the computer system and re-applying her gloves. She cleaned the second port and flushed the second port. She removed her gloves and inputted into the computer system, obtained the patient’s temperature, inputted into the computer again and then re-applied her gloves. She inputted into the dialysis machine (DM). Staff E removed her gloves, inputted into the computer system, re-applied her gloves and inputted into the DM again. She removed her gloves and applied her gloves. She removed her gloves and re-applied and moved to another station. She came back to Patient #9’s station, removed her gloves and hand sanitized. 2. On 08/29/2024 at 9:50 a.m. Staff E, PCT was observed with Patient #10, accessing his AV fistula. Staff E was inputting into the computer system. She applied her gloves, inputted into the dialysis machine (DM), removed her gloves, inputted into the computer system, applied her gloves, opened supplies onto the patient’s table. Staff E moved the patient’s clothing and placed a mask on the patient. She placed the drape under his arm and cleaned the arm. She removed her gloves and replaced her gloves. She put the footrest up for his legs. She removed her gloves and left the patient area, to retrieve a stethoscope. She put her gloves on and checked for the bruit and thrill. She placed the uncleaned stethoscope on the hook on the dialysis machine. She removed her gloves and replaced her gloves and removed her gloves again and inputted into the computer system. Staff E left the station and retrieved supplies, came back to the station, left the station again and retrieved a paper and brought it back to the station. She placed it on the patient’s bedside table. She inputted into the computer system, applied gloves, inputted into the DM. She cleaned the AV site, took her gloves off and replaced her gloves. She moved the stethoscope. She removed her gloves and replaced her gloves and accessed the site, obtained blood for labs. She accessed the second site. She removed her gloves, applied her gloves, inputted into the DM, and finished hooking the patient up to the DM. 3. On 08/29/2024 at 10:15 a.m. Staff E, PCT was observed with Patient #11, accessing her AV fistula. Staff E was across the floor / room with gloves in her hand. She applied the gloves, touched the Dialysis machine (DM), and applied the blood pressure cuff to the patient’s arm. She removed her gloves and applied her gloves. She opened the supplies. She used a stethoscope to check the bruit and thrill. She hooked the stethoscope on the DM. She cleaned the patient’s arm then disinfected the arm. She removed her gloves and applied her gloves. She cleaned the stethoscope. She removed her gloves, hand sanitized, inputted into the computer system and applied one glove. She inputted into the DM, removed her glove and inputted into the computer system. She took the patient’s temperature, inputted into the computer system. She put on her gloves, inputted into the DM, removed her gloves and hand sanitized. She went and retrieved supplies and a paper and placed on the clean field of the patient’s. she hand sanitized, put on her gloves and took her gloves off again. She went to the supply drawer again. She hand sanitized and applied her gloves. She accessed one AV site and obtained blood for labs. She accessed the second site. The nurse administered heparin for the patient. Staff E removed her gloves and hand sanitized. 4. On 08/29/2024 at 10:48 a.m. Staff E, PCT was observed removing her gloves, applying gloves and inputting into a DM at Station 17. She removed her gloves and applied her gloves and inputted into a DM at Station 17. She removed her gloves and applied her gloves and inputted into the DM at Station 20. She removed her gloves and retrieved supplies and re-applied her gloves. She discontinued the AV Fistula dialysis at Station 20. Throughout the procedure she did not hand sanitize. 5. On 08/29/2024 at 9:55 a.m. Staff D, PCT was observed initiating a CVC for dialysis for Patient #12. Staff D removed her gloves and applied her gloves and placed the blood pressure cuff on the right lower extremity of the patient. She handed the patient the remote. She removed her gloves and inputted into the computer system. She replaced her gloves and inputted into the Dialysis machine (DM). She removed her gloves, hand sanitized, inputted into the computer system and replaced her gloves. She inputted into the DM, removed her gloves and hand sanitized. She replaced her gloves and touched her face shield with her gloved hands. She opened the supplies, his gown and draped the patient. She removed the gauze covering the ports. She removed her gloves, hand sanitized and replaced her gloves. She removed the gauze from the CVC exit site, cleaned the ports with disinfectant, then cleaned the CVC exit site. She circled from the outside of the site toward the inside of the port site. She removed her gloves, hand sanitized and re-gloved. She covered the CVC exit site with gauze. She removed her gloves and re-gloved and moved to the next station (21) to input into the DM. Staff D removed her gloves, hand sanitized and re-gloved. She cleaned one port of Patient #12 and withdrew blood into a syringe and performed the same on the second port. She removed her gloves, hand sanitized, re-gloved and moved back to station 21 again to input into that DM. She moved back to Patient #12’s station and removed her gloves and re-gloved, inputted into the DM and finished hooking Patient #12 to the DM. During an interview on 08/30/2024 at 11:20 a.m. Facility Administrator (FA) and MCS/ LPN (Manager of Clinical Services / Licensed Practical Nurse) stated the staff was to hand sanitize between one patient to another, from the computer system to the patient, from the keyboard (DM) to the patient, during changing of gloves. Any time they move from a dirty process to a clean process. They are to change gloves and hand sanitize after removing dirty dressings. They are to change gloves and hand sanitize between glove changes. The staff was to hand sanitize before and after the use of the computer system. Review of the facility’s policy, “Infection Control for Dialysis Facilities,” revised April 2023 showed the purpose to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Hand Hygiene: All teammates, physicians and non-physician will perform hand hygiene A. Upon entering and exiting the patient treatment area, B. prior to gloving and immediately after removal of gloves, C. After contamination with blood or other infectious material, D. After patient and dialysis delivery system contact, 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: 7. A. Gloves should be changed when: i. when soiled with blood, dialysate or other body fluids; 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; iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. 14. Nondisposable items are to be disinfected after each patient use, prior to removal from treatment area slash station and contaminated between uses if item cannot be cleaned and disinfected it will be dedicated for use on a single patient. A. Stethoscopes will be disinfected with alcohol prep pad and/or 1: 100 bleach solution and if they are visibly contaminated with blood or body fluids should be disinfected with the one to 10 bleach solution. 15. The chair side cart, terminals mounted on the counter, monitor and keyboards are considered clean areas.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 34768 Based on interview and record review the facility failed to achieve and sustain the prescribed dose of dialysis to meet the prescribed Dialysate Flow Rate (DFR) for three of eight sampled patients ( #4, #6, #8) and Blood Flow Rate (BFR) for four of eight sampled patients (#1, #4, #6, #8). Findings included: 1. Review of Patient #1 showed she was admitted to the facility on 02/07/2019 to receive dialysis three times a week with an AV (Arteriovenous) fistula. Review of the physician orders revealed a BFR of 350 ml / min. On 08/28/2024 the BFR was documented at 300 ml/min for 6 of 7 assessments. The record lacked documentation for the reason for the BFR not following orders. 2. Review of Patient #4 showed she was admitted to the facility on 03/09/2021 to receive dialysis three times a week with an AV (Arteriovenous) graft. Review of the physician orders revealed a DFR of 800 ml (milliliter)/ min (minute) and a BFR of 450 ml / min. On 08/16/2024 the DFR was documented at 810 ml/min for 5 of 6 assessments and 730 ml/min for 1 of 6 assessments. On 08/16/2024 the BFR was documented at 200 ml/min for 4 of 6 assessments, 100 ml/min for 1 of 6 assessments and 400 ml/min for 1 of 6 assessments. The record lacked documentation for the reason for the BFR and DFR not following orders. During an interview on 08/30/2024 at 11:20 a.m. the Facility Administrator (FA) and Manager of Clinical Services (MCS) reviewed, verified and stated if the BFR and / or DFR did not match the the physician prescription documentation should be present stating why it did not match and the MD had approved the change. They verified both Patient #1 and #4 lacked the documentation. 20536 3. Review of Patient #8’s medical record revealed he was admitted to the facility on 1/9/2024 with a primary diagnosis of End Stage Renal Disease. Review of the IDT Patient Profile Worksheet to include Treatment Orders, and dated 8/26/2024, revealed the Patient’s BFR flow rate is to be at 450 ml/min, and the DFR flow rate is to be at 800 ml/min. Review of the Treatment Details Report dated 8/28/2024, under the events comments, revealed at 07:00, Patient #8’s DFR = 690, which was 110 ml/min out from the ordered range of 800. Further review of the Details report did not indicate any progress notes that reflected the reason of the out from range flow rate, nor what was done about it. Review of the Treatment Details Report dated 8/19/2024, under the events comments, revealed at 07:56, Patient #8’s DFR = 200, which was 250 ml/min out from the ordered range of 450. Also, the DFR = 680, which was 120 ml/min out from the ordered range of 800. Further review of the Details report did not indicate any progress notes that reflected the reason of the out from range flow rate, nor what was done about it. Review of the Treatment Details Report dated 8/16/2024, under the events comments, revealed at 08:37, Patient #8’s BFR = 250, which was 200 ml/min out from the ordered range of 450. At 08:19, Patient #8’s BFR = 250 ml/min, which was 200 ml/min out from range from the ordered 450. At 07:19, Patient #8’s DFR = 610 ml/min, which was 190 ml/min out from range from the ordered 800. Further review of the Details report did not indicate any progress notes that reflected the reason of the out from range flow rate, nor what was done about it. 4. Review of Patient #6’s medical record revealed she was admitted to the facility on 8/20/2024 with a primary diagnosis of End Stage Renal Disease. Review of the IDT Patient Profile Worksheet to include Treatment Orders, and dated 8/29/2024, revealed the Patient’s BFR flow rate is to be at 350 ml/min, and the DFR flow rate is to be at 400 ml/min. Review of the Treatment Details Report dated 8/20/2024, under the events comments, revealed at 07:52, Patient #6’s BFR = 200, which was 150 ml/min out of range from the ordered 350. Further review of the Details report did not indicate any progress notes that reflected the reason of the out from range flow rate, nor what was done about it. On 8/30/2024 at 1:00 p.m. an interview with the Facility Administrator (FA) confirmed the out from range BFR and DVR values relate to Patient’s #8 and #6. She revealed there should have been notes to reflect these ranges as well as notes to show what was done about it. Review of the facility’s policy, “Pre-Entra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2024 showed the purpose to obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patients dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 2. The nursing assessment will be performed and documented by a licensed nurse. Iii. The assessment includes the following components: Verification of prescription including machine parameters 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. Prescription components include but are not necessarily limited to: f. blood flow rate g. dialysate flow rate. INTRADIALYTIC DATA COLLECTION ASSESSMENT: 9 B. At a minimum, obtain and document the following: III. blood and dialysate flows, arterial and venous pressures. 10. If the dialysis prescription is not being met (including dialysis flow rate or change to / inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 11. Abnormal findings are findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. 12. The licensed nurse notifies the physician as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record.”