Davita Davie City 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: 40153 Based on observations, interviews, and chart review, the facility failed to ensure proper hand hygiene during initiation of dialysis with a central venous catheter (CVC) for 1 of 5 patients observed (Patient #7). The findings included: A chart review revealed Patient #7 was admitted to the facility on 03/28/2025 for in-center hemodialysis. In an observation conducted on 07/30/25 at 10:55 AM, Staff B, Patient Care Technician (PCT), was at station #11 performing initiation of dialysis via CVC for Patient #7. Staff B performed hand hygiene, placed a pair of clean gloves, touched his face mask, and proceeded to touch Patient #7 ’ s access site. He removed his gloves, cleaned his hands, touched the computer keyboard, and then touched Patient #7 ’ s access site without hand hygiene. In an interview conducted on 07/31/25 at 2:30 PM with the facility ’ s Administrator, she was made aware of the findings.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 40153 Based on observations, interviews, and chart review, the facility failed to ensure medications were not left unattended at the chairside during dialysis treatments for 1 of 5 patients observed ( Patient #6). The findings included: A chart review revealed Patient #6 was admitted to the facility on 11/08/2024 for in-center hemodialysis. In an observation conducted on 07/30/25 at 10:47 AM, Patient #6 was seated at Station #9 waiting on staff to connect her to the dialysis machine. Closer observation revealed two syringes of Heparin medication at the chairside with no staff in attendance. In an interview conducted on 07/31/25 at 2:30 PM with the facility ’ s Administrator, she was made aware of the findings.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 40153 Based on observations and interviews, the facility failed to maintain the integrity of all surfaces (must be intact, clean, and free of damage) during 1 of 1 tour of the main dialysis treatment room. The findings included: In an observation conducted on 07/30/2025 at 10:09 AM in the main dialysis treatment room the following was observed: 1. The cabinet under the clean sink was noted with debris and a bottle of cleaning detergent. 2. The cabinet under the clean sink was noted with debris, signs, and decorations. 3. The refrigerator in the medication room was noted with an internal temperature of 50 degrees Fahrenheit, not the necessary 40 degrees Fahrenheit or below. In an interview conducted on 07/31/25 at 2:30 PM with the facility ’ s Administrator, she was made aware of the findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47207 Based on policy review, medical record reviews and interviews, the facility failed to provide an appropriate dialysis treatment for Patient (P 3) during 3 treatments between 6/28/25 and 7/28/25. The findings included: On 7/31/2025 at around 10 30 AM a medical record review was being completed for Patient (P3). The Treatment Details Report for the patient indicates a Blood Flow Rate (BFR) of 450 mL/min and a Dialysis Flow Rate (DFR) of 800.00 mL/min. On dates 7/23/25, 7/21/25 and 7/14/25 the BFR was noted to be at (350), (200-350), and (350-400) respectively. During the interview with Staff A on 7/30/25 around 1220 PM, she stated that the nurse has a 30-minute window to correct the treatment at the beginning of the shift. A review of Policy 1-03-08 Titled Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment the follow sections; “INTRADIALYTIC DATA COLLECTION/ASSESSMENT 8. The licensed nurse will round on those patients without abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes b. At a minimum, obtain and document the following: i. Blood Pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ...” The treatment records have no documentation providing a rationale for the different BFR settings on those treatment days. The physician prescribed BFR documented for treatment was BFR 450.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 40153 Based on interviews and record review, the facility failed to ensure that a monthly unstable care plan was completed for 1 of 4 hemodialysis patients (Patient #2). The findings included: A record review revealed that Patient #2 was admitted to the facility on 09/22/2024 for in-house hemodialysis. An unstable care plan was completed on 02/24/25 by the multidisciplinary team. The next unstable care plan was done on 04/02/2025, and no other unstable care plans were noted after 04/02/2025. Further record review revealed that a stable care plan was completed on 07/16/2025. In an interview conducted on 07/31/25 at 2:30 PM with the facility ’ s Administrator, she was made aware of the findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 47207 Based on policy review, medical record review, and interviews, the facility failed to have Patients P2 and P3 sign their plans of care. The findings included: A review of 4 medical records, including care plans, was completed. Two of the 4 patients, (P 2 and P 3) reviewed did not have patient signatures on the care plans. Review of the Policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care Policy 1-14-01 Oct 2024. “14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and by signed by team members including the patient of the patient’s personal representative If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was no provided.” P 3 initiated dialysis March 1, 2020. His previous Plane of Care was completed and signed June 28, 2024, by staff and patient. The most recent Plan of Care was signed by staff on 6/28/2025 had no signature from the patient. When staff were asked on 7/30/2025 between 1:30 and 2:30 PM they responded that the patient has been in the hospital. A review of the patient treatment records indicated the patient had been present in the facility on 7/02/2025, 7/04/2025, 7/06/2025. 40153 2. A record review revealed that Patient #2 was admitted to the facility on 09/22/2024 for in-center hemodialysis. An unstable care plan dated 04/02/25 did not have Patient #2 ’ s signature noted in the care plan. In an interview conducted on 07/31/25 at 2:20 PM with the facility ’ s Administrator, she was made aware of the findings.”