Davita West Beach Dialysis Center

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 45827 Based on observation, facility record review and interview, the facility failed to ensure all supplies and equipment were readily avalable and present in the facility’s emergency evacuation kit. The findings include: On 11/05/2024 at approximately 3:30 PM, the facility’s emergency evacuation kit was inspected with assistance of the Facility Administrator (FA). The emergency evacuation kit whenc opared to the enclosed emergency evacuation kit checklist, did not contain a blood pressure (BP) cuff, a flashlight and only contained two of the three required face shields. On 11/05/2024 a review of the Health & Safety Policy & Procedures, Policy: 4-07-02, Emergency Evacuation Kit Checklist was completed. The policy state, “Note: Supplies for one full shift of patients; all modalities of patients. Complete the desired quantity to meet the needs of your facility. For “complete” and “not expired” indicate (Y) for criteria met and (N) for criteria not met. If not met, note corrective action.” Under the section Supply (at least one full shift): BP cuff, the desired quantity is listed at one with a yes to indicate complete; flashlight, the desired quantity is listed at one with a yes to indicate complete; PPE - face shields, the desired quantity is listed at three with a yes to indicate complete. The Emergency Evacuation Kit Checklist was dated as completed on 11/04/2024. On 11/05/2024 at approximately 3:30 PM an interview was conducted with the FA who confirmed the emergency evacuation kit did not contain a BP cuff, a flashlight and only contained two face shields. The FA further confirmed the Emergency Evacuation Kit Checklist was marked to indicate the kit should contain the BP cuff, flashlight and three face shields.”

“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: 51235 Based on observations, staff interviews and review of the facility’s policy and procedure, the facility failed to ensure that staff changed gloves and performed hand hygiene after removing an old dressing for 1 of 2 observations of central venous catheter (CVC) care. (#5) The findings include: During an observation of central venous catheter (CVC) care for patient #5, on 11/4/2024 at approximately 11:40 AM, RN (Registered Nurse) A did not remove their gloves and perform hand hygiene after removing patient #5 old CVC dressing. After removing the old CVC dressing, RN A proceeded to clean the CVC exit site with an antiseptic and applied a new dressing without performing hand hygiene or changing gloves. On 11/4/2024 at approximately 2:00 PM, RN A was interviewed. RN A confirmed he should have removed his gloves; performed hand hygiene and then donned a new pair of gloves after removing the old CVC dressing. A review of the facility’s Policy and Procedure, 1-04-02A, titled “Central Venous Catheter (CVC) with Tego Connectors or CVC end caps procedure,” under the heading “Procedure “4. Remove old dressing and discard; 5. Observe site for signs and symptoms of infection; 6. Remove gloves and discard; 7. Perform hand hygiene per procedure and re-glove”.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 45827 Based on observation, policy review and interview, the facility failed to ensure the accuracy and sensitivity while testing water for hardness due to using expired test strips. The findings include: On 11/04/2024 at approximately 9:35 AM a tour of the facility’s water room was conducted. A bottle of low-range water hardness reagent strips (used to test for total hardness in water) was observed with an expiration date of 2024/06. On 11/05/2024 a review of the facility’s Incenter Hemodialysis Policies & Procedures, Procedure: 1-18-01, Hardness Test Using RPC Water Hardness Test Strips was completed. On page one under the section titled Notes it lists, “Do not use test strips after the manufacturer expiration date which is printed on bottle.” On page one under the section Rationale, 1, it states, “Test strips must be stored and handled according to manufacturer’s instruction for proper function of the test strips.” On 11/06/2024 at approximately 11:30 AM an interview was conducted with the Facility Administrator (FA) who confirmed the expired strips were being used. The FA stated the water hardness test is completed at the end of each day and the expired test strips should not have been used to test water hardness.”