Davita Del Rio 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: 20536 42154 Based on policies, observations and interviews, the facility failed to minimize the potential spread of infections by not ensuring appropriate hand hygiene was performed by 1 (Staff A) of 1 staff members before and after removing gloves. Findings included: Reviewed policy and procedure titled, “Infection Control for Dialysis Facilities”, # 1-05-01 ...Hand Hygiene all teammates, Physicians and on-Physician (BPP) will perform hand hygiene ... prior to gloving and immediately after removal of gloves ...after patient and dialysis delivery system contact ... between patients even if the contact is casual, before touching clean areas such as supplies, supply cart and chairside keyboard/ mouse ... On 8/18/2025 at 8:08 a.m. Staff A, Patient Care Technician (PCT) was observed walking over to chair/station five, where Patient #8 was seated. Staff A was already observed wearing blue plastic gloves, a face shield and a face mask, and it was unknown when he donned the gloves prior to reaching chair/station five. Staff A removed a blood pressure cuff from Patient #8, then touched his (Staff A) head and the patient’s jacket and backpack while still gloved. Staff A assisted Patient #8 to the weight machine then Patient #8 left the treatment floor. Staff A had on the same gloves and had not changed them, nor washed or sanitized his hands after patient contact. On 08/18/2025 at As Patient #8 walked away, Staff A walked over to a supply cupboard that was directly across from chair/station six. He opened the cupboard doors with his gloved right hand and pulled out a box of supplies with his gloved left hand. Staff A still had not changed his gloves nor wash/sanitized his hands. He walked the supplies over to chair/station five. At 8:12 a.m., Staff A then removed both blue plastic gloves, face shield and face mask and discarded them. He then immediate grabbed two new blue plastic gloves and donned them. He did not wash/sanitize his hands prior to donning the gloves. He then walked to his computer work station positioned between chair/station five and six and proceeded to touch his keyboard while gloved. He also touched the computer screen while gloved. On 08/18/2025 at 8:13 a.m. Staff A doffed both gloves and discarded them. He then immediately took one plastic glove and did not don it. He only used the glove as a barrier between his bare fingers and touching the machine screen of station/chair number five. He then discarded the glove. Staff A then donned two more gloves and started to disinfect the machine of station/chair number five. At 8:20 a.m. Staff A removed the plastic gloves and discarded them. Staff A still did not either wash or sanitize his hands after donning/doffing plastic gloves. He was only observed to glove, de glove, and re glove. On 08/18/2025 at 8:25 a.m. Staff A was finally observed to walk over to a hand sanitizer station and sanitized his bare hands prior to re-gloving. Staff A was observed with over six glove changes after touching a patient, after touching patient belongings, after touching soiled equipment, after touching clean supply containers and after touching his head several times from 8:01 a.m. through to 8:24 a.m., without washing his hands nor sanitizing his hands. On 08/18/2025 at 8:31 a.m. after station/chair number five had been disinfected, another patient #9 was observed to walk to the chair and sat down. Staff A, already wearing gloves, touched Patient #9 with his left gloved hand and guided the patient down into the chair. Staff A doffed both plastic gloves and discarded them. On 08/18/2025 at 8:35 a.m. he donned new gloves and walked over to a supply cabinet directly across from station/chairs five and six. Staff A took out new clean supplies with his gloved hands and walked over to station/chair number five and placed the supplies on the side chair table. He then was observed to take a container with test strips and conducted a testing while still wearing the same gloves. After he took the test reading, he then doffed his gloves and discarded them. He did not wash/sanitize his hands after de gloving and re gloving. On 08/18/2025 at 8:37 a.m. Staff A donned two new gloves and touched his computer workstation/computer positioned between chair/station number five and six. After he was finished with the computer, the de gloved and donned two new gloves without first washing or sanitizing his hands. Staff A continued to provide Patient #9 with assistance with treatment set up for several minutes and doffed his gloves three more times and donned new gloves without first washing/sanitizing his hands. On 08/18/2025 at 10:12 a.m. Staff A was observed doing an exit site care for a central venous catheter (CVC) and initiating the dialysis treatment for the CVC. Staff A applied gloves and removed the old dressing from the CVC site located on the upper right chest, then removed the gloves and donned new gloves to apply a dressing to the CVC exit site. After he removed his gloves. Staff A applied new gloves and connected the patient to the dialysis machine; he then removed his gloves. Staff A hand hygiene opportunities before applying gloves and removing gloves. On 08/18/2025 at 10:32 a.m. Staff A was observed at station #7 applied gloves and removed old dressing on CVC exit site, then Staff A removed the gloves. New gloves were applied for CVC site cleaning care, and those gloves were removed. New gloves applied and Staff A applied a clean dressing on CVC site. Staff A removed his gloves and applied new gloves then went to another patient dialysis machine on station #6 to check the alarm. After checking the alarm, he returned to station # 7 and changed his gloves and attached the patient up to his dialysis machine. Staff A missed numerous areas of opportunities of hand hygiene before applying gloves and removing gloves. During an interview on 08/18/2025 at approximately 11:30 AM, the Clinical Coordinator confirmed that she spoke to Staff A after the observations were completed in regards to not doing hand hygiene.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 42154 Based on observations, and staff interviews, the facility failed to ensure the patient dialysis treatment area was free from spread of potentially infectious waste by failing to secure open acid jugs leaving the fluid open to the elements, in 3 of 3 acid jug containers (Dialysis acid jugs contain a concentrate of acid that is used to mix with bicarbonate to create dialysate) and in 2 of 16 Citrus acid jugs (Cleaning and Decalcification dialysis machines). Findings included: On 08/19/2025 at approximately 7:25 AM a flash tour was conducted of the dialysis unit. 3 unsecured dialysate jugs lids was noted at station’s # 2, #4, and #11 and 2 unsecured lids of citrus acid jugs were noted behind the dialysis machined at station # 8 and 11. On 08/19/2025 at 7:59 AM an opened half used Citrus Acid jug with no date and initials of when it was opened was noted on the clean counter. During an interview on 08/19/2025 at approximately 11:30 AM, the Regional Operations Director was shown the photo evidence of the open acid jugs. The Regional Operations Director just shook her head and wrote something down on a piece of paper. Photo evidence obtained.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 20536 Based on observations, staff interviews and facility policy review, the facility failed to ensure 8 of 8 boxes of vaccumed sealed blood collection tubes were maintained and free from expiration. Findings included: On 8/18/2025 at 7:40 a.m., the facility’s treatment floor was observed with a staff work station. Behind the staff work station is a hand washing sink with two open shelves above it. The shelves contained supplies to include unused and unopened vacutainers (vaccumed sealed blood collection tubes), as well as packages of opened vacutainers. One opened package of vacutainers with approximately a quarter of vacutainers used, revealed an expiration date of 7/31/2025. There were seven other packages unopened. Photographic evidence was taken. An interview, Patitent Care Technician (PCT) Staff A stated he was not responsible for the replacement of supplies behind the staff workstation. Staff A stated he believed the Clinical Coordinator was responsible for that. Staff A also said he does not really deal with the vacutainers; that is usually the responsibility of the nurses on the floor. During an interview on 8/18/2025 at 1:00 p.m., the Clinical Care Coordinator stated it is usually her or the Administrative Assistant (AA) responsibility to order and replace supplies within the treatment floor. She confirmed she and the AA should be reviewing all supplies for expiration dates and did not realize there were packages of Vacutainers that were opened and being used, and while expired. The Clinical Care Coordinator did not have a specific policy in relation to medical supplies that are expired.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 42154 Based on observation and interviews, the facility failed to ensure medication was dispensed and administered with aseptic techniques in 2 (heparin) of 2 medications vials. Findings included: On 08/18/2025 at 9:02 Staff B RN was observed to pick up an open heparin vial and inserted a needle syringe and withdrew medications for 6 different patients. Staff B RN opened a new Heparin vial and pulled out 3 more syringes for the patients. No antiseptic or alcohol was used to wipe the stopper prior to needle inserted. During an interview on 08/18/2025 at 9:32 AM, the Clinical Coordinator disclosed Staff B, RN said she did not use alcohol prior to pulling up the medications.”