Davita Preserve Point 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: 35966 Based on observation, staff interview and policy review, the facility failed to follow infection control practices during Central Venous Catheter (CVC) Exit Site Care and Initiation of Dialysis with Central Venous Catheter for two of two observations on 3/11/24 (Patient #1, Patient #5); failed to follow infection control practices when using computer keyboard between patient stations for one observation; failed to follow infection control practices when cleaning the hemodialysis machine for one observation; and failed to follow infection control practices when preparing the hemodialysis machine for one observation. The findings include: 1. During an observation of CVC Exit Site Care for Patient #5 at Station 16 on 3/11/24 at 10:00 AM, Staff C removed the old dressing, removed her gloves, and discarded the dressing and gloves into a waste bin. Staff C then put on clean gloves before performing hand hygiene. Staff C cleaned the area around the CVC exit site with antiseptic, applied a sterile dressing, and removed her gloves. Staff C then began the Initiation of Dialysis with a CVC by donning new gloves without performing hand hygiene, and began disinfecting the CVC hubs. During the interview with Staff C on 3/11/24 at 10:25 AM, it was confirmed that she had forgotten to perform hand hygiene before putting on new gloves. 2. During an observation of CVC Exit Site Care for Patient #1 at Station 5 on 3/11/24 at 10:35 AM, Staff D removed the old dressing and discarded the dressing into a waste bin. Staff D then cleaned the area around the CVC exit site with antiseptic and applied a sterile dressing. Staff D began the Initiation of Dialysis with a CVC by disinfecting the CVC hubs, flushed the ports with saline, and initiated treatment without changing gloves or performing hand hygiene. Staff D then proceeded to use the computer keyboard located between stations which accesses the patient’s electronic medical record while wearing the gloves used during the CVC Exit Site Care and Initiation of Dialysis. During the interview with Staff D on 3/11/24 at 10:40 AM, it was confirmed that the keyboard is a clean area and he did not take his gloves off. He stated he did not change his gloves while taking care of Patient #1 because his hands “get too sweaty” and “It’s too hard to change the gloves as often as I should.” 3. During an observation of Cleaning and Disinfection of the Dialysis Machine on 3/11/24 at 10:16 AM at Station 3, Staff D was cleaning the hemodialysis machine when Patient #10 needed assistance with his pants. Staff D stopped cleaning the machine and assisted the patient with the drawstring on his pants. Staff D continued to clean the dialysis machine without changing gloves and performing hand hygiene. 4. During an observation of Preparation of the Hemodialysis Machine at Station 4 on 3/13/24 at 10:45 AM, Staff D was asked by Staff A for supply assistance at Station 3. Staff D paused the preparation of the hemodialysis machine, walked to the supply area and opened a drawer for gauze, handed the gauze to Staff A, and continued to prepare the machine without removing gloves and performing hand hygiene. The facility policy titled “Infection Control for Dialysis Facilities” revised on April 2023 states “All teammates, Physicians and Non-Physician will perform hand hygiene upon entering and exiting the patient treatment area, prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, after interacting with wall boxes, between patients even if contact is causal, before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” The policy continues to state “Gloves should be changed when soiled with blood, dialysate or other body fluids, when going from “dirty” area or task to “clean” area or task, when removing from a contaminated body site to a clean body site of the same patient and, 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.” The facility policy/procedure titled “Central Venous Catheter (CVC) with Clearguard HD antimicrobial end caps procedure” states, “3. Place patient in comfortable supine position, as tolerated. Verify patient’s clothing is secured away from the exit site/work area. Place the second moisture proof barrier under catheter limbs. Instruct patient to turn head to opposite side of CVC exit site. 4. Remove old dressing and discard. 5. Observe site for signs and symptoms of infection such as redness, drainage, swelling or tenderness. If present, report to RN/physician. 6. Verify that both arterial and venous catheter limbs are clamped. 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove.” An interview with the Facility Administrator on 3/11/24 at 1:00 PM confirmed that hand hygiene is to be performed after every glove change. An interview with the Facility Administrator and Manager of Clinical Services on 3/13/24 at 11:00 AM confirmed glove change and hand hygiene is to be performed when moving between clean and dirty areas. .”

“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: 35966 Based on observations, interviews and review of the facility’s parenteral medication preparation policies and procedures, the facility failed to label nine Heparin syringes with time of preparation (time the medication was drawn into syringe), label the 9 syringes with the nurse’s initials who prepared the medication, and failed to store the prepared syringes at the nurse’s station. Six syringes were left unattended on a counter adjacent to the nurse’s station. The counter is in a highly traveled area and can be accessed by patients and visitors. One heparin syringe was observed on the chairside table at Station 5 with no patient seated to receive dialysis treatment. One heparin syringe was observed on the counter across from Station 5. One heparin syringe was observed on the chairside table at Station 16 with no patient seated to received dialysis treatment. The findings include: On 3/11/24 at approximately 9:40 AM, an observation was made of six syringes labeled as Heparin on the open counter adjacent to the nurse’s station. The syringes were observed to have a pre-printed label that included the medication name, dosage and date. The labels had two spaces to indicate the time the medication was prepared and a space for the nurse’s initials who prepared the medication. The two spaces were left blank. The syringes were out on the open counter, accessible to patients and visitors. On 3/11/24 at approximately 9:45 AM, an observation was made of 1 syringe labeled as Heparin sitting on the chairside table of Station 5. The pre-printed label did not indicate who prepared the medication or when. The patient had not arrived for dialysis treatment at this time. Across from Station 5, another syringe labeled as Heparin sat atop a copy of the patient schedule for the day. The syringe was not labeled with who prepared the medication or when. On 3/11/24 at approximately 9:50 AM, an observation was made of 1 syringe labeled as Heparin sitting on the chairside table of Station 16. The label did not indicate who prepared the medication or when. The patient had not arrived for dialysis treatment at this time. The facility’s policy: 1-06-01A, titled, Preparation and Administration of Parenteral Medications (Non-Epo, Non-Parsabiv) with all Dialyzer Types, last revised October 2023 states, “Label the syringe with the patient’s name, name of the prescribed medication, dose, date, time, and initials of licensed teammate preparing the dose. Preprinted labels may be used if available. Distribute the medication to the patient station in an aseptic manner.” During an interview with the Facility Administrator and the Manager of Clinical Services on 3/11/24 at 11:00 AM, it was confirmed the medications must be initialed and include a time of preparation. It was also stated that medications must not be brought to the treatment station prior to the patient arriving for treatment and that medications are to be kept at the nurse’s station when they are not being administered. .”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 35966 Based on observation and staff interview, the facility failed to keep a common supply cart with medical supplies away from patient treatment stations. The findings include: On 3/11/24 at 10:00 AM, Staff #A was observed rolling a medical supply cart to treatment station #16 to provide care to a patient. The supply cart was a black square plastic cart with wheels that had a box of gloves, straws, cups, water, and stethoscope. An interview with the Facility Administrator at 11:00 am on 3/11/24 confirmed that a common supply cart should not be rolled to patient stations. The facility policy titled “Preparation and Administration of Parenteral Medicals (Non-epo, Non-Parsabiv) with all dialyzer types” revised October 2023 states, “Rolling medication carts must not be used to dispense or administer medications”. .”

“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: 35966 Based on observation, staff interview, and policy review, the facility failed to ensure that patients had vacated the dialysis station before initiating disinfection of the dialysis machine; the facility failed to disinfect the prime waste containers at two (#2, #4) stations; failed to change sanitation cloths between the cleaning of the hemodialysis machine and the treatment chair for two (#2, #4) stations; and failed to disinfect the treatment chair surfaces, to include the open-sides and inclined-surface of the chairs for two (#2, #4) stations. The findings include: 1. During an observation conducted on 3/11/24 beginning at approximately 9:20 AM, Patient Care Technician (PCT) B, disinfected the hemodialysis machine at station 11 and prepared it for the next patient. This was completed while a patient remained in the dialysis chair awaiting vascular access hemostasis (stopping the flow of blood). PCT B moved on to disinfect the dialysis machine at station 13 and prepared it for the next patient while a patient remained seated in the dialysis chair awaiting hemostasis. During an interview on 3/11/24 at 11:00 AM, the Facility Administrator confirmed that patients need to vacate the dialysis station prior to initiating disinfection of the station. The facility policy titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” revised April 2023 stated, “Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient.” The Centers for Medicare & Medicaid Services (CMS) states in memo Survey & Certification 17-32-ESRD (dated 6/2/17 and accessed 3/11/24), “The Centers for Disease Control and Prevention (CDC) has recommended that a dialysis station, in order to prevent cross contamination, be completely vacated by the previous patient before the ESRD staff may begin cleaning and disinfection of the station and set up for the next patient.” 2. (a) During observation of cleaning and disinfection of Station #2 on 3/13/24 at 10:25 AM, PCT #D began to clean the hemodialysis machine with a cloth soaked in 1:10 bleach. PCT #D did not remove or sanitize the prime waste container that was attached to the side of the hemodialysis machine. PCT #D then used the same bleach cloth to wipe down the treatment chair. PCT #D failed to open the treatment chair arms and tilt-back the reclining feature of the chair to disinfect all surfaces of the chair. (b) During observation of cleaning and disinfection of Station #4 on 3/13/24 at 10:30 AM, PCT #D began to clean the hemodialysis machine with a cloth soaked in 1:10 bleach. PCT #D did not remove or sanitize the prime waste container that was attached to the side of the hemodialysis machine. PCT #D then used the same bleach cloth to wipe down the treatment chair. PCT #D failed to open the treatment chair arms and tilt-back the reclining feature of the chair to disinfect all surfaces of the chair. The facility policy titled “Infection Control for Dialysis Facilities” revised on April 2023 states, “At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top and sides of dialysis machine; touchscreens; countertops). Priming containers are to be emptied prior to disinfection. Drain line and water supply line should not be placed with the ends in prime containers or in a position where they can drip into or contaminate the prime bucket.” An interview with the Manager of Clinical Services on 3/13/24 at 11:20 AM confirmed the prime waste container is to be removed and sanitized, the staff is to use a separate cloth on the chair and the hemodialysis machine, and the chair is to be reclined and cleaned down the sides of the seat cushion. .”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 35966 Based on observation and staff interview, the facility failed to maintain a safe environment for its patients by not ensuring the staff entrance door from the parking lot was closed and secured. The findings include: At 8:55 am on 3/11/24, an external door labeled “118” was observed with the latch unlocked. The surveyor pulled the door open and observed a hallway that lead to offices, a breakroom, supplies, and the patient treatment floor. The surveyor closed the door and entered the facility from the patient entrance. An interview with the Facility Administrator at 9:05 am on 3/11/24 confirmed the door was stuck open. The Administrator stated they had previous issues with the door that should have been repaired. The facility policy titled “Physical Environment” revised April 2018 states, “Access to patient treatment areas, water treatment system, supply storage and dialysis equipment is restricted to authorized personnel only.” .”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 35966 Based on record review and staff interview, the facility failed to follow physician orders for prescribed Blood Flow Rate (BFR) for one of four (Patient #1) sampled Hemodialysis Patients; and the facility failed to follow physician orders for prescribed Dialysate Flow Rate (DFR) for two of four (Patients #1 & #4) sampled Hemodialysis Patients. The findings include: 1. (a). Review of the hemodialysis treatment sheet record for Patient #1 dated 2/21/24 showed the BFR was changed from 400 to 305 at 12:32 PM and continued until end of treatment at 1:25 PM. The physician order for 2/21/24 showed a BFR of 400. Interview with the Manager of Clinical Services on 3/12/24 at 1:00 PM confirmed the BFR was lowered and there was no documentation indicating why it was changed. The treatment sheet record dated 3/4/24 showed the BFR was changed from 400 to 330 at 12:01 PM and continued until end of treatment at 12:56 PM. The physician order for 3/4/24 showed a BFR of 400. An interview with the Manager of Clinical Services on 3/12/24 at 1:00 PM confirmed the BFR was lowered and there was no documentation indicating why it was changed. (b). Review of the hemodialysis treatment sheet record for Patient #1 dated 3/1/24 showed a DFR of 500 at 9:41 AM and continued until end of treatment at 12:42 PM. The physician order for 3/1/24 showed a DFR of 600. An interview with the Manager of Clinical Services on 3/12/24 at 1:00 pm confirmed the DFR was set incorrectly at the beginning of treatment and there was no documentation indicating why physician orders were not followed. 2. (a). Record review of the hemodialysis treatment sheet for Patient #4 showed on 2/19/24 the patient received a DFR of 500 from the beginning of treatment at 12:00 PM until treatment ended at 2:52 PM. The hemodialysis treatment sheet dated 2/26/24 showed the patient received a DFR of 500 from the beginning of treatment at 2:17 PM until treatment ended at 5:13 PM. The hemodialysis treatment sheet dated 3/1/24 showed the patient received a DFR of 500 from the beginning of treatment at 12:02 PM until treatment ended at 2:56 PM. The physician orders for those dates showed a DFR of 600. An interview with the Manager of Clinical Services on 3/12/24 at 1:00 pm confirmed the DFR was set incorrectly for the duration of treatment with no documentation as to why the orders were not followed. .”