Davita Iris 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: 50244 Based on observation, a review of facility policy and procedure, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of three Patient Care Technicians (PCT DD), one of two Registered Nurses (RN BB), and one of one Licensed Practical Nurse (LPN KK) observed, performed hand hygiene (washed hands or used an alcohol based hand sanitizer) after removal of contaminated gloves. This failure increased the risk for cross contamination with the potential to expose all staff and 100 patients who dialyzed at this facility, to blood borne pathogens in the dialysis environment. Findings include: During observation in the Patient Treatment Room on 3/12/2024 from 10:00 a.m. through 12:30 p.m., the following was revealed: - At 9:45 a.m., LPN KK left Station (S) 9, removed her contaminated gloves, but did not perform hand hygiene before donning clean gloves to disconnect Patient #36’s dialysis bloodlines. - At 10:32 a.m., RN BB did not perform hand hygiene after removal of contaminated gloves. RN BB then obtained clean supplies from the clean supply drawer and donned clean gloves without performing hand hygiene between glove changes. - At 10:36 a.m., RN BB repeated this same breach in infection control by not performing hand hygiene between glove changes at S22. At 10:34 a.m., PCT DD did not perform hand hygiene after removal of contaminated gloves, then proceeded to obtain clean supplies from the clean supply drawer. PCT DD did not perform hand hygiene between glove changes. - A review of facility Policy: 1-05-01, titled “Infection Control for Dialysis Facilities” with latest revision date of dated April 2023, stated: “All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene prior to and immediately after removal of gloves”. These findings were discussed with the Regional Director of Operations at approximately 1:00 p.m. on 3/12/2024.”

“QAPI-INDICATOR-NUTRITIONAL STATUS CFR(s): 494.110(a)(2)(ii) The program must include, but not be limited to, the following: (ii) Nutritional status. This Standard is not met as evidenced by: 50244 Based on a review of the fiscal year (FY) 2024 Quarterly Dialysis Facility Report (QDFR: A report prepared for ESRD facilities from the Centers for Medicare and Medicaid Services (CMS), to provide a comparative summary of treatment patterns and patient outcomes for End Stage Renal Disease patients, as compared to other facilities in the U.S.), Quality Assessment and Performance Improvement (QAPI) meeting minutes, and staff interviews, it was determined that this facility failed to develop, implement and evaluate a plan to trend and analyze the Serum Albumin (simple protein found in the blood) outcomes of Peritoneal Dialysis (PD) patients for six of six months (September 2023 - February 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of the 14 PD patients who were under the care of this facility. Findings include: A review of the facility’s FY 2024 QDFR and QAPI meeting minutes for six months (September 2023 - February 2024), revealed the following: - The facility’s FY 2024 QDFR revealed that PD patients who had Serum Albumin <4.0 g/dL was 75.0 %, whereas the US average for PD was 50.5 %. The facility’s monthly Serum Albumin outcomes for PD patients from September 2023 - February 2024, were as follows: September 2023 - 82 % of patients had Serum Albumin <4.0 g/dL October 2023 - 80 % of patients had Serum Albumin <4.0 g/dL November 2023 - 89.7 % of patients had Serum Albumin <4.0 g/dL December 2023 - 62 % of patients had Serum Albumin <4.0 g/dL January 2024 - 75 % of patients had Serum Albumin <4.0 g/dL February 2024 - 89% of patients had Serum Albumin <4.0 g/dL - A review of the facility’s QAPI meeting minutes from September 2023 - February 2024, revealed a lack of documentation of the facility’s action plans for low albumin outcomes and lack of evidence of the evaluation of the effectiveness of the Action Plans. - These findings were discussed with the PD training nurse on 3/13/2024 at 3:45 p. m. She acknowledged the findings and stated that some patients were currently receiving Intradialytic Parenteral Nutrition (IDPN) and she added that processes were ongoing to qualify additional patients for this nutrition therapy. - The Medical Director also acknowledged these findings on 3/14/2024 at approximately 11:00 a.m.”