Davita Savannah Riverside at Home

“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: 49321 Based on observation, a review of facility policy, review of the Centers for Disease Control and Prevention (CDC) Recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that two of two Registered Nurses [RN AA and Peritoneal Dialysis (PD) Nurse) and one of one Rounding Physician (RP AA) observed, performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves, when going from a “dirty” task to a “clean” task, after touching contaminated equipment, after patient contact, and before exiting the treatment room. Failure to perform infection control techniques such as hand hygiene, increased the risk for cross contamination with the potential to expose patients and staff to bloodborne pathogens in the dialysis environment. This deficient practice had the potential to negatively affect 78 in-center hemodialysis patients who dialyzed at this facility. Findings include: During observation in the Patient Treatment Room on 7/10/24 between 10:15 a.m. and 2:30 p.m., the following was revealed: - RN AA was observed inserting a fistula needle on a patient at Station (S) 15, then she removed her right hand glove, walked to the clean supply drawer and obtained a needle. She then put another glove on her right hand and inserted the second fistula needle. RN AA did not perform hand hygiene after glove removal and prior to obtaining a needle from the clean supply drawer. - While RN AA was entering data in the computer (clean task) at S 15, the dialysis machine sounded an alarm. RN AA answered the alarm and touched the machine (dirty task) without wearing gloves. When finished, she resumed entering data in the computer. RN AA did not perform hand hygiene when going from a “dirty” task to a “clean” task. - The PD Nurse silenced a dialysis machine alarm at S4 with no gloves on. - While RN AA was documenting on the computer which was located between S9 and S10, the dialysis machine at S10 sounded an alarm. RN AA obtained a glove, did not wear the glove but covered her right index finger with it, and then touched the machine/silenced the alarm, and discarded the glove. RN AA then went back to the computer and entered data in the computer without performing hand hygiene. - RP AA made rounds in the Patient Treatment Room with his hand-held computer. He touched the treatment chair at S2, went to S3 and shook hands with a patient, proceeded to S6 and touched the dialysis machine, then exited the treatment floor. RP AA did not perform hand hygiene after touching a treatment chair and dialysis machine; before and after contact with a patient; and before exiting the treatment floor. - A review of the facility’s Policy #1-05-01 titled, “Infection Control for Dialysis Facilities” with latest revision date of April 2023 stated: Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene: b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal ... During an interview on 7/10/24 at approximately 2:45 p.m., the Group Facility Aministrator stated that everyone working or rounding in the treatment floor is aware of the importance of properly wearing gloves and washing their hands.”

“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: 49321 Based on observation, staff interview, and a review of the Food and Drug Administration (FDA) Guidelines, it was determined that one of one Charge Nurse, who was responsible for checking medications’ expiration date, failed to ensure expired antibiotics (medicines that fight bacterial infections) were discarded and not made available for use. This deficient practice had the potential to negativly effect 78 patients who were under the care of this facility. Findings include: During a tour of the treatment room on 7/10/24 at 10:15 a.m., it was revealed that: - One box of Cefazolin (16 vials/1gram each) for intramuscular or intravenous use expired on 6/2024. - One box of Cefazolin (25 vials/1gram each) for intramuscular or intravenous use expired on 6/2024. The Group Facility Administrator confirmed the above findings on 7/10/24 at 10:20 a.m. , and stated “I do not know how they missed this”. According to FDA, certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illness and antibiotic resistance.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 49321 Based on observation, patient and staff interviews, and a review of facility policy, it was determined that the facility failed to ensure that one of four direct patient care staff [Clinical Coordinator/Charge Nurse (CN)] observed, treated one of one patient (P#1) who requested early termination of dialysis, with respect and dignity. Findings were: During observation in the Patient Treatment Room on 7/10/24 between 10:15 a.m. and 2:30 p.m., the following was revealed: -As this surveyor was escorted to the treament area by the Group Facility Administrator (GFA), the CN yelled out accross the treatment floor to the GFA and stated “The nurses are quiting and soon you will be looking for a Clinical Coordinator”. - P#1, who was seated at Station (S) 7 complained that her right arm was hurting real bad. The CN walked over and with an abrupt loud voice said to P#1 “What is wrong with you? Your arm is always hurting. You need to get it checked out! I am going to get an AMA (Against Medical Advise) form and you better sign it! You need to go to the doctor. You do this every treatment. I am going to put you on third shift.” - P#1 was interviewed on 7/10/24 at 11:30 a.m. When asked if the CN always speaks to her in the same manner and tone, P#1 stated “It’s alright; she is always like this”. - The CN also addressed Registered Nurse (RN) AA, who was accross the treatment floor. With a loud voice, the CN stated “What are you doing? Hurry up. The patient is waiting”. During an interview on 7/10/24 at 12:00 p.m., Direct Patient Care Staff EE stated “I have never worked in an enviroment like this. The CN is rude, very loud, and do not know how to talk to staff or patients.” The CN was interviewed on 7/10/24 at 2:00 p.m. When asked about yelling accross the treatment floor, she stated “Yes I do. I am just a loud person”. And when asked about her tone and manner, she stated “This is just how I talk”. During a telephone interview with P#2 on 7/11/24 at 5:30 p.m., he stated that nurse (referring to CN) is terrible. She does mean things like not answering my dialysis machine when it is alarming. She threatened to put me on the third shift because I had to get off the machine early one day due to family obligation. She is always hollering across the treatment floor and she used to yell curse words accross the treatment floor. I have learned to stay out of her way. During an interview on 7/10/24 at approximately 3:00 p.m., the GFA stated “She is loud and I have spoken to her about that.” A review of Policy: 3-01-07A titled, “Patient’s Rights” with the latest revision date of October 2021 stated: Your Rights as a Patient: 3. To be treated with respect, dignity, and recognition of my individuality, choices strenghts, abilities, cultrural values, religious beliefs and personal needs, to the extent possible during treatment; and sensitivity to my psychological needs and ability to cope with ESRD (End Stage Renal Disease). 5. To be free from abuse, neglect... 6. To receive adequate, safe, sanitary, and efficient dialysis treatment and respectful care by competent personnel in a comfortable enviroment. 30. To be informed about and participate, if desired, in all aspects of my individualized plan of care and be informed of the right to refuse treatment and to be fully informed of the medical consequences of refusing treatment/appointment..”