Davita Pella Dialysis

“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: 50072 Based on policy review, observations, and interview, the facility failed to disinfect the dialysis treatment stations according to policy. The facility staff reported an in-center hemodialysis patient census of 29 at the time of the survey. Failure to disinfect dialysis treatment stations according to policy could lead to cross contamination to other patients and surfaces, potentially placing all 29 patients receiving in-center hemodialysis treatments at risk for infections or other adverse outcomes. 1. Review of the facility policy # Policy: 1-05-01, titled INFECTION CONTROL FOR DIALYSIS FACILITIES, with the latest revision date of April 2023, reads in part: DISINFECTION 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. 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, front and sides of dialysis machine; touchscreens; countertops) ... 2. Observations on 03/03/25 at 11:06 am showed Staff B completing the disinfection process at treatment station #4. Staff C failed to wipe down the TV or the TV arm. At 11:34 am, after completion of the disinfection process, a visible red spot consistent with blood, was noted on the front of the treatment chair tray table. Visible red spots and smear were noted on top of the nearby sharps container. Staff B acknowledged the spot on the chair tray table and further disinfected to remove it. 3. Observations on 03/03/25 at 12:12 pm showed Staff E completing the disinfection process at treatment station #2. Staff E failed to wipe down the TV or the TV arm located within the treatment station. 4. During an interview with Staff B on 03/03/2025 at 12:27 pm, they confirmed the TV and TV arm are included in the treatment station and supposed to be wiped down during the disinfection process. 5. During an interview with the Medical Director on 03/04/25 at 4:24 pm, they indicated “there is always room for improvement” with regards to following policies related to infection control.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 50072 Based on policy review, observations, and interviews, the facility failed to ensure staff perform CVC (Central Venous Catheter) care accordance to facility policy. Dialysis catheters provide direct access to the patient’s bloodstream. A CVC is a soft synthetic tube, inserted into a large vein in the neck, chest, or leg and has lumens/limbs that remain outside of the patient’s body to provide a vascular access for the patient’s dialysis treatment. Failure to perform CVC care in accordance with the facility’s policies and procedures could result in contaminants entering the patient’s bloodstream when staff access the catheter during initiation or discontinuation of the dialysis treatment. This could lead to infection. At the time of the survey, the facility reported an in-center hemodialysis patient census of 29. Findings for 2 of 3 discontinuation of dialysis treatments for patients with a CVC access (Staff G with Patient #5 and Staff G with Patient #7) include: 1. Review of facility procedure: 1-04-02B, titled CENTRAL VENOUS CATHETER (CVC) WITH CLEARGUARD HD ANTIMICROBIAL END CAPS PROCEDURE, updated October 2024, reads in part, Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. For disconnection process, hub scrub will be completed immediately prior to cap placement...33. Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds. Rationale: Scrubbing with alcohol reduces the risk of infection. 2. Observation during discontinuation of the patient dialysis treatment showed staff did not scrub the CVC hubs with the alcohol prep pad for the length of time specified in the facility’s written procedure. On 03/04/25 at 10:25 am, showed Staff G disconnecting Patient #5 with a CVC vascular access from their dialysis treatment. Observation showed Staff G did not scrub each CVC hub with an alcohol prep pad for 15 seconds according to policy. Staff G rotated the alcohol prep pad on the first hub for 9 seconds and the second hub for 10 seconds prior to attaching the CVC protective caps. 3. Observation during discontinuation of the patient dialysis treatment showed staff did not scrub the CVC hubs with the alcohol prep pad for the length of time specified in the facility’s written procedure. On 03/04/25 at 11:20 am, showed Staff G disconnecting Patient #7 with a CVC vascular access from their dialysis treatment. Observation showed Staff G did not scrub each CVC hub with an alcohol prep pad for 15 seconds according to policy. Staff G rotated the alcohol prep pad on the first hub for 11 seconds and the second hub for 9 seconds prior to attaching the CVC protective caps. 4. During an interview with Staff B on 03/03/25 at 12:11 pm, they indicated the scrub time using an alcohol prep pad on CVC hubs after dialysis treatment is 15 seconds. 5. During an interview with the Facility Administrator on 03/04/25 at 4:55 pm, they indicated when using an alcohol prep pad to scrub the CVC hubs post dialysis treatment, the intended scrub time is 15 seconds. They further noted facility staff were recently audited on this procedure.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 36083 Based on documents review, interviews, and observation, the facility did not ensure correct dialyzer for 1 of 4 patients observed for prescription verification (Patient #8), and dialysis flow rate (DFR) for 1 of 4 incenter hemodialysis patients’ medical records reviewed (Patient #1). The facility reported a census of 29 in-center hemodialysis patients at the time of the survey. Findings include: 1. The Policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessments” effective April 2024, directs staff members to verify patients’ prescriptions prior to the initiation of treatments. The prescription components to be verified include dialyzer make and model, and DFR. 2. On 3/3/25 at 12:10 PM, observation showed Patient #8 with an ongoing dialysis treatment and a dialyzer labeled as “Nipro Elisio 17H” at Station #7. At 12:16 PM, Patient Care Technician (PCT) C verified that Patient #8’s dialysis treatment order for dialyzer was Nipro Elisio 19H, however, PCT C also verified that Patient #8 was on treatment with Nipro Elisio 17H, contrary to the prescription. PCT C indicated staff members knew about the error when she stated, “[Registered Nurse (RN) A] told me it was the wrong dialyzer.” 3. Patient #8’s Patient Summary Report, dated 2/20/25, showed active treatment orders including a dialyzer identified as Nipro Elisio 19H. 4. On 3/4/25 at 3:40 PM, RN A stated that it had been challenging to maintain adequate dialysis for Patient #8, thus, the importance of using a bigger size dialyzer (Nipro Elisio 19H) because of its ability to clean more blood within the prescribed time. 5. Patient #1’s Patient Summary Report, dated 2/28/25, showed active treatment orders with a DFR of 800 milliliters per minute (ml/min). The document also showed a downward trend of Patient #1’s dialysis adequacy, as follows: 1.47 on 1/13/25 and 1.24 on 2/14/25. 6. Patient #1’s Treatment Details Report, dated 2/19/25, showed that the prescribed DFR was 800 ml/min. The document also showed that staff members started the treatment set-up and verified with the treatment orders, and continued intradialytic monitoring until the end of treatment. However, the document further showed that Patient #1’s treatment started on 2/19/25 at 5:19 AM and ended at 9:03 AM with the wrong DFR of 300 ml/min. 7. On 3/4/25 at 4:30 PM, the facility administrator (FA) stated staff members were expected to follow facility’s policy regarding making sure dialysis treatment orders were followed when setting up, and all throughout the duration of patients’ treatments. The FA also acknowledged the importance of following orders because patients have individual treatment orders patterned to their specific needs. The FA stated, “I am bothered that those [errors] were not caught during the second [prescription] check.””