Davita Table Rock Dialysis Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 39430 Based on observation, policy review, and staff interview, it was determined the facility failed to provide a sanitary environment. This failure directly impacted 1 of 2 patients observed during CVC take off (Patient #1) and 2 of 2 designated dirty sinks, and had the potential to impact all patients, staff, and visitors utilizing the facility. This resulted in the potential cross contamination from common surfaces. Findings include: 1. A facility policy titled, “INFECTION CONTROL FOR DIALYSIS FACILITIES,” revised October 2020 stated, “Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station ... Gloves should be changed when: ... when going from a ‘dirty’ area or task to a ‘clean’ area or tasks.” This policy was not followed. Examples included: The following observations were made in the treatment area on 3/27/24 begining at 10:20 AM: - At 10:25 AM, a PCT was observed accessing the CVC port of Patient #1 when the alarm of the dialysis rang. She turned off the alarm and returned to accessing the CVC port without changing gloves or using hand sanitizing. The PCT did not sanitize hands between touching the machine and the patient. - At 10:29 AM, a PCT was observed accessing the CVC port of Patient #1 when the dialysis machine needed adjusting. She touched the machine and returned to accessing the CVC port without changing gloves or using hand sanitizing. The PCT did not sanitize hands between touching the machine and the patient. - At 10:32 AM, a PCT was observed accessing the CVC port of Patient #1 when the dialysis machine needed adjusting. She touched the machine and returned to accessing the CVC port without changing gloves or using hand sanitizing. The PCT did not sanitize hands between touching the machine and the patient. The PCT was interviewed on 3/27/24 at 10:45 AM and the observations were reviewed in her presence. She confirmed she did not perform hand hygiene between touching the dialysis machine and accessing Patient #1’s CVC. The MCS was interviewed 3/27/24 at 1:30 PM and the observations were reviewed in his presence. He confirmed the hand hygiene use was incorrect and had the ability to result in cross contamination. The facility failed to ensure PCTs used proper hand hygiene to prevent cross contamination. 2. A facility policy titled, “INFECTION CONTROL FOR DIALYSIS FACILITIES,” revised October 2020 stated, “Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Teammates will not handle ... clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled.” This policy was not followed. Examples included: The following observations were made in the treatment area on 3/25/24 beginning at 9:30 AM: - Two of 2 designated dirty sinks had a visible rust and thick black residue on the base of the tap and hot and cold handles. - Clean bleach disinfectant bottles were stored below the dirty sink. The disinfectant bottles were spotted with a white residue on the outside of the bottles. Additionally, the countertop above the sink and floor underneath the sink were covered with a white residue, dirt, and debris. - Two open patient acid bath jugs were stored beneath the dirty sinks. The above observations were reviewed and observed by the MCS and FA on 3/25/24 beginning at 2:15 PM. They confirmed the above observations, and confirmed the above areas needed to be addressed and that the open patient use acid baths should not be stored beneath a dirty sink. The facility failed to maintain a sanitary environment.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 42316 Based on record review and staff interview, it was determined the facility failed to ensure patient’s right to receive care as outlined in their POCs were upheld for 1 of 8 patients (Patient #4) whose medical records were reviewed. This resulted in patients not receiving dialysis time as prescribed. Findings included: Patient #4 was a 63 year old female admitted to the facility 1/29/24 for ICHD. Her dialysis prescription ordered a 180 minute treatment twice weekly. A review of 9 treatment records from 2/12/24 to 3/11/24 documented the following: - A treatment on 2/12/24 was shortened by 17 minutes. There was no documentation why the treatment was shortened. - A treatment on 3/01/24 was shortened by 8 minutes. There was no documentation why the treatment was shortened. - A treatment on 3/11/24 was shortened by 12 minutes. There was no documentation why the treatment was shortened. The MCS was interviewed on 3/27/24 at 1:19 PM and Patient #4’s treatment sheets were reviewed with him. He confirmed the above treatments were shortened without documentation why. The facility failed to ensure Patient #4 received her full dialysis treatments.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 39430 Based on record review and staff interview, it was determined the facility failed to ensure an initial POC was developed and implemented in a timely manner for 1 of 8 ICHD patients, (Patient #4) whose records were reviewed. This failure created the potential for the patient’s initial needs to remain unassessed and unaddressed. Findings include: Patient #4 was a 63 year old female who was admitted to the facility and began her ICHD treatments on 1/29/24. Review Patient#4’s record showed her initial ICHD POC was dated 3/22/24, 53 days after her admission to ICHD and treatments had been started. In an interview on 3/27/24 at 10:45 AM, the facility’s MCS confirmed Patient #4’s late initial POC. He stated they had implemented a new EMR for the tracking of patient POC’s and Patient #4’s initial POC was missed. Additionally, he stated the assessments had been completed however the POC was not implemented and signed by each discipline. The facility failed to ensure a timely ICHD POC was developed and implemented for Patient #4.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 42316 Based on observation, record review, and staff interview, it was determined the medical director failed to ensure policy was followed for CVC orders for 1 of 2 patients (Patient #1) whose CVC exit site care was observed. This resulted in Patient #1’s CVC being open to air without a written order from the physician. Findings included: A facility policy titled, “Central Venous Catheter (CVC) Care,” revised October 2022 stated, “Cuffed catheters with well healed exit sites may not require a dressing, per physician order, but still require examination and cleaning of exit site each treatment.” This policy was not followed. An example included: Patient #1 was a 47 year old female patient receiving incenter services since 4/10/21. She had a permanent CVC for dialysis. Observations were conducted in the treatment area on 3/25/24 beginning at 9:30 AM. Patient #1 was observed receiving treatment at station 8 via CVC. The CVC was open to air without a dressing for the duration of treatment. The floor RN was interviewed during the above observations and asked why Patient #1’s CVC was open to air without a dressing. The RN stated well established CVCs did not need a dressing if there was a physician order. Patient #1’s medical record was reviewed. There was no order for Patient #1’s CVC to be without a dressing. Patient #1’s observations and medical record were reviewed with the MCS on 3/26/24 at 1:49 PM. The MCS confirmed there was no order for the CVC to be open to air without a dressing. He confirmed there should have been an order present. The medical director failed to ensure orders were in place for Patient #1’s CVC to be open to air.”