Davita Benton Dialysis

“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: 49741 A. Based on observation, document review, and interview, it was determined the facility failed to ensure infection prevention and control measures were followed to prevent the potential for cross contamination. Findings include: 1. On 8/27/25 at approximately 11:20 AM, an observational tour was conducted of the dialysis facility. The CCHT (Certified Clinical Hemodialysis Technician) (E#4) failed to remove gown prior to leaving treatment area and entering the water room to complete a water test. (E#4) also failed to change to new gown upon returning to the treatment area. 2. On 8/27/25 at 2:00 PM, the policy titled, “Infection Control for Dialysis Facilities (Revised April 2023)” was reviewed. The policy stated, “PPE (Personal Protective Equipment) (i.e,, gowns, gloves, eye protection, face shield) ... PPE is to be: a. Removed prior to leaving the treatment area.” 3. On 8/27/25 at 12:45 PM, an interview was conducted with the Facility Administrator (E#1) and Manager of Clinical Services (E#2). (E#1) and (E#2) observed and verbally agreed that staff should be removing gowns before leaving treatment area, and then a new gown should be applied once returning to treatment area. B. Based on observation, policy review, and interview, it was determined that the Dialysis Facility failed to ensure all inventory of patient care supplies was discarded when they expired. Findings include: 1. A tour of the treatment and storage areas was completed on 8/27/25 between 10:30 AM and 11:30 AM. During the tour, the following supplies were found to be outdated and were available for patient use. a. Six 3M Performance Respirator Masks had expired. The manufacturer’s expiration date was 11/24. b. Forty Low Dead Space Syringes had expired. The manufacturer’s expiration date was 7/31/25. c. One sterile packaged male luer (fitting) lock adapter tubing set with a broken seal. 2. The Facility policy “Infection Control for Dialysis Facilities” (revised April 2023) was reviewed. It indicated, “ ... Supplies ... b. Expiration date and package integrity will be verified prior to use ... d. Anytime the integrity of a package with or without an expiration date is in question, i.e. (for example), torn, ripped, wet or contaminated, the package and it contents must be disposed of an not used. 3. On 8/27//2025 at approximately 1:15 PM, an interview was conducted with the Manager of Clinical Services (E#2). (E#2) observed and verbally agreed that the supplies should be disposed of and not available for patient use. C. Based on observation, document review, and interview it was determined the Dialysis Facility failed to ensure prepared bleach solution was labeled per policy. Findings include: 1. During a tour of the Dialysis Facility conducted on 08/27/25 at 10:41 AM, three containers of bleach solution were observed on the counters of the treatment floor without being labeled with staff initials, expiration/date, or time. 2. The Facility policy titled, “Preparation of One to One Hundred (1:100) Bleach Solution” was reviewed. It indicated, “ ... 12 ... With indelible marking pen and label, label container with expiration date, time, and initials. The solution is good for 24 hours only. The solution must be changed when the maximum allowable time is exceeded (24 hours) or when the solution becomes cloudy or turbid.” 3. On 08/27/25 at 11:18 AM, an interview was conducted with the Certified Clinical Hemodialysis Technician. (E#5) observed the three containers of bleach solution and verbally agreed they should be labeled with the initials, time, and expiration date by the staff who prepared the solution.”

“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: 49741 Based on document review, observation, and interview, it was determined that the facility failed to ensure that supplies were stored off the floor to prevent contamination. Findings included: 1. On 8/27/25 at 11:25 AM, an observational tour was conducted in the water room. Seven empty plastic acid containers were observed directly on the floor. 2. On 8/27/25, a document titled, “Physical Environment (Revised April 2018)” was reviewed. It noted, “10. ... Supplies will not be stored directly on the floor but stored on shelves or pallets if allowable per specific state or local codes.” 3. On 8/27/25 at 11:00 AM, an interview was conducted with the Manager of Clinical Services (E#2), who observed items and verbally agreed that the containers should be off the floor, and on shelves or pallets.”

“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: 39025 Based on observation, document review, and interview it was determined the Dialysis Facility failed to ensure prepared syringes of medications were labeled per policy. Findings include: 1. During a tour of the Dialysis Facility conducted on 08/27/25 at 10:41 AM, twelve syringes of heparin labeled for patients (Pt#6, Pt#7, Pt#8, Pt#9) were observed laying on the medication counter in the treatment room. The syringes were not labeled with staff initials, date, or time. 2. The Facility “Medication Policy” (Revised October 2023) was reviewed. It indicated “... 20 ... If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication ...” 3. On 08/27/25 at 10:45 AM, an interview was conducted with the Registered Nurse. (RN - E#3) observed the twelve heparin syringes and verbally agreed they should be labeled with the initials and time of who drew up the medication as listed in the policy.”