Davita Hazel Crest Renal Center

“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: 37971 Based on document review, observation, and interview, it was determined that for 1 (E #2) of 3 Patient Care Technicians (PCTs) observed for infection control practices while cleaning the dialysis stations, the facility failed to ensure staff removedl of soiled gloves and hand hygiene prior to proceeding to new task. Findings include: 1. On 02/06/2024 the facility’s policy titled, “Infecton Control For Dialysis Facilities” (dated 04/2023), was reviewed and required, “...All teammates ...perform hand hygiene ...after dialysis delivery system contact ...disposable gloves should be changed when going from a “dirty” area or task to a “clean” area or task ...after touching dialysis delivery system ...and prior to touching another patient’s dialysis delivery system ...” 2. On 02/06/2024 between 9:00 AM - 11:45 AM, an observational tour of the dialysis treatment area was conducted. At approximately 10:30 AM, the PCT (E#2) disinfected the dialysis machine at station #5 and with the same dirty gloves (E #2) went to grab more disinfectant wipes and dipped the dirty gloves into the bleach solution and continued to clean the dialysis chair. At approximately 10:32 AM, (E #2) with the same dirty gloves removed the dirty disposable sheet from the dialysis chair at station #6. At approximately 10:33 AM (E #2) went with the same dirty gloves grabbed more wipes, dipped into the bleach solution and walked towards station #6 and started cleaning with dialysis machine. 3. On 02/06/2024 at approximately 10:45 AM, the PCT (E #2) was interviewed. E #2 stated that (E #2) thought that it was ok to dip dirty gloves into the bleach solution. 4. On 02/06/2024 at approximatley 10:50 AM, the Charge Nurse (E #3) was interviewed. E#3 stated that the dirty gloves should have been removed before grabbing more wipes and the PCT should not have dipped the dirty gloves into the bleach solution.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 37971 Based on document review, observation, and interview, it was determined that for 1 of 3 Patient Care Technicians (PCT) (E #2) observed while in the treatment area, the facility failed to ensure that the staff followed infection control practices and prevent cross-contamination as required. Findings include: 1. On 02/06/2024 the facility’s policy titled, “Infection Control for Dialysis Facilities” dated 04/2023 was reviewed and required, “...It is requirement for all teammates ...to have only natural nails and fingernail length should not extend more than 1/4 inch ...” 2. On 02/06/2024 between 9:00 AM - 11:45 AM, and observational tour of the treatment area was conducted. During tour PCT (E #2) was observed providing care to dialysis patients with approximately 1 inch long artificial finger nails. 3. On 02/06/2024 at approximately 10:50 AM, the Clinical Manager (E #4) was interviewed. E #4 stated that the staff (E #2) should not have worn the artificial finger nails that long while taking care of dialysis patients. E #4 stated that the staff (E #2) had just returned from vacation. E #4 stated that sometimes the gloves can get ripped too and cause infection and tear of skin for patients.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 37971 Based on document review and interview it was determined for 5 of 5 (Pt. #6, #7, #8, #9, and #10) in-center clinical records reviewed for mortality, the facility failed to ensure the tracking and trending of causes of death for dialysis patients was appropriately documented in the monthly quality meetings as required. Findings inlcude: 1. On 02/07/2024 the facility’s policy titled, “Continuous Quality Improvement Program” dated 04/2021 was reviewed and required, “...Facility Administrators (FAs) conduct periodic Facility Health Meetings (FHMs) ...the facility will measure, analyze, and track quality indicators ...not be limited to the following ...mortality review of deaths ...” 2. On 02/07/2024 at approximately 1:30 PM, the facility’s admission, discharge, and transfer log from January 2023 through January 2024, was reviewed. The discharge log included the following: -(Pt. #6) date of first dialysis: 04/02/2019 and date of expiration: 03/02/2023 in hospital; -(Pt. #7) date of first dialysis: 12/08/2021 and date of expiration: 05/08/2023 in hospital; -(Pt. #8) date of first dialysis: 08/06/2022 and date of expiration: 06/02/2023 outside United States; -(Pt. #9) date of first dialysis: 01/05/2015 and date of expiration: 09/04/2023 in hospital; and -(Pt. #10) date of first dialysis: 08/15/2019 and date of expiration: 09/26/2023 in hospital. The discharge summary log was maintained by the administrative assistant and each patient discharge summary sheet was signed by the Clinical Manager (E #4). 3. On 02/07/2024 at approximately 1:45 PM, the facility’s “Facility Health Meetings (FHM) Report” for January 2023 through January 2024 was reviewed. The FHM report documentation indicated zero deaths tracked and reviewed from Janaury 2023 to October 2023, and for November 2023, the graph showed five (5) deaths. The FHM Report was tallied with the facility’s discharge log and there were inconsistencies with tracking and documentation. 4. On 02/07/2024 at approximately 2:15 PM, the Facility Administrator (E #1) was interviewed. E #1 stated that (E #1) was not sure why the graph was not showing the deaths being reviewed during the FHM. E #1 stated that there had been a glitch in the system where the cumulative report was not flowing into the FHM reports. E #1 stated that moving forward the technical team will be contacted to make sure the number of deaths are reflected as documented in the FHM reports and there’s appropriate graph and documentation.”