Davita Maryville Dialysis

“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: 51190 Based on observation, document review, 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 10/21/24 at 12:55 PM, an observational tour was conducted in the water room. A bag of salt pellets and container of salt pellets were observed directly on the floor. 2. On 10/21/24, a document titled, “Physical Environment (Revised April 2018)” was reviewed. It noted, “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 10/21/24 at 1:00 PM, an interview was conducted with the facility administrator (E#1), who verbally agreed that the items should be off the floor, and on shelves.”

“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: 51190 Based on observation, document review, and interview, it was determined the Facility failed to ensure the proper cleansing of single and multidose vials to prevent the potential for cross-contamination. 1. On 10/21/24 at 12:10 PM, an observation of registered nurse (E#2) was made at the medication preparation area. E#2 failed to clean the septum of the single dose vial of Parsabiv 5mg/1ml prior to inserting needle to withdraw medication. E#2 acknowledged his failure to clean septum. 2. On 10/21/24 at 12:30 PM, a document titled, “Medication Policy”, was reviewed. It noted, “An aseptic environment and aseptic technique is used when preparing medications. Careful attention to proper hand washing is performed at this time.” 3. On 10/21/24 at 1:40 PM, an interview was conducted with the facility administrator (E#1). E#1 verbally agreed that the multi-use and single use vials should be wiped with alcohol before withdrawing medication and that she will remind the nurses of this practice.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49741 Based on document review and staff interview, it was determined for 2 of 5 (Pt #4 and Pt #5) patient records reviewed for BFR and DFR, the ESRD Facility failed to ensure the patient’s BFR and DFR was achieved and maintained in accordance with the dialysis prescription. Findings include: 1. On 10/21/2024 at approximately 2:00 PM, the clinical record of Pt #4 was reviewed. Pt #4 was admitted to the facility on 8/30/2023, with a diagnosis of ESRD. A physician’s order dated 10/11/2024, prescribed a DFR of 800. On 10/11/2024, Pt #4 was dialyzed at a DFR of 500. The record lacked documentation as to why the DFR was not achieved as prescribed or that the licensed nurse was notified. 2. On 10/22/2024 at approximately 11:45 AM, Pt #5’s record was reviewed. Pt #5 was admitted to the facility on 10/24/2023 with a diagnosis of ESRD. Pt #5’s clinical record contained a physician order dated 09/21/2024 that noted the BFR of 450. Pt #5’s treatment sheet dated 09/21/2024 indicated patient was dialyzed at a BFR of 404. P t#5’s treatment sheet dated 10/03/2024 indicated Pt #5 was dialyzed at a BFR of 379. The record lacked documentation as to why the DFR was not achieved as prescribed or that the licensed nurse was notified. 3. The Facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, (revised by the facility, April 2024), was reviewed on 10/22/2024 at approximately 11:00 AM stated, “3. Patient identity, prescription and machine settings ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law ... Pre-Treatment Data Collection/Assessment ... 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” 4. During an interview with the Facility Administrator (E #1) on 10/22/2024, at approximately 10:15 AM, it was confirmed that the DFR for Pt #4 was prescribed at 800 and was not delivered as prescribed. E #1 also confirmed that the BFR for Pt #5 was prescribed at 450 and was not delivered as prescribed.”