Davita Jerseyville 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: 49741 Based on document review, observation, and interview, it was determined that for 3 of 3 technicians (E#2, E#3, E#4) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. Findings Include: 1. On 3/24/25 from 9:45 AM to 12:00 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: · At approximately 10:30 AM through 11:30 AM, Patient Care Technician (E#2) was observed cleaning dialysis stations 3, 4 and 5. After cleaning all surfaces, E#2 did not allow the dialysis chairs to fully air dry before returning to sitting position and closing the arms of the chairs. · At approximately 11:30 AM through 12:00 PM, Certified Clinical Hemodialysis Technician (E#3) was observed cleaning dialysis stations 12 and 15. After cleaning all surfaces, E#3 did not allow the dialysis chairs to fully air dry before returning to sitting position and closing the arms of the chairs. · At approximately 11:50 AM, Certified Clinical Hemodialysis Technician (E#4) was observed cleaning dialysis station 6. After cleaning all surfaces, E#4 did not allow the dialysis chair to fully air dry before returning to sitting position and closing the arms of the chair. 2. On 3/24/25 the Facility’s policy titled, “Infection Control for Dialysis Facilities” (Revised April 2023), was reviewed and noted, “12... b... iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time”... “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).” 3. On 3/14/2024 at approximately 12:00 PM, an interview was conducted with the Facility Administrator (E #1). E #1 observed and verbally agreed that the dialysis chairs should be fully reclined with chair arms open to allow adequate time for surfaces to air dry in order to provide sufficient disinfectant contact time.”

“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: 39025 Based on document review and staff interview, it was determined for 1 of 4 (Pt #3) patient records reviewed for BFR (Blood Flow Rate) the ESRD (End Stage Renal Disease) Facility failed to ensure the patient’s BFR was achieved and maintained in accordance with the dialysis prescription, and failed to notify the physician of this inadequacy. Findings include: 1. On 03/25/25, Pt #3’s record was reviewed. Pt #3 was admitted for in-center hemodialysis on 09/02/24 with a diagnosis of Type I diabetes mellitus with chronic kidney disease. Pt #3’s clinical record contained a physician order dated 03/14/25 which prescribed a BFR of 250 mL/min (milliliters/minute). The following was noted on the treatment sheets - a) Pt #3’s treatment sheets dated 03/17/25 documents a BFR averaging 355 mL/min throughout the treatment duration, failing to achieve the prescribed BFR of 250 mL/min. The record lacked documentation of notification to the physician and a physician order to change BFR. b) Pt #3’s treatment sheets dated 03/19/25 documents a BFR averaging 200 mL/min throughout the treatment duration, failing to achieve the prescribed BFR of 250 mL/min. The record lacked documentation of notification to the physician and a physician order to change BFR. c) Pt #3’s treatment sheets dated 03/21/25 documents a BFR averaging 374 mL/min throughout the treatment duration, failing to achieve the prescribed BFR of 250 mL/min. The record lacked documentation of notification to the physician and a physician order to change BFR. 2. On 03/26/25, the facility policy titled, “In-center Hemodialysis Policies & Procedures” (Effective 1/3/08) was reviewed. It documents in part, - “ ... Intradialytic Data Collection/Assessment: ... 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 ... 12. The licensed nurse notifies the physician ... as needed of changes in patient status.” 3. On 03/25/25 at 2:30 PM, an interview was conducted with the Facility Administrator (E#1). E #1 reviewed Pt #3’s treatment records and verbally agreed the BFR was not achieved, the record did not indicate why and lacked notification of the physician.”