Davita Schaumburg Renal Center

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, it was determined that for 2 of 3 staff (E#3 and E#7) observed, the facility failed to ensure that gloves were removed and hand hygiene performed when going from dirty to clean tasks/areas. Findings include: 1. The facility’s policy titled, “Infection Control for Dialysis Facilities” (revised April 2023), was reviewed and required, “...All teammates... will perform hand hygiene... g. before touching clean areas such as supplies, supply cart...” 2. The facility’s policy titled, “Central Venous Catheter (CVC) with TEGO Connectors or CVC End Caps Procedure” (revised October 2023), was reviewed and required, “...If teammate performing this procedure [CVC care] assisted the patient to put on their face mask, re-perform hand hygiene per procedure and put on clean gloves...” 3. During a tour of the dialysis treatment area on 03/12/2024, the following were observed: - At approximately 9:30 AM, a Patient Care Technician/PCT (E#7) was preparing to initiate dialysis for a patient. While setting up the patient, E#7 dropped an absorbent pad on the floor. E#7 went to grab a new pad from the clean supply drawer without changing gloves and performing hand hygiene. - At approximately 9:54 AM, a Registered Nurse (E#3) was assessing a patient. E#3 removed the stethoscope and a bag of lab tubes that were hanging on the IV (intravenous) pole at a patient’s dialysis station. E#3 then went to the clean supply closet to grab an alcohol pad without performing hand hygiene. - At approximately 10:33 AM, RN (E#3) went to a patient’s station to administer IV (intravenous) medication. E#3 pulled down E#3’s face shield with gloved hands and then proceeded to administer the medication without changing gloves and performing hand hygiene. - At approximately 11:02 AM, PCT (E#7) was at a patient’s station preparing to perform CVC exit site care. E#7 lifted the patient’s mask up to cover the patient’s nose and mouth. E#7 then went to sort and open the clean supplies for the procedure, without changing gloves and performing hand hygiene. 4. An interview was conducted with PCT (E#7) on 03/13/2024, at approximately 10:17 AM. E#7 stated that gloves should be removed and hand hygiene completed when leaving a patient station to grab clean supplies. E#7 also stated that if PPE (personal protective equipment) such as face shield or masks are touched, staff should change gloves and perform hand hygiene prior to continuing a clean procedure.”

“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: 39802 Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#7) observed cleaning a blood spill, the facility failed to ensure that the appropriate concentration of disinfectant solution was used. Findings include: 1. The facility’s policy titled, “Infection Control for Dialysis Facilities” (revised April 2023), was reviewed and required, “...Disinfection: ... For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized...” 2. During a tour of the dialysis treatment area on 03/12/2024, at approximately 10:30 AM, blood had leaked from a loose port on a dialysis machine. A Patient Care Technician/PCT (E#7) went to grab some clean wipes and saturated the wipes using the the 1:100 (one to one hundred) solution instead of the 1:10 to clean up the blood spill. 3. An interview was conducted with PCT (E#7) on 03/13/2024, at approximately 10:17 AM. E#7 stated that the 1:10 (or 10%) bleach solution should have been used to wipe up the blood spill.”

“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: 39802 Based on document review, observation, and interview, it was determined that the facility failed to ensure that expired supplies were not available for use. Findings include: 1. The facility’s policy titled, “Infection Control for Dialysis Facilities” (revised April 2023), was reviewed and required, “...Supplies will be stored in a manner that maintains their integrity... Expiration date and package integrity will be verified...” 2. During a tour of the dialysis treatment area on 03/12/2024, the following expired items were observed: - 1 of 1 opened hand sanitizer in the medication room had an expiration date of 05/2023. - 1 of 4 opened hand sanitizer bottles on the treatment floor had an expiration date of 03/2023. - 1 of 6 bottles of hand sanitizer in the clean supply closet had an expiration date of 08/2023. - 3 of 7 opened bottles of Minncare (disinfectant used for the water distribution system) residual test strips had an expiration date of 02/15/2024. The 3 expired bottles were found in the clean supply closet. 3. An interview was conducted with the Registered Nurse (E#3) on 03/12/2024, at approximately 12:30 PM. E#3 stated that the expired supplies should have been thrown away.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#6) observed performing CVC (central venous catheter) care, the facility failed to ensure that appropriate infection control measures were used when terminating dialysis treatment. Findings include: 1. The facility’s procedure titled, “Central Venous Catheter (CVC) with TEGO Connectors or CVC End Caps Procedure” (revised October 2023), was reviewed and required, “...perform a 15 second hub scrub every time the CVC is connected or disconnected from the blood lines...” 2. During a tour of the dialysis treatment area on 03/12/2024, at approximately 8:27 AM and again at approximately 9:08 AM, a Patient Care Technician (E#6) was terminating dialysis treatment for patients with CVCs. E#6 disconnected the bloodlines from each port (arterial and venous) and attached a saline syringe to flush each port without wiping the connections/hubs with alcohol (before or immediately after disconnecting the bloodlines). 3. An interview was conducted with PCT (E#6) on 03/13/2024, at approximately 9:52 AM. E#6 stated that they don’t have to wipe when disconnecting the bloodlines because they were already wiped before they were connected (at the start of treatment). E#6 stated they would wipe with alcohol after they flush the ports with saline or when the nurse gives medications.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 39802 A. Based on document review, observation, and interview, it was determined that for 4 of 4 patients (Pts. #7-#10), the facility failed to ensure that vascular access sites were assessed post-dialysis treatment for the presence of a bruit (sound of blood flowing through access) and a thrill (vibration indicating blood flow). Findings include: 1. The facility’s policy titled, “Post Dialysis Vascular Access Care: Fistula/Graft using Safety Fistula Needles” (revised April 2023), was reviewed and required, “...Observe for edema, redness, prolonged bleeding, and presence of thrill (rumbling sensation that can be felt)/bruit...” 2. The facility’s policy titled, “Utilizing Vascular Access Clamps” (revised April 2019), was reviewed and required, “...During use, the thrill and bruit of the access will be checked above and below the clamp...” 3. During a tour of the dialysis treatment area on 03/13/2024, the following were observed: - At approximately 8:30 AM, dialysis needles were removed from a patient (Pt. #7) at station #5 post-treatment. The Patient Care Technician/PCT (E#7) secured on clamp on the first access site. The first clamp was removed at 8:41 AM. At approximately 8:43 AM, E#7 placed the clamp on the second access site (after needle removal), which remained on until approximately 8:57 AM. E#7 did not assess the access site during use the clamps or after, prior to the patient leaving the treatment floor. - Between approximately 9:00 AM and 10:00 AM, three other patients (Pts. #8-#10) were observed to have a clamp placed on one of the access sites, while the patients held the second access site with a gloved hand at the same time. Staff did not assess for the presence of the bruit or thrill during use of the clamps or prior to the patients leaving the treatment floor. 4. An interview was conducted with PCT (E#7) on 03/14/2024, at approximately 8:36 AM. E#7 stated that the thrill and bruit should be assessed before and after dialysis treatment and during use of a clamp. B. Based on observation, document review, and interview, it was determined that for 3 of 3 patients (Pts. #7-#9), the facility failed to ensure that vascular access clamps were utilized in accordance with a physician’s order as required. Findings include: 1. During a tour of the dialysis treatment area on 03/13/2024, between approximately 8:45 AM and 10:00 AM, Pts. #7-#9 were noted to have vascular clamps used to achieve hemostasis (stop bleeding) after dialysis treatment. - Clamps were used for both of Pt. #7’s access sites (arterial and venous). - For Pts. #8 and #9, a clamp was used on the top (venous) access site. 2. The facility’s policy titled, “Utilizing Vascular Access Clamps” (revised April 2019), was reviewed and required, “...A physician’s order is always required for utilization of vascular access clamps. Vascular access clamps should not be used routinely...” 3. The clinical records of Pts. #7-#9 were reviewed on 03/13/2024, at approximately 1:45 PM, with the Facility Administrator (E#1). - Pt. #7 did not have active orders for using either arterial or venous clamps at the time of the above observation. Orders for use of both clamps were placed on 03/13/2024, at 10:25 AM (after the tour was completed). - Pt. #8’s record lacked orders for post-treatment clamp use for the venous access site. An order for post-treatment arterial clamp use was placed on 03/14/2024, at 10:23 AM. - Pt. #9’s record lacked orders for use of post-treatment clamps. - During the review, E#1 stated that orders should be placed and active before clamps can be used. 4. An interview was conducted with Patient Care Technician (E#7) on 03/13/2024, at approximately 10:17 AM. E#7 stated that a physician’s order is required in order to use clamps on a patient.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that for 2 of 2 (Pt. #5 and Pt. #6) clinical records reviewed for peritoneal dialysis, the facility failed to ensure that treatment flowsheets that contained self-monitoring data were completed, as required. Findings include: 1. On 3/13/2024, the facility’s policy titled, “Daily Home Treatment Record (Flowsheet)” (revised 9/2023), was reviewed and included, “...Purpose: To provide guidance for proper documentation of home peritoneal dialysis treatments ...to assist in assessing the patient’s response to peritoneal dialysis treatments ...5. Dialysis Home Treatment Record ...record submitted ...of applicable treatment data including, but not limited to ...vital signs ...Policy: ...3. ...this post-treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record ...6. ...Based on what the patient submits, some follow up may be necessary and the patient’s health record must be updated to reflect any new information obtained.” 2. On 3/13/2024, the clinical record for Pt. #5 was reviewed. Pt. #5 was admitted to the facility on 11/28/2019 with a diagnosis of ESRD (end-stage renal disease). The dialysis daily home treatment records between 12/16/2023 and 1/12/2024 indicated that before and after treatment weights were not being performed. The record also did not include patient re-education of collection and documentation of weight before and after treatment. 3. On 3/13/2024, the clinical record for Pt. #6 was reviewed. Pt. #6 was admitted to the facility on 9/06/2021 with a diagnosis of ESRD. The dialysis daily home treatment records between 12/13/2023 and 2/15/2024 indicated that before and after treatment weights were not being performed. The record also did not include patient re-education of collection and documentation of weight before and after treatment. 4. On 3/13/2024 at approximately 2:00 PM, an interview with the Peritoneal Dialysis Registered Nurse (E # 2) was conducted. E #2 stated that the patients should record their weight before and after treatment on their flowsheets. E #2 stated that if the patient does not record the weights, patients should be re-educated of the purpose and importance of tracking weight. E #2 acknowledged that Pt. #5 and Pt. #6 clinical records lacked consistent weight documentation before and after treatment and re-education of completion of the flowsheet in its entirety should be provided.”