Davita Crystal Springs Dialysis

“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: 52901 Based on document review, observation and interview, for 1 of 1 (E#1/Patient Care Technician), staff observed performing exit site care of a CVC (central venous catheter) for Pt#5, the facility failed to ensure that staff changed gloves and performed hand hygiene as required per policy. Findings include: 1. The facility’s policy titled, “Central Venous Catheter (CVC) with Tego Connectors or CVC Caps Care Procedure (October 2024)” was reviewed on 07/28/2025 and required, “Remove old dressing and discard ... Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Place sterile 2 x 2 gauze over the catheter exit site” 2. On 07/28/2025 from 9:45 AM to 11:30 AM, during an observational tour of the treatment floor, the following was observed: -At 11:00 AM, E #1 was changing the CVC dressing for Pt. #5. E #1 had gloves on and removed Pt. #5 dressing and proceeded to clean the CVC site and place a new dressing. E #1 did not change gloves or perform hand hygiene between tasks. 3. At approximately 11:10 AM, an interview with E #1 was conducted. E#1 stated, “I was under pressure and should have changed my gloves after removing the dirty dressing.””

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 48264 Based on documentation review, observation and interview, for 1 of 1 (E#2/Patient Care Technician) staff observed cannulating an arteriovenous fistula (AVF, dialysis access), the facility failed to ensure that staff did not touch the site after prepping the site, potentially causing contamination. Findings included: 1. The facility’s policy titled, “AV Fistula or Graft Cannulation with JMS Sysloc Mini Safety Needles (SFN/accessing equipment of dialysis/removal of toxins and excess fluid from blood) and Administration of Heparin (medication to prevent blood clots) Loading (increased dose of medication at the beginning of a course of treatment) Dose” (April 2025) was reviewed on 7/28/2025 and included, “ ...Procedure: ...13. Do not palpate insertion site once area has been prepped ...Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation ...”. 2. During an observational tour of Dialysis unit on 07/28/2025 from 9:45 AM to 11:30 AM, the following was observed: -At approximately 10:15 AM, E#2 was observed prepping the dialysis site for a patient at station #12. E#2 cleansed the insertion site, E#2 then palpated insertion site and then cannulated the site, without re-prepping insertion site. 3. An interview was conducted with E #2 on 7/28/2025 at approximately 10:45 AM. E#2 stated that the access site should not have been touched after being prepped to prevent infection.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 27125 Based on document review and interview, for 3 of 5 (Pt. #1, Pt. #4,and Pt. #5) in center hemodialysis records reviewed, the facility failed to ensure that vital signs (blood pressure/pulse) were taken every 30 minutes while receiving dialysis treatments. Findings included: 1. The Facility’s policy titled, “Pre [before]-Intra [during]-Post [after] Treatment Data Collection, monitoring and nursing assessment (April 2024)” was reviewed and included, “Purpose: To obtain and document baseline and ongoing information about the patient. ... This information will be used in planning and documenting the patient’s dialysis treatment ... for reviewing the patient’s response to treatment and status prior to discharge. ... Intradialytic treatment monitoring and data collection ... includes: vital signs ... Non -Nocturnal [not at night] treatments are completed at least every thirty minutes. 2. The clinical record of Pt. #1 was reviewed on 7/29/2025. Pt. #1 was admitted on 3/24/2025 with the diagnosis of end stage renal disease (ESRD). The following treatment sheets included missed thirty minute vital signs during treatment: - 7/16/2025 - vital signs taken at 4:34 PM and again at 5:34 PM (60 minutes). - 7/26/2025 - vital signs taken at 11:04 AM and again at 12:04 PM (60 minutes). 3. The clinical record of Pt. #4 was reviewed on 7/29/2025. Pt. #4 was admitted on 7/13/2018 with a diagnosis of ESRD. The following treatment sheets included missed thirty minute vital signs during treatment: - 7/17/2025 - vital signs taken at 9:39 AM and again at 10:39 AM (60 minutes). - 7/18/2025 - vital signs taken at 7:07 AM and again at 8:07 AM (60 minutes). - 7/21/2025 - vital signs taken at 8:33 AM and again at 9:33 AM (60 minutes). 4. The clinical record of Pt. #5 was reviewed on 7/29/2025. Pt. #5 was admitted on 11/13/2019 with a diagnosis of ESRD. The following treatment sheet included missed thirty minute vital signs during treatment: - 7/16/2025 - vital signs taken at 11:53 AM and again at 1:14 PM (81 minutes). 5. During an interview on 7/30/2025 at 9:00 AM, the Facility Administrator (E#3) stated that vital signs need to be taken and documented every 30 minutes during dialysis treatment to assess how the patient is tolerating treatment.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 27125 Based on document review and interview, 1 of 5 (Pt. #5) in center hemodialysis records reviewed, the facility failed to ensure that each patient was seen by the attending nephrologist (kidney doctor) at least once a month. Findings include: 1. The facility’s policy titled, “Progress note policy (October 2024)” was reviewed on 7/29/2025 and required, “Progress notes are completed to verify documentation of patient’s problems/needs, interventions, and response to intervention. ... The attending nephrologist is required to record notes at least monthly ... and provides other interdisciplinary team members with an up-to-date status of the patient at all times.” 2. The clinical record of Pt. #5 was reviewed on 7/29/2025. Pt. #5 was admitted on 11/13/2019 with a diagnosis of end stage renal disease. Physician progress notes included 4/21/2025 and 7/9/2025 (missing May and June 2025). 3. During an interview on 7/30/2025 at 9:00 AM, the Facility Administrator (E#3) stated, “ The physician is supposed to see every patient and document a progress note every month.””