Davita Springfield South 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: 52207 Based on observation, document review, and interview it was determined the facility failed to label patient medications per facility policy. Findings include: 1. On 7/2/2025 at approximately 10:00 am, an observational tour was conducted. During the observational tour the following was noted in the medication prep area: a) four (4) medication cups with medication in them and patient labels on the cups, were labeled with patient information but were not timed or initialed by the person who prepared the medication cups. b) 4 of 4 pre-drawn heparin syringes were labeled with patient information and time but were not initialed by the person who prepared the syringes. 2. On 7/2/2025 at approximately 1:00 pm document review of the policy titled, “Medication Policy (policy:1-06-01)” was completed. The policy states, “If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient’s name, name of the medication, date, time prepared, dose, and initials of teammate preparing the medication.” 3. On 7/2/2025 at approximately 1:40 pm, an interview with Registered Nurse (E #4) was conducted. E #4 was asked to verbally explain their medication policy while they were preparing a Heparin syringe. During the interview E #4 did speak about writing a time on the Heparin syringes however they failed to speak about putting their initials on the medications.”

“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: 52206 Based on observation, document review, and staff interview, the facility failed to follow standard infection control practice when cleaning the dialysis chairs in between patients per facility policy. Findings include: 1. During observation of the treatment floor on 7/1/2025, at approximately 11:15am, E#3 failed to allow 2 of 2 treatment chairs to air dry prior to closing the side armrest panels. On 7/2/2025 at approximately 11:10am E#2 and E#3 each failed to allow 2 of 2 treatment chairs to air dry prior to closing the side armrest panels. 2. Review of the facility’s Infection Control for Dialysis Facilities (policy: 1-05-01) states, “12, b., iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time.” 3. In an interview with the Facility Administrator, E #1, on 7/2/2025 at approximately 11:20 am, E # 1 verbally confirmed the expectation that treatment chairs are to left open to air dry after cleaning/per policy.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 52206 Based on observation, document review, and staff interview, the facility failed to ensure that oxygen tanks were stored in clearly marked racks indicating whether a tank is full, in use, or empty. Findings include: 1. During observation of the treatment floor on 7/1/2025 at approximately 11:35 am, a single oxygen tank storage rack with both empty and full/in use oxygen tanks was observed. The rack did not segregate or have a method to identify which tanks were empty, full, or in use other than a label on the handle of the tank stating ‘empty’. 2. Review of the facilities Emergency Equipment Checks policy (policy: 1-02-08) states, “7. The oxygen tank(s) will be checked for an adequate amount of oxygen (500psi or more) and stored in compliance with local and/or state regulations.” 3. In an interview with the Facility Administrator, E #1, on 7/1/2025 at approximately 11:50 am, E #1 Verbally confirmed the presence of both empty and full/in use oxygen tanks in the single rack.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50771 Based on document review and interview, it was determined that for 1 of 7 clinical records reviewed (Pt #2), the facility failed to ensure that Against Medical Advice (AMA) forms were completed, as required per policy. Findings include: 1. The clinical record for Pt #2, was reviewed on 7/2/2025. The clinical record indicated that for 7 of 12 treatment records reviewed, the seven treatment records dated 6/2/2025, 6/4/2025, 6/6/2025, 6/9/2025, 6/11/2025, 6/13/2025 and 6/23/2025 were shortened, due to late arrival of the patient, transportation issues of the patient or patient request. The treatments were shortened ranging from 58 minutes to 1 hour 10 minutes. Unable to locate AMA form for early termination of treatment, as required by policy. 3. The Facility’s policy titled, “Prescribed Treatment Time Not Met” (policy # 1-01-09, revised April 2024) was reviewed and requires, “... 1. The registered nurse will verify that a patient signs the Early Termination of Treatment Against Medical Advice form anytime the patient requests to terminate their treatment earlier than the prescribed runtime. 2. The Early Termination of Treatment Against Medical Advice form is available in the electronic health record ...B. Prescribed Treatment Time Not Met ...1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs ...” 4. On 7/3/2025 at approximately 10:00 AM, an interview was conducted with the Facility Administrator (E#1). During discussion regarding early termination and arriving late for treatment, E#1 verbally confirmed that AMA forms are to be completed, per policy.”