Davita Renal Center New Lenox

“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: 32741 Based on document review, observation and interview, it was determined that for 2 of 3 Patient Care Technicians (E #3 and E #6) and 2 of 2 Registered Nurses (E #4 and E #5) 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 6/10/2024, the Facility’s policy titled, “Infection Control for Dialysis Facilities” (dated April 2023) was reviewed and required, “At the end of each treatment, the dialysis station will be cleaned and disinfected. 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 machines; touchscreens; countertops)...” 2. On 6/10/2024 between 8:45 AM and 11:00 AM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 9:10 AM, the Patient Care Technician (E # 3) did not wipe the sides of the dialysis chair and did not open the dialysis chair to disinfect the sides of the dialysis chair at Station #17. -At approximately 9:35 AM, the Registered Nurse (E #5) did not open the sides of the dialysis chair while disinfecting/cleaning the dialysis chair to ensure disinfection of all areas of the dialysis chair at Station #5. -At approximately 10:00 AM, the Registered Nurse (E #4) did not fully open the sides of the dialysis chair while disinfecting/cleaning the dialysis chair to disinfect all areas of the dialysis chair at Station #12. -At approximately 11:00 AM, the Patient Care Technician (E #6) did not fully open the sides of the dialysis chair while disinfecting/cleaning the dialysis chair to disinfect all areas of the dialysis chair at Station #1. 3. On 6/10/2024 at 11:05 AM, E #6 stated that all areas of the dialysis station should be cleaned and disinfected. E #6 stated that the sides of the dialysis chair should be opened fully.”

“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: 32741 Based on document review, observation, and interview, it was determined that for 2 of 3 Patient Care Technicians - PCT (E #6 and E #7) and 1 of 1 Registered Nurse (E #5) observed for disinfecting AVF (arteriovenous fistula) cannulation sites, the Facility failed to ensure that staff followed infection control practices to disinfect and prevent contamination of AVF sites, as required. Findings include: 1. On 6/10/2024, the Facility’s policy titled, “AV Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” (dated October 2022) was reviewed and required, “Isopropyl Alcohol 70% - effective contact time - 60 seconds...” 2. An observational tour of the dialysis treatment area was conducted on 6/10/2024, between approximately 8:45AM and 11:00 AM. The following was observed: - At approximately 10:10 AM, a PCT (E #6) was at station #3, preparing to initiate dialysis for a patient with an AVF. E#6 wiped each access site for 10 seconds each (not the required 60 seconds). -At approximately 10:20 AM, a PCT (E #7) was at station #14, preparing to initiate dialysis for a patient with an AVF. E #7 wiped each access site for 25 seconds each (not the required 60 seconds). -At approximately 10:30 AM, a Registered Nurse (E #5) was at station #5, preparing to initiate dialysis for a patient with an AVF. E #5 wiped each access site for 10 seconds (not the required 60 seconds). 3. On 6/10/2024 at 11:05 AM, an interview was conducted with E #6. E #6 stated that each site should be disinfected for 30 seconds.”

“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: 32741 Based on document review, observation and interview, it was determined that for 2 of 2 Registered Nurses (E #2 and E #4), the Facility failed to ensure that staff demonstrated knowledge of the Facility’s infection control practices for the disinfection of CVC (central venous catheter - used for dialysis access) insertion site for initiation of the dialysis treatment, as required. Findings include: 1. On 6/10/2024, the Facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” (dated October 2023) was reviewed and required, “Device Disinfectant and Skin Antiseptic -2% Chlorhexidine Gluconate/70% Isopropyl Alcohol - effective for CVC access exit site - effective contact time -30 seconds back and forth motion...” 2. On 6/10/2024 between 8:45 AM to 11:00 AM, an observational tour of the dialysis treatment area was conducted. - At approximately 9:55 AM, the Registered Nurse (E #4) was observed disinfecting the CVC site prior to connection at station #17. E #4 disinfected the CVC site with alcohol wipe for 20 seconds instead of 30 seconds, as required. - At approximately 10:15 AM, the Registered Nurse (E #2) was observed disinfecting the CVC site. E #2 disinfected the CVC site with alcohol wipe for 25 seconds instead of 30 seconds, as required. 3. On 6/10/2024 at 11:10 AM, an interview was conducted with the Registered Nurse (E #4). E #4 stated that the CVC site disinfection should be performed for 2 minutes.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 1 of 1 brine tank (holds salt solution for water softening), the Facility failed to ensure that the tank contained the required amount of salt pellets needed to prevent water hardness. Findings include: 1. The Facility’s daily water checklist was reviewed on 6/12/2024. One of the checks required on the checklist is the brine tank that included, “Salt level in brine tank? (Y/N). At the start of each operation day, check salt level in the brine tank ...” 2. Signage/guidance posted on the water softener tank (located next to brine tank) included, “ ...We want to see salt and water. Salt should be level with water...” 3. On 6/10/2024 at 12:00 PM, a tour of the Facility’s water room was conducted. The water room contained a brine tank that works in conjunction with the water softener tank (remove calcium and magnesium to prevent water hardness). The brine tank was noted with salt pellets less than half full. The water level was approximately 6 inches above the salt pellets (not level as required). -On 6/12/2024 at 11:00 AM, an additional tour of the Facility’s water room was conducted. The brine tank remained with the water level approximately 6 inches above the salt pellets. This finding was confirmed with the Biomedical Technician (E #8). 4. On 6/10/2024 at 12:10 PM, an interview was conducted with a Registered Nurse (E #4). E #4 confirmed the salt/water level in the brine tank. E#4 stated that the salt in the brine tank should be level or above the water.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 9 in-center hemodialysis clinical records (Pt #3) reviewed for appropriateness of the dialysis prescription, the Facility failed to ensure that Heparin pump was turned off 60 minutes prior to the end of treatment, as ordered. Findings include: 1. On 6/11/2024, the Facility’s policy titled, “Anticoagulation” (dated April 2024) was reviewed and indicated, “It is recommended that the heparin hourly infusion be discontinued 60 minutes prior to end of treatment for patients with arterio-venous (AV) fistula and/or AV grafts per physician order.” 2. On 6/11/2024, Pt #3’s clinical record dated 8/26/2023 thru 6/11/2024 was reviewed and indicated: -Pt. #3 was admitted to the Facility on 8/26/2023 with the diagnosis of end stage renal disease. -Pt. #3’s physician order dated 9/20/2023 required, “Heparin Sodium 1,000 units/ml systemic infusion (pump) 600 units IVP (intravenous push) per hour, stop time for hourly dose: 60 minutes.” Pt. #3’s treatment records dated 5/30/2024 thru 6/10/2024 were reviewed and indicated the following: -Pt. #3’s treatment record dated 5/30/2024 noted treatment discontinued at 1:29 PM. Heparin pump off time at 1:29 PM. Heparin pump shut off time should have been 12:29 PM (per MD order). -Pt. #3’s treatment record dated 6/8/2024 documented treatment discontinued at 1:03 PM. Heparin pump off time at 12:45 PM. Heparin pump shut off time should have been at 12:03 PM (per MD order). 3. On 6/11/2024 at 1:00 PM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that MD orders for Heparin should have been followed.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 32741 Based on document review, and interview, it was determined that for 3 of 9 (Pt. #2, Pt. #3 and Pt. #8) in-center hemodialysis clinical records reviewed for intradialytic monitoring, the Facility failed to ensure that the staff provided necessary care and services to manage the patients volume status when abnormal blood pressures were identified. Findings include: 1. On 6/11/2024, the Facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” (dated April 2024) was reviewed and required, “Abnormal Findings - Member of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time...Blood pressure-intradialytic - systolic greater than 180 mm/Hg or less than 90 mm/Hg, diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” 2. On 6/11/2024, Pt. #2’s clinical record (dated 4/1/2021 thru current) was reviewed. Pt. #2 was admitted on 4/1/2021 with a diagnosis of end stage renal disease. Pt. #2’s treatment flowsheets dated 5/26/2024 thru 6/8/2024 were reviewed and the following was noted: -Pt. #2’s treatment flowsheet dated 5/28/2024 included documentation that Pt. #2’s blood pressure was 184/112 at 8:35 AM and blood pressure was 190/101 at 8:43 AM. Pt. #2’s clinical record lacked documentation of nurse notification and if any interventions were implemented to address the elevated blood pressures on 5/28/2024. -Pt. #2’s treatment flowsheet dated 5/30/2024 noted the following blood pressures: -7:33 AM - blood pressure 185/98; 8:03 AM -196/106; 8:33 AM - 198/104; 9:03 AM - 186/104 and 9:33 AM -189/98. Pt #2’s clinical record lacked documentation of nurse notification and if any interventions were implemented to address Pt. #2’s elevated blood pressures on 5/30/2024. 3. On 6/11/2024, Pt. #3’s clinical record (dated 8/26/2023 thru current) was reviewed. Pt. #3 was admitted on 8/26/2023 with the diagnosis of end stage renal disease. Pt. #3’s treatment flowsheets dated 5/28/2024 thru 6/8/2024 were reviewed and the following was noted: -Pt. #3’s treatment flowsheet dated 5/28/2024 noted blood pressure at 1:25 PM was 74/42 and blood pressure at 1:27 PM was 90/56. Pt. #3’s clinical record lacked documentation of nurse notification and if any interventions were implemented to address Pt. #3’s low blood pressure on 6/8/2024. 4. On 6/11/2024, Pt. #8’s clinical record (dated 2/28/2023 thru current) was reviewed. Pt. #8 was admitted on 2/28/2023 with a diagnosis of end stage renal disease. -Pt. #8’s treatment flowsheets dated 5/27/2024 and 6/7/2024 were reviewed and the following was noted: -Pt. #8’s treatment flowsheet dated 5/27/2024 noted blood pressure at 10:17 AM was 80/62 and blood pressure at 11:11 AM was 96/67. Pt. #8’s clinical record lacked documentation of nurse notification and if any interventions were implemented to address Pt. #8’s low blood pressure of 5/27/2024. 5. On 6/11/2024 at 1:00 PM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that abnormal blood pressures should be reported to the Registered Nurse.”