Davita O’fallon Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 49555 A. Based on observation, document review, and interview, it was determined the facility failed to ensure infection prevention and control measures were followed to prevent the potential for cross contamination. Findings include: 1. On 9/30/24 at approximately 1:00 PM, an observational tour was conducted of the treatment area. It was noted that 3 of 16 dialysis treatment chairs vinyl was torn with the foam exposed on the armrests and chair seat. 2. On 9/30/24, the document titled “Minutes of the Governing Body” was reviewed. The document noted, “The Governing Body of the O’fallon Dialysis Center met on August 28th, 2023 ...The purpose of the governing body meeting is to document the review of the dialysis chairs that are in need of repair ... We have 3 chairs that had to have parts ordered. Per conversation the parts are being ordered and are to be shipped to the clinic.” 3. On 9/30/24, an undated and untitled document was reviewed. The document noted a list of concerns, which stated, “Station 5: There is a chair in the huddle room that is not working and has rip....ordered seat cover, adjusted arm latches, repaired foot rest.” 4. On 9/30/24 at 1:30 PM, an interview was conducted with the Facility Administrator (E #1). E#1 verbally agreed that the chairs had tears and stated, “We are aware of some tears in the chairs. We ordered new chairs last week. We addressed this concern in the governing body meeting, but we are not sure how long it will be.” B. Based on observation, document review and interview, it was determined that the Facility failed to provide a safe physical environment by ensuring that spills were cleaned up in an appropriate amount of time. Findings include: 1. On 10/1/24 at 9:45 AM, an observational tour was conducted. The following was observed: A. Clear liquid was observed on the floor near Station #1 at 9:45 AM. B. A large amount of clear liquid was observed on the floor near Station #5 at10:10 AM. At 10:15 AM, a patient was observed walking around the wet area. 1. On 10/1/24, a policy titled, “Teammate Slip, Trip and Fall Prevention Program” was reviewed. The document noted, “The walking surfaces should be: Cleaned correctly so floors are not slippery or keeps the slip resistance properties, if a non-slip floor...Work Environment: ... In order to minimize the potential for a teammate slip trip or fall incident or injury, attention should be given to reduce the potential working environment hazards. Examples of potential working environment hazards include but are not limited to: ...wet surfaces ...”. 2. On 10/1/24, an interview was conducted with the Manager of Clinical Services (E#2) at 10:25 AM. E#2 was made aware of the liquid on the floor and verbally agreed that the liquid should be cleaned immediately. E#2 made staff aware of wet areas and advised them to clean wet areas. Patient care tech (E#3) was observed cleaning up the spills at 10:30 AM.”

“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: 50645 Based on document reiview and interview, it was determined for 2 of 5 (Pt #3, Pt #4) patient records reviewed with abnormal findings, the facility failed to ensure reporting of abnormal blood pressures per policy. Findings include: 1. The policy titled “ PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (revised April 2024) was reviewed on 10/01/24. The policy noted, “ ... Members 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: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg.. Diastolic greater than or equal to 100 mm/Hg Blood Pressure Post Treatment:... Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Standing diastolic BP greater than 90 mm/Hg Sitting: systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg”. 2. On 09/30//24 at approximately 2:00 PM, Pt #3’s record was reviewed. Pt #3 was admitted to the facility on 08/01/22 with a diagnosis of end-stage renal disease. 1 of 13 treatment records between 09/6/24 and 09/27/24 noted the following: a) 09/27/24, 3 of 8 blood pressures (highest blood pressure (b/p) was 200/72) were out of range and not reported to the physician. The record lacked documentation the physician was notified of the abnormal b/p’s by the nurse. 3. On 10/01/24 at approximately 9:30 AM, Pt #4’s record was reviewed. Pt #4 was admitted to the facility on 11/18/22 with a diagnosis of end-stage renal disease. 1 of 13 treatment records between 05/31/24 and 09/09/24 noted the following: a) 05/31/24, 2 of 7 blood pressures (highest blood pressure was 201/88). b) 06/19/24, 3 of 8 blood pressures (highest blood pressure was 194/93). c) 06/24/24, 3 of 7 blood pressures (highest blood pressure was 195/88). d) 07/01/24, 3 of 7 blood pressures (highest blood pressure was 190/92). e) 09/09/24, 4 of 7 blood pressures (highest blood pressure was 195/79). Were out of range and not reported to the physician. The record lacked documentation the physician was notified of the abnormal b/p’s by the nurse. 4. An interview was conducted on 10/01/24 at approximately 2:00 PM with Facility Administrator (E#1). E #1 reviewed Pt #3 and Pt #4’s records and verbally agreed the facility failed to ensure reporting of abnormal blood pressures per policy.”

“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: 49555 Based on document review and staff interview, it was determined for 1 of 5 (Pt #1) patient’s records reviewed for BFR and DFR, the ESRD Facility failed to ensure the patient’s BFR and DFR was achieved and maintained in accordance with the dialysis prescription. Findings include: 1. On 9/30/2024 Pt #1’s record was reviewed. Pt #1 was admitted to the facility on 10/20/2023 with a diagnosis of ESRD. Pt #1’s clinical record contained a physician order dated 9/16/2024 that noted the BFR of 400 and a DFR of 800. Pt #1’s treatment sheet dated 9/20/2024, 9/23/2024, 9/25/2024, and 9/27/2024 (4 of 13 treatments) indicated Pt #1 was dialyzed at a BFR of 285-400 and a DFR of 300-500. The record lacked documentation as to why the prescribed blood floor or dialysate flow was not ran. 2. On 10/1/2024 the policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” (revised October 2023) was revied. The policy noted, “ ...3 ...The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law ....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.” 3. On 10/1/2024 at approximately 2:00PM, an interview with the Facility Administrator (E #1) was conducted. E #1 reviewed the treatment record of Pt #1 and verbally agreed the BFR and DFR was not achieved and there was no documentation in the records indicating why.”