Davita Comprehensive Renal Care - Hammond

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure staff removed gloves and performed hand hygiene after contamination in 1 of 2 observations of central venous catheter [CVC] (catheter into large vein) exit site care, 1 of 2 observations [PCT 5] of discontinuation of dialysis with a CVC, 2 of 2 [PCT 4] observations of access of arteriovenous fistula [AVF] (a type of dialysis access) or arteriovenous graft [AVG] (a type of dialysis access) for initiation of dialysis, and 1 of 2 [PCT 5] observations of discontinuation of Dialysis and post dialysis access care for AVF or AVG. Findings include: 1. A revised policy, dated April 2023, titled “Infection Control for Dialysis Facilities” indicated that hand hygiene should be performed prior to gloving and immediately after removal of gloves, after patient contact, and after dialysis delivery contact. 2. During an observation on 05/27/2025, beginning at 10:27 AM, at station #11, PCT 3 was providing CVC exit site care for Patient 7. PCT 3 removed Patient 7’s old CVC dressing and discarded it. PCT 3 then cleansed the CVC exit site with antiseptic without removing gloves, performing hand hygiene, and donning clean gloves. 3. During an observation on 05/28/2025, beginning at 9:06 AM, at station #12, PCT 5 was discontinuing dialysis with a CVC to Patient 14. PCT 5 reinfused the hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) machine and then proceeded to disinfect the CVC connections without removing gloves, performing hand hygiene, and donning clean gloves. 4. During an observation on 05/28/2025, beginning at 9:45 AM, at station # 2, PCT 4 was performing access of AVF for initiation of dialysis to Patient 9. PCT 4 located and palpated the cannulation sites and applied antiseptic to the site without removing gloves, performing hand hygiene, and donning new gloves. 5. During an observation on 05/28/2025, beginning at 10:26 AM, at station # 10, PCT 4 was performing access of AVF for initiation of dialysis to Patient 12. PCT 4 located and palpated the cannulation sites and applied antiseptic to the site without removing gloves, performing hand hygiene, and donning new gloves. 6. During an observation on 05/28/2025, beginning at 9:20 AM, at station # 11, PCT 5 was performing discontinuation of dialysis and post dialysis care for AVF to Patient 11. PCT 5 reinfused the HD machine and removed needles without removing gloves, performing hand hygiene, and donning new gloves. 7. During an interview on 05/29/2025, beginning at 1:30 PM, PCT 8 indicated that hand hygiene and glove changes should be performed before and after touching the patient , before cannulation, and after cannulation for AVF/AVG, and before CVC care.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure the PCT (PCT 3) maintained a sanitary environment in 1 of 2 floor observation periods. Findings include: 1. A revised policy, dated April 2023, titled “Infection Control for Dialysis Facilities, indicated that non-disposable items are to be disinfected prior to removal from treatment area/station, and that clean areas should be clearly separated from contaminated areas and designated for the preparation/handling of medications/unused supplies and equipment. 2. During an observation on 05/27/2025, beginning at 10:35 AM, at station #11, PCT 3 was initiating hemodialysis [HD] (a precess to filter the blood in a patient whose kidney’s do not work normally) to Patient 7. PCT 3 brought a bottle of hand sanitizer to station #11 and used the hand sanitizer throughout the process of initializing dialysis. PCT 3 then brought the hand sanitizer to a designated clean area without cleaning/disinfecting the bottle, contaminating the designated clean area. 3. During an interview on 05/27/2025, beginning at 10:53 AM, PCT 3 indicated that took the bottle of hand sanitizer to the HD station to be used for frequent hand hygiene and returned to clean area.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure that Patient 11’s hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) access site was in view while receiving HD treatment in 1 of 2 treatment floor observations. Findings include: 1. A revised policy, dated April 2024, titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” indicated that the vascular access site and blood line connections should be visible throughout the dialysis treatment. 2. During an observation on 05/28/2025, beginning at 8:56 AM, Patient 11 had a blanket covering the left arm arteriovenous fistula [AVF] (dialysis access) until 10:37 AM, when Patient 11 repositioned self and moved blanket so that access was able to be viewed. 3. During an interview on 05/29/2025, beginning at 1:30 PM, PCT 8 indicated that a patient’s HD access site needs to be visible, and if a patient refused, the RN or FA should be notified.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed ensure staff (RN 1) met personnel qualifications in 1 of 3 personnel record reviews. Findings include: 1. A revised policy, dated October 2024, titled “Tuberculosis Monitoring and Follow-Up”, indicated that employees will be given a baseline test for tuberculosis and test results will be recorded. 2. During a personnel record review on 05/29/2025, RN 1, who had a hire date of 01/04/2021, did not have evidence of any baseline Tuberculosis test performed from time of hire to present. 3. During an interview with the Facility Administrator [FA] on 05/29/2025, beginning at 11:29 AM, the FA indicated that she does not have evidence that a Tuberculosis Skin Test was done for RN 1. The FA additionally indicated that RN 1 was a transfer RN from a different facility and that it is possible that documents from the transfer did not get uploaded.”

“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: 51199 Based on record review and interview, the dialysis facility failed to ensure PCT 8 and RN 3 followed policies and procedures related to administering the correct hemodialysis [HD] (a process to clean the blood of a patient whose kidneys do not work normally) prescription in 1 of 4 in-center hemodialysis clinical record reviews, Findings include: 1. A revised policy, dated April 2024, titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” indicated that prescription and machine settings (including blood flow rate [BFR]) should be verified prior to initiation of treatment, and if the dialysis prescription is not being met, the reason will be documented and the licensed nurse informed. 2. During a clinical record review on 05/28/2025, for Patient 4, a Treatment Detail Report indicated the following: A. The prescribed BFR was 300 B. The BFR administered was 350 for the entire course of the HD treatment C. The HD treatment was initiated by PCT 8 at 10:18 AM D. RN 3 verified that the patient prescription matched what was being administered at 10:59 AM 3. During an interview on 05/29/2025, beginning at 1:30 PM, PCT 8 indicated that a PCT will generally initiate HD treatment, and the RN must verify the prescription matches what is being given when doing his/her rounds within 1 hour of treatment start time. 4. During an interview on 05/29/2025, beginning at 11:00 AM, the Medical Director indicated that the BFR should not be administered higher than the prescribed rate for any reason.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to ensure that medical records were accurate in 1 of 1 clinical record reviews of a patient who did not have arteriovenous fistula [AVF] (dialysis access) site in view while receiving hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) during observation of the HD treatment floor. Findings include: 1. A revised policy, dated April 2024, titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” indicated that treatment monitoring includes assessment and documentation that the vascular access site and blood line connections are visible throughout the dialysis treatment. 2. During an observation of the treatment floor on 05/28/2025, beginning at 8:56 AM, Patient 11, at station #11, had a blanket completely covering his/her AVF from 8:56 AM until 10:37 AM. 3. A Treatment Details Report, dated 05/28/2025, for Patient 11, indicated the following: A. Dialysis access site was visible at 9:00 AM B. Dialysis access site was visible at 9:30 AM C. Dialysis access site was visible at 10:00 AM D. Dialysis access site was visible at 10:30 AM 4. During an interview on 05/29/2025, beginning at 1:30 PM, PCT 8 indicated that a patient’s HD access site needs to be visible, and if a patient refused, the RN or FA should be notified.”