Davita East Evansville 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: 38262 Based on observation, record review, and interview, the facility failed to secure the lids to the bleach containers for 3 of 3 observation days and failed to ensure the staff used bleach wipes immediately after preparation for 2 of 3 observation days. Findings include: 1. A revised 10/2023 “Bleach Policy” policy indicated that staff are to cover the bleach solution containers with a lid. The policy stated the bleach solution would degrade over time and become less effective when open to air. 2. During a flash tour on 02/25/2025 at 9:13 AM, the surveyor found two 1:100 bleach containers and one 1:10 bleach container with the lid off sitting on the counter in a clean area. 3. During a flash tour on 02/25/2025 at 9:13 AM, the surveyor found four sharp containers (a container used to dispose of sharp objects like needles and syringes safely) with bleach wipes on top of each container. 4. During an observation on 02/26/2025 between 8:35 AM and 9:40 AM, the surveyor found one 1:10 and two 1:100 bleach containers with the lids not secured at pod B. During an interview on 02/26/2025 at 8:55 AM, PCT 3 stated she was unsure why the lids were not secure on the bleach containers. PCT 3 was able to fasten lids to the containers without difficulty. 5. During an observation on 02/26/2025 at 8:50 AM, the surveyor found two sharp containers with bleach wipes resting on top of each container. During an interview on 02/26/2025 at 8:55 AM, PCT 3 stated she prepared all the bleach wipes at the beginning of the shift and placed the bleach wipes on top of the red sharps containers in case of a blood spill. PCT 3 stated she did not know if the bleach wipes would degrade if not used immediately after preparation. 6. During a random interview on 02/26/2025 at 12:00 PM, PCT 1 stated she was unsure why staff did not secure the bleach container lid to the container. She said the bleach would evaporate if the lids were left off. 7. During an interview on 02/26/2025 at 2:47 PM, RN 1 stated she was unsure why the bleach container had no lid. She said the bleach would evaporate if the lid were left off. 8. During an observation on 02/27/2025 at 9:40 AM, the surveyor found a 1:100 bleach container in a designated dirty area at pod B with the lid off. During an interview on 02/27/2025 at 4:00 PM, the FA stated that staff are to secure the lids of the bleach containers when not in use.”

“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: 38262 Based on observation, record review, and interview, the staff failed to ensure hand hygiene and/ or glove changes were performed before and after removing gloves, before collecting clean supplies, before caring for a patient, before preparing medication, and after touching dirty equipment affecting 5 of 8 staff members observed providing patient care (PCT 1, PCT 2, PCT 3, PCT 7, RN 2) Findings include: 1. A revised 10/2023 “Medication Policy” policy indicated that staff must use aseptic techniques when administering medications. The policy indicated that staff should prepare medications in an aseptic environment and perform proper hand hygiene. 2. A revised 04/2019 “Utilizing Vascular Access Clamps” policy indicates staff should perform hand hygiene and apply new gloves before patient contact and after touching the dialysis delivery system. 3. A revised 04/2023 “Infection Control for Dialysis Facilities” policy indicated all teammates would perform hand hygiene before gloving and immediately after removal of gloves, after coming in contact with infectious material, after patient and dialysis delivery system contact between patients, before touching clean (supplies, supply cart, and chairside keyboard/mouse). Gloves should be changed when going from a dirty area or task to a clean area or task, after touching one patient or their dialysis delivery system, and before arriving to care for another patient or touch another patient’s dialysis delivery system. 4. During an AV fistula initiation observation on 02/25/2025 at 11:22 AM, PCT 2 removed one glove, went to a clean area to collect supplies, returned to station #7, placed the glove on the ungloved hand, and provided care to Patient #22. After completing care for Patient #22, PCT 2 retrieved the biohazard trash container with a gloved hand, brought the container to station #7, and then touched the dialysis machine. PCT 2 failed to remove gloves and hand hygiene before going to the clean area to collect supplies; she failed to remove one glove, hand hygiene, and don new gloves before providing patient care to Patient #22. PCT 2 failed to remove gloves and hand hygiene after touching the biohazard trash container and before providing patient care. 5. During an observation on 02/25/2025 at 11:50 AM, PCT 1 retrieved the biohazard trash container with a gloved hand, brought the container to station #6, and provided care to Patient #14. PCT 1 failed to remove gloves and hand hygiene after touching the biohazard trash container and before providing patient care. 6. During an observation on 02/25/2025 at 11:55 AM, PCT 2, with ungloved hands, gripped the top edge of the biohazard trash container to remove it from Station #6, then touched Station #10’s computer keyboard. PCT 2 failed to glove before touching the biohazard container; she failed to hand hygiene after touching the biohazard container and before touching the computer keyboard. 7. During a CVC exit site care observation on 02/25/2025 at 11:30 AM, PCT 1 removed her gloves, collected new gloves from the glove box at a computer station, donned new gloves, and provided care to Patient #14. PCT 1 failed to hand hygiene between gloving. 8. During discontinuation of dialysis with a CVC observation on 02/25/2025 at 2:10 PM, PCT 7 gloved, touched the computer keyboard, collected clean supplies, placed supplies on a chair side table at Station # 16, returned to the computer keyboard, then removed bloodlines from Patient #15. PCT 7 failed to change gloves and hand hygiene after touching the computer and before collecting clean supplies and placing them on the chair side table; failed to change gloves and hand hygiene after placing supplies on the chair side table and before touching the computer keyboard; failed to change gloves and hand hygiene after touching the computer and before removing Patient #15’s bloodlines. 9. During discontinuation of dialysis with a CVC observation on 02/25/2025 at 2:50 PM, PCT 1 removed the first bloodline from Patient #16, attached it to the dialysis machine to start reinfusing blood, and then disinfected CVC connections on Patient #15. PCT 1, with gloved hands, discarded all used and unused supplies and then assessed the patient with personal items. PCT 1 failed to change gloves and hand hygiene after removing bloodlines and disinfecting the CVC connections; failed to change gloves after touching dirty supplies and assisting the patient with personal items. 10. During a Discontinuation of dialysis with an AV observation on 02/25/2025 at 10:40 AM, PCT 2 disconnected one bloodline, reinfused blood, removed gloves, and then touched the computer keyboard. PCT failed to perform hand hygiene after removing gloves. PCT 2 placed one glove on, went to the clean area, collected supplies with both hands for Patient # 19, returned to Station #8, removed gauze from Patient #19 AV site, and then placed clean gauze over the AV site. PCT 2 failed to remove gloves and hand hygiene before collecting clean supplies, after collecting supplies, and before providing AV site care. PCT 2, with ungloved hands, removed dirty supplies from Station # 8 and then touched the computer keyboard. PCT 2 failed to use hand hygiene and gloves before removing dirty supplies and touching the keyboard. 11. During a medication preparation and administration observation on 02/25/2025 at 12:17 PM, RN 2 failed to hand hygiene before preparing Patient #20 medication. 12. During a medication preparation and administration observation on 02/25/2025 at 12:20 PM, RN 2 failed to hand hygiene before preparing Patient #21’s medication. 13. During an observation on 02/26/2025 at 8:55 AM, PCT 3 reached inside the biohazard container to pull it closer to station 15 using gloved hands. She removed the bloodlines from the machine and placed them in the biohazard container. The surveyor observed that the front part of PCT 3’s gown and sleeves came directly in contact with the red bag liner. Afterward, she provided patient care to Patient #12. PCT 3 failed to change gloves, perform hand hygiene, and change into a new gown after touching the biohazard trash container. During an interview on 02/26/2025 at 8:55 AM, PCT 3 stated she should change gloves and perform hand hygiene after touching dirty items. 14. During an interview on 02/26/2025 at 11:50 AM, PCT 1 indicated staff should change their hand hygiene and gloves when going from dirty to clean, before and after working on the computer, touching biohazard containers, and before and after changing gloves. Staff are not allowed to have one glove on and leave the station to retrieve supplies from a clean area. Staff should remove gloves and hand hygiene before collecting supplies, then should hand hygiene and re-glove. 15. During an interview on 02/26/2025 at 2:45 PM, RN 1 emphasized the importance of hand hygiene in various situations, including during glove changes, transitioning from a dirty to a clean area, and after handling trash containers. She highlighted that staff must perform hand hygiene before preparing medication and that RN should clean the IV access port with alcohol before access. She stated that if staff use gloves to pull biohazard containers to the station, a glove change and hand hygiene are necessary before providing care. RN 1 staff are not to wear gloves while working on the computer.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility staff failed to store supplies in a designated clean area for 1 of 3 observation days. Findings include: A revised 04/2023 policy titled “Infection Control for Dialysis Facilities” indicated that staff are to disinfect non-disposable items after each patient use and before removal from the treatment station. During an observation on 02/26/2025 at 9:42 AM, the surveyor found one can of Cryodose (topical numbing spray for injections), with its lid off, sitting on the treatment chair tray next to Patient #23 during dialysis treatment. During an interview on 02/26/2025 at 9:55 AM, PCT 4 stated that staff are to wipe the Cryodose with a bleach wipe after patient use, place the lid back on the Cryodose, and secure it in a locked drawer. During an interview on 02/26/2025 at 2:47 PM, RN 1 stated staff should place the Cryodose in a dirty area if they cannot disinfect the can after patient use. She stated staff should wipe the Cryodose can off with a bleach wipe, apply the lid, and place it in a locked drawer after use. She stated that staff should not leave the Cryodose to sit on the treatment chair tray during dialysis treatment.”

“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: 38262 Based on observation, record review, and interview, the facility failed to follow applicable infection control procedures when cleaning and disinfecting contaminated surfaces and equipment for 2 of 2 observations of cleaning and disinfecting the dialysis station. (Stations #16 & #17) Findings include: 1. A revised 04/2023 policy titled “Infection Control for Dialysis Facilities” indicated that staff should clean and disinfect all surfaces of the dialysis station, including TV, blood pressure cuffs, and countertops. Staff must disinfect non-disposable items after each patient’s use before removal from the treatment/station area. 2. During cleaning and disinfection of the dialysis station observation on 02/25/2025 at 2:30 PM, PCT 7 failed to disinfect between the seat cushion and the right side of the chair; she failed to raise the chair side table and disinfect the chair under a chair side table while disinfecting Station 16. 3. During an observation on 02/27/2025 at 10:00 AM, PCT 6 removed the prime waste container from the dialysis machine at station 17 and emptied the contents into the sink. She returned to the station and placed the prime waste container onto the designated clean, snappy computer tray without disinfecting it. She walked to the bleach container to retrieve a wipe and clean the prime waste container. PCT 6 failed to disinfect the prime waste container before placing it in a designated clean area. During an interview on 02/27/2025 at 10:10 AM, PCT 6 stated she should disinfect the prime waste container before returning it to a clean area. PCT 6 stated that the snappy computer area was dirty. PCT 6 then changed her statement to say the area was considered clean.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 48387 Based on observation, record review, and interview, the staff failed to use an aseptic technique when administering intravenous (IV) medication for 2 of 4 RN IV-administered medication observations. (Patient #20 & Patient #21) Findings included: 1. A revised 10/2023 “Medication Policy” policy indicated that staff must use aseptic techniques when administering medications. The policy indicated that staff should prepare medications in an aseptic environment and perform proper hand hygiene. 2. During a medication preparation and administration observation on 02/25/2025 at 12:17 PM, RN 2 failed to use antiseptic on top of the vial stopper before accessing the vial with a needle; RN 2 failed to clean the IV line port before accessing and administering Patient #20’s medication. 3. During a medication preparation and administration observation on 02/25/2025 at 12:20 PM, RN 2 failed to use antiseptic on top of the vial stopper before accessing the vial with a needle; RN 2 failed to clean the intravenous IV line port before accessing and administering Patient #21’s medication. 4. During an interview on 02/26/2025 at 2:45 PM, RN 1 indicated before accessing the medication vial, the team members should clean the top with alcohol. Team members should use alcohol on the port before accessing IV lines.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 48387 Based on observation, record review, and interview, the staff failed to follow manufacturer instructions on the wait time to obtain accurate pH test results for 2 of 2 observations of staff preparing the Hemodialysis Machine. (Station #6 and Station #11). Findings include: 1. A document titled “E-Z Check 6.8 - 8.5 pH test Strips” indicates users should compare test results to the color scale on the bottle between 20 and 25 seconds after briskly shaking off excess solution. 2. During a random observation on 02/25/2025 at 11:40 AM, PCT 1 removed the pH test (a test to measure how acidic or basic a solution is) strip from the solution for station #6 and read the pH strip without looking at the clock or watch to allow for a 5-10 second test strip process time. PCT 1 failed to collect an accurate pH reading. 3. During a random observation on 02/25/2025 at 11:00 AM, PCT 1 removed the pH test strip from the solution for station #11 and read the pH strip without looking at the clock or watch to allow for a 5-10 second test strip process time. PCT 1 failed to collect an accurate pH reading. 4. During an interview on 02/26/2025 at 11:50 AM, PCT 1 indicated that staff should wait 15 seconds to read the results after dipping the pH strips. PCT 1 indicated during observation on 02/25/2025 that she did not wait 15 seconds to read the results. 5 During an interview on 02/26/2025 at 2:45 PM, RN 1 indicated staff should shake off excess fluid, wait 5 seconds and compare the results to the colors on the bottle.”

“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: 38262 Based on observation, record review, and staff interviews, the facility ’ s medical director failed to ensure staff followed all policies and procedures, including the Medication Policy, Utilizing Vascular Access Clamps Policy, Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy, and Initial Patient Assessment for New Patients Policy. (Patients #1, #4, #5, #6, #12, and #26 with the potential to affect all patients. Findings Include: Medication Policy A revised 11/2023 policy titled “Medication Policy” indicated, but was not limited to, “each vial is labeled with the initials of the person opening the vial and the expiration date.” During an observation on 02/25/2025 at 9:45 AM, the surveyor found two opened multiple-dose vials in medication refrigerator 1: Parsabiv (hyperparathyroidism medication) 10mg/2mL and Parsabiv 5mg/1mL. There were no initials or expiration dates on the vials by the person opening the medication. During an interview on 02/25/2025 at 9:48 AM, RN 1 stated that staff must initial and date the two opened multiple-dose vials located in medication refrigerator 1 at the time of opening. Vascular Clamp Assessment Policy 1. A revised 04/2019 policy titled “Utilizing Vascular Access Clamps” indicated that if staff uses vascular clamps, they should assess the thrill (palpable vibration) and a bruit (audible whooshing sound heard through a stethoscope) during use. The policy indicated staff should not leave vascular clamps on a patient for longer than 20 minutes. 2. During an observation on 02/25/2025 between 10:55 and 11:15 AM, Patient #26 sat with one clamp in place on the first AV fistula needle site; the staff failed to evaluate the thrill and bruit of the access before or during clamping. At 11:20 AM, PCT 7 removed the first clamp and placed the second clamp over the second needle removal site. From 11:20 AM to 11:40 AM, a second clamp was in place on the AV fistula; the staff failed to evaluate the thrill and bruit of the access before or during clamp application. 3. During an interview on 02/26/2025 at 11:50 AM, PCT 1 indicated that clamps should be left for 5 to 10 minutes unless ordered by the physician. Patients should be checked for a thrill, both above and below the access site, every 5 minutes. 4. During an observation on 02/26/2025 at 8:55 AM, PCT 3 placed a vascular clamp on Patient #12 ’ s left AV access site after disconnecting the bloodlines. PCT 3 left the station. Patient #12 ’ s clamp stayed in place for 20 minutes. RN 1 came to the station to remove the clamp. The staff failed to assess the site for thrill and a bruit while using a vascular clamp. 5. During an interview on 02/26/2025 at 9:30 AM, RN 1 stated that staff could apply vascular clamps to access sites for 10 minutes. She stated Patient #12 has to leave the vascular clamp on longer to stop the bleeding. She stated staff should assess for thrill and bruit during clamp use. 6. During a random interview on 02/26/2025 at 12:00 PM, PCT 1 indicated that clamps should be left for 5 to 10 minutes unless ordered by the physician. Patients should be checked for a thrill, both above and below the access site, every 5 minutes. 7. During an interview on 02/26/2025 at 4:15 PM, the Manager of Clinical Services stated staff should assess for a thrill and bruit every 5 to 10 minutes when clamps are in place. Pre-Intra-Post Treatment Data Collection Policy 1. A revised 04/2024 policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” indicated that licensed nurses should confirm patients’ prescriptions and perform a nursing assessment on patients within one hour of treatment initiation. The policy indicated that a PCT or nurse would obtain and document a post-assessment for each patient. 2. A review of Patient #1 ’ s record evidenced a Treatment Details Report dated 02/12/2025. The treatment record failed to evidence that the staff completed and documented a post-assessment. During an interview on 02/27/2025 at 2:50 PM, the Manager of Clinical Services indicated the nurse is required to do a post-assessment; she failed to provide evidence of a post-assessment in Patient #1 ’ s record for 02/12/2025. 3. A review of Patient #4 ’ s record evidenced a Treatment Details Report dated 01/24/2025. The treatment record failed to evidence that the staff completed and documented a post-assessment. During an interview on 02/26/2025 at 2:47 PM, RN 1 stated staff should complete a post-assessment before the patient leaves the treatment area. RN 1 wasn ’ t sure why she did not complete a post-assessment on Patient #4. 4. A review of Patient #5 ’ s record evidenced a Treatment Details Report dated 02/14/2025. The treatment record failed to evidence that the staff completed and documented a post-assessment. During an interview on 02/28/2025 at 9:00 AM, the Manager of Clinical Services reviewed Patient #5 ’ s record. She stated the CWOW (electronic medical record) would not close out until a post-assessment was complete. She stated it must be a glitch in the CWOW system and that she would have to contact them. 5. During an interview on 02/28/2025 at 9:00 AM, the Manager of Clinical Services reviewed Patient #5 ’ s record. She stated the CWOW (electronic medical record) would not close out until a post-assessment was complete. She stated it must be a glitch in the CWOW system and that she would have to contact them. 6. On 02/28/2025 at 8:35 AM, the Medical Director stated the nurse should complete a post-assessment on all patients. Initial Patient Assessment for New Patients Policy A revised 04/2024 policy titled “Initial Patient Nursing Assessment for New Patients” indicated the RN was required to perform an initial pre-assessment evaluation of all patients before initiating their first dialysis treatment at the facility. A review of Patient #6 ’ s record evidenced an admission date of 01/14/2025, an Initial Patient Nursing Assessment date of 01/21/2025, and a Treatment Details Report dated 01/14/2025. The facility nurse failed to complete the initial assessment before initiating Patient #6 ’ s first dialysis treatment. During an interview on 02/27/2025 at 4:00 PM, the FA stated the RN should have completed the initial assessment before initiating Patient #6 ’ s first dialysis treatment. During an interview on 02/28/2025 at 9:15 AM, the Manager of Clinical Services stated the nurse who initiated the first treatment was a float nurse who was not currently at the facility. She said RN 1, who completed the initial assessment, did not know why the float nurse didn ’ t complete the assessment timely.”