Davita Spring Street Dialysis

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 38262 Based on record review and interview, the facility failed to update the dialysis prescriptions and emergency contact information binder for 1 of 1 evacuation kit reviewed, with the potential to affect 22 of 22 active in-center dialysis patients during an emergency evacuation. (Evacuation Binder) Findings include: An April 2022 policy titled Facility Emergency Management Plan (ICHD, Home) was provided by the Administrator on 11/14/2023 at 12:49 PM. The policy indicated, but was not limited to, “Emergency Evacuation Kit ... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list. FA or designee will verify patient information is updated and replaced at least monthly. ...” During the treatment area observation on 11/13/2023 at 10:00 AM, the emergency evacuation binder was reviewed with Registered Nurse (RN) 1. The prescriptions and emergency contact information for 22 current in-center patients in the emergency evacuation binder were dated 09/23/2023. At that time, RN 1 stated that the prescriptions are to be updated monthly by the Alternate Administrator. During an interview on 11/15/2023 at 10:10 AM, the Medical Director stated the expectation was for the staff to follow facility policy.”

“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: 48387 Based on observation, record review and interview the facility failed to ensure gloves were changed appropriately, and hand hygiene was performed effectively for 6 of 10 patient care observations and 1 of 2 station disinfection (Patient #1, #4, #6, #7, #12) (Station #2) Findings include: 1. A 2019 revised policy titled “Infection Control for Dialysis Facilities” was provided on 11/13/2023 at 3:55 PM by the Facility Administrator. The policy indicated, but was not limited to, “ ... 1. Hand hygiene is to be performed upon entering patients treatment area, prior to gloving, after removal of gloves ... after patient and dialysis delivery system contact, between patients even if the contact is casual ... 47. Hand hygiene should be performed ... before patient contact ... 76. Gloves are to be removed and hands washed or alcohol based hand rubs used before and after touching keyboard ... “. 2. During an observation on 11/13/2023 at 10:15 AM, Patient Care Technician (PCT) 1 touched a shared computer keyboard and then gloved to disconnect bloodlines from Patient #6 without performing hand hygiene. PCT 1 then assisted another patient before returning to patient #6. PCT donned new gloves without performing hand hygiene and then performed final bandage change on needle sites. 3. During an observation on 11/13/2023 at 11:50 AM, PCT 2 emptied the prime waste receptacle at Station 2 and changed gloves without performing hand hygiene 4. During an observation on 11/13/2023 at 12:40 PM, PCT 2 discontinued dialysis without first performing hand hygiene,removed the needles from the patient’s arteriovenous (AV) fistula (an irregular connection between an artery and a vein). PCT failed to perform hand hygiene after completing Patient #4’s care and removing gloves. 5. During an observation on 11/13/2023 at 12:50 PM, PCT 2 took a bunched up glove in his/her gloved hand to push buttons on the dialysis machine at station 7 then returned to patient care, without performing hand hygiene or changing gloves. 6. During an observation on 11/13/2023 at 1:45 PM, PCT 2 provided patient care to Patient #12, exited the isolation room then he/she removed one glove, with the ungloved hand. He/She removed their N95 mask then removed their safety glasses and placed the earpiece of their safety glasses into their mouth to hold while removing their remaining personal protective equipment. 38262 7. During an observation on 11/13/2023 at 11:47 AM, PCT 1 failed to remove gloves and perform hand hygiene after initiating dialysis treatment to Patient #1 and before leaving station 4. 8. During an observation on 11/13/2023 at 11:52 AM, PCT 2 used a waded-up glove to silence Patient #7’s dialysis alarm. PCT 2 failed to immediately remove gloves and perform hand hygiene after disconnecting bloodlines from Patient #7 and before handling Patient #7’s personal items. 9. During an interview on 11/13/2023 at 4:00 PM, the Regional Manager of Clinical Services indicated staff should not be rolling up gloves to touch the dialysis screen and staff should be performing hand hygiene before and after gloving. 10. During an interview on 11/15/2023 at 9:47 AM, the Medical Director (MD) indicated he/she would expect staff to follow facility policy.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 48387 Based on observation, record review, and interview the facility failed to ensure sink stations were equipped with warm water for 1 of 2 observation days. Findings include: 1. A 2019 revised policy titled “Infection Control for Dialysis Facilities” was provided on 11/13/2023 at 3:55 PM, by Administrator. The policy indicated, but was not limited to, “ ... 39 ... Sinks must be plumbed with both hot and cold water ... 44 ... Clean areas should be clearly designated ...” 2. A 2019 revised policy titled “Physical Environment” was provided on 11/14/2023 at 11:14 AM, by Administrator. The policy indicated, but was not limited to, “ ... 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates and the public ...”. 3. During an observation of the treatment room on 11/13/2023 at 9:50 a.m. 6 of 6 sink stations failed to be plumbed with hot water. 4. During an interview on 11/13/2023 at 9:30 AM, Patient Care Technician (PCT) 1 indicated there was no hot water on the treatment floor or in the bathrooms, due to the water heater going out last Wednesday. 5. During an interview on 11/13/2023 at 4:00 PM, the Facility Administrator (FA) indicated he/she was aware of the water heater being out of service. 6. During an interview on 11/15/2023 at 9:47 AM, the Medical Director (MD) indicated he/she was informed on Monday (11/13/2023) that the facility had no hot water.”

“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: 48387 Based on observation, record review, and interview the facility failed to properly clean and disinfect surfaces and equipment for 1 of 2 dialysis stations. (Station 6) Findings Include: A 2019 revised policy titled “Infection Control for Dialysis Facilities” was provided on 11/13/2023 at 3:55 PM, by the Facility Administrator. The policy indicated, but was not limited to, “ ... 73. Sufficient disinfectant should be applied so that surfaces are visibly wet ...” During an observation on 11/13/2023 at 12:15 PM, Patient Care Technician 1 disinfected all of Station 6 using onlyb one cloth/wipe for the entire station. This surfaces failed to be visibly wet. During an interview on 11/13/2023 at 1:00 PM, Registered Nurse 1 indicated dialysis stations should be disinfected using more than one bleach wipe after patient use.”

“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: 38262 Based on observation, record review, and interview, the facility failed to properly label an open multi-dose vial of Tubersol (medication used to test for tuberculosis). Findings include: 1. A 2023 revised policy titled “Medication Policy” was provided on 11/14/2023 at 12:50 PM, by the Administrator. The 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 of the treatment room on 11/13/2023 at 9:50 a.m., an unlocked medication cart had an opened Cinacalcet 30 mg with illegible markings of open date and initials. The following opened medications: Cinacalcet 60 mg dated 09/22/23, Calcitriol 0.25 mcg dated 10/30, and a vial of Heparin 30,000 unit/ 20 ml dated 11/15/23 were not initialed. 2. During the treatment floor observation on 11/13/2023 at 10:00 AM, the medication refrigerator contents were reviewed and evidenced an opened vial of Tubersol ® (test for bacteria that affects the lungs) undated and without initials. At that time, Registered Nurse (RN) 1 stated he/she opened the vial on Friday and forgot to date and initial it. 48387 3. During an interview on 11/13/2023 at 4:00 PM, the Regional Manager of Clinical Services indicated all open medications should be dated and initialed upon opening.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 38262 Based on record review and interview, the facility failed to ensure the monthly Reverse Osmosis (RO), purified water, rejection water flow rate was performed and recorded on the water treatment log for 1 of 1 water treatment log reviewed. Findings include: A September 2013 policy titled Monthly Water Treatment System Monitoring was provided by Bio Med 2 on 11/14/2023 at 12:17 PM. The policy indicated, but was not limited to, “1. All observations and test results are to be recorded on the Monthly Water Treatment Log.” The Monthly Water Treatment log was reviewed along with Bio Med 2 on 11/14/2023 at 11:12 AM. The RO Monthly Rejection Water Flow Rate was not performed or recorded for 04/2023, 05/2023, 06/2023, 07/2023, and 08/2023. Bio Med 2 stated the facility replaced the person that was to perform the test and the test was apparently not performed during the transition. On 11/14/2023 at 12:10 PM Bio Med 1 was still determining why nothing was recorded for five months.”

“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: 48387 Based on observation, record review, and interview the facility failed to maintain equipment in a safe and functional working condition for 1 of 2 observation days. Findings include: 1. A 2019 revised policy titled “Physical Environment” was provided on 11/14/2023 at 11:14 AM, by the Administrator. The policy indicated, but was not limited to, “ ... 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates, and the public ...” 2. During an observation of the water room on 11/13/2023 at 9:35 PM, an acid leak was observed, coming from a pipe between the primary and secondary acid tanks, with a build-up of crystallization from connecting pipes to the floor. A mini freezer was set directly on the floor, over the drain, between the acid tanks, with the door open. The water heater was leaking from a pipe that was connected to the bottom of the heater, resulting in standing water in the walkway of the water room. 3. During an interview on 11/13/2023 at 2:20 PM, the Biomed Supervisor indicated black stains on the wall were spilled acid, that had not been cleaned up. He/she indicated spills should be cleaned up at the time of the incident by the person who created the spill and the mini freezer should not be placed on the floor over the drain to defrost. 4. During an interview on 11/13/2023 at 2:25 PM, Biomed 1 indicated he/she was not aware of the acid leak, and it was his/her responsibility to fix the leak. 5. During an interview on 11/15/2023 at 9:47 AM, the Medical Director indicated leaks should be fixed, acid spills should be cleaned up and the freezer should not be placed on the floor in the water room to be defrosted.”

“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: 48387 Based on record review and interview the facility’s interdisciplinary team failed to monitor, report, and treat blood pressures outside of normal ranges during and post dialysis treatment on 2 of 5 record reviews. (Patient #4 and #5) Findings include: 1. A 2019 revised policy titled “Infection Control for Dialysis Facilities” was provided on 11/13/2023 at 3:55 PM, by the Facility Administrator (FA). The policy indicated; but was not limited to, “ ... 70. All dialysis patients must be clinically stabilized (i.e., stable blood pressure, ... ) following their dialysis treatments before being moved from the dialysis station ...” 2. A 2019 revised policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” was provided on 11/13/2023 at 3:55 PM, by the FA. The policy indicated; but was not limited to, “ ... 6. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis ... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status ... Members of the patient team should report ANY changes in patients conditions or concerns of patient well-being immediately to the licensed nurse ...Blood pressure Pre-treatment: 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 or less than 50 mm Hg.” 3. The clinical record for Patient #4 was reviewed on 11/13/2023 and evidenced the following: A treatment record dated 10/20/2023 indicates a post-treatment BP of 158/110. A treatment record dated 10/23/2023 indicating pre-treatment 195/70, intra-treatment blood pressures of 182/67, 193/79, 182/61, 184/74, 193/76, 138/105, a post-treatment BP of 182/72. A treatment record dated 10/27/2023 indicating pre-treatment 186/80, and intra-treatment blood pressures of 194/70, 204/72, 174/72, 193/39. A treatment record dated 10/30/2023 indicated intra-treatment blood pressures of 181/85, 180/87, 185/87, and a post-treatment BP of 202/95. A treatment record dated 11/01/2023 indicates intra-treatment blood pressures of 158/114, 181/68, and a post-treatment BP of 222/86. A treatment record dated 11/03/2023 indicated intra-treatment blood pressures of 159/103, 162/117, 182/106, 187/65, and a post-treatment BP of 207/78. A treatment record dated 11/06/2023 indicated pre-treatment 195/72, and intra-treatment blood pressures of 181/93, 138/106. A treatment record dated 11/08/2023 indicating pre-treatment 216/93, intra-treatment blood pressures of, 216/69, 206/56, 197/34, 184/38, 184/36, 184/36, a post-treatment BP of 170/58. A treatment record dated 11/10/2023 indicated intra-treatment blood pressures of, 162/32, 166/46, 180/40, 190/34, and 148/59. 4. The clinical record for Patient #5 was reviewed on 11/13/2023 and evidenced the following: A treatment record dated 10/23/2023 indicated intra-treatment blood pressures of 177/96, 194/103, 198/112, and a post-treatment BP of 155/101. A treatment record dated 11/01/2023 indicates intra-treatment blood pressures of 168/106, 174/113, and 255/114. 5. During an interview on 11/14/2023 at 1:10 PM, the Administrator’s Assistant indicated he/she was unable to locate documentation the physician was notified of blood pressures out of normal ranges in Patient #4’s chart. 6. During an interview on 11/14/2023 at 2:20 PM, the FA indicated he/she would expect staff to contact the physician with blood pressures outside normal limits. 7. During an interview on 11/15/2023 at 8:45 AM, Registered Nurse (RN) 1 indicated he/she discusses blood pressure outside of normal parameters, however, fails to document in the clinical record. He/she indicated no treatment or doctor notification for most of the patients with high blood pressure because high blood pressure is normal for those patients, and he/she knows this because he/she knows her patients. RN 1 also indicated he/she does a post-treatment assessment and if there are no complaints by the patient then they would be sent home. He/she indicated if it was a new patient having blood pressures outside normal ranges, then the physician would be notified, due to not knowing the patient’s normal. RN 1 indicated if blood pressure is extremely low, he/she would contact the physician to receive an order for a fluid bolus (a single, large dose of medicine) or to confirm if his/her treatment should continue. He/she indicated if a call was made or new orders were received, there would be a note made in the chart. 8. During an interview on 11/15/2023 at 9:47 AM, the Medical Director indicated he/she would expect staff to notify him/her of blood pressures outside of normal limits for that patient.”