Davita Three Rivers 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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure bleach solution was stored per policy for 2 of 4 treatment floor observations. Findings include: 1. Review of the Bleach Policy, revised October 2023, indicated “ ... Bleach solution needs to be covered with a secure lid ... Without a secure lid, the bleach solution is open to air causing the solution to degrade over time and become less effective ...” 2. A treatment floor observation was conducted on 12/19/25 from 9:45 AM to 10:20 AM. At 9:49 AM, observed unattended 1:10 bleach solution near the “dirty” sink across from Station 4 with the lid completely open. During an interview on 12/19/25 at 9:50 AM, PCT 1 relayed she must have forgotten to close it when asked if the bleach container with clamps was usually open. 3. A treatment floor observation was conducted on 12/19/25 from 2:00 PM to 3:25 PM. At 2:48 PM, observed the 1:10 and 1:100 bleach solution containers outside the isolation room with the lids not secured. At 3:09 PM, the 1:100 bleach solution was closed. The 1:10 bleach solution was observed to still be open at 3:22 PM. During an interview on 12/19/25 at 2:21 PM, RN 1 relayed bleach solution should remain covered until you use it, and then it needed to be re-covered.”

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff followed infection control procedures related to hand hygiene and glove use for 3 of 5 PCTs observed (PCT 2, 3, 4). Findings include: 1. Review of the Infection Control for Dialysis Facilities policy, revised April 2023, indicated “ ... All teammates ... will perform hand hygiene ... prior to gloving and immediately after removal of gloves ... after patient and dialysis delivery system contact ...” 2. On 12/19/25 at 2:10 PM, observed PCT 3 removed gloves used to touch the dialysis machine and then entered a supply drawer for saline syringes without first performing hand hygiene. During an interview on 12/19/25 at 2:17 PM, PCT 3 relayed hand hygiene should be performed after glove removal. 3. On 12/19/25 at 3:13 PM, observed PCT 4 changed gloves without performing hand hygiene in between. During an interview on 12/29 25 at 3:49 PM, PCT 4 relayed hand hygiene should be performed every time you change gloves. 48224 4. During an observation on 12/22/25 at 10:55 AM, PCT 2 was observed initiating dialysis via CVC with Patient #20. PCT 2 flushed the CVC access sites, then touched the machine monitor, rearranged the machine closer to Patient #20 and proceeded to connect the blood lines. PCT 2 failed to change gloves after touching and rearranging the dialysis machine prior to connecting the blood lines. During an interview on 12/22/25 at 1:23 PM, the Administrator stated the dialysis machine was considered dirty and gloves should have been changed after touching and rearranging the dialysis machine.”

“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: 45607 Based on observation record review and interview, the Medical Director failed to ensure staff followed all policies and procedures related to medication preparation and storage for 1 of 1 Medical Director. Findings include: 1.Review of the Medical Director Qualifications and Responsibilities Policy, dated September 2008, indicated “ ... Medical Director Responsibilities ... Oversight of policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the center ...” 2. Review of the Medication Policy, revised October 2023, indicated “ ... All teammates administering medications must utilize aseptic technique ... Multi-use vials used for IV administration must be entered each time with a new sterile syringe and needle due to Centers for Disease Control (CDC) guidance ... All medications are checked monthly for expiration dates ... Disposal of expired medications ... are removed from the treatment and inventory areas and disposed of per state/local regulations ...” 3. Observation of IV heparin (a medication used to prevent blood clots) preparation for Patient #12 was conducted on 12/19/25 beginning at 2:03 PM. PCT 3 drew up heparin into a syringe and then re-entered the heparin vial with the same needle. PCT 3 also did not scrub the stopper with an alcohol swab prior to the second needle entry. PCT 3 repeated the same process for the second syringe of heparin for Patient #12. During an interview on 12/19/25 at 2:15 PM, PCT 3 indicated she shouldn’t have to scrub the vial stopper again before re-entering the vial with the same needle, but she wasn’t sure about it. During an interview on 12/22/25 at 1:23 PM, the FA relayed when drawing up medication from a multi-dose vial, the procedure was to scrub and then access only once. The FA further indicated if the staff did not draw up enough medication the first try, they should get a second syringe to make the total of the dosage. The FA also relayed the policy did not specifically state the vial must be scrubbed again before re-entry, but they had looked up some training which indicated the vial should be scrubbed before each needle entry. 4. On 12/19/25 at 10:17 AM, observed 10 vials of Vancomycin (a medication used to treat serious bacterial infections) with an expiration date of 11/2025 in a treatment floor medication drawer. During an interview on 12/19/25 at 2:21 PM, RN 1 relayed expired medication should not be in the medication drawer. After being shown the expired Vancomycin, RN 1 put a note on the package indicating it was expired. 5. During an interview on 12/23/25 at 1:28 PM, the Medical Director relayed she was responsible for ensuring staff followed all policies and procedures.”