Davita La Porte Dialysis

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 47022 Based on observation, record review, and interview, the facility failed to evidence they implemented their biohazard and infection control policies within the dialysis unit for 1 of 1 active in-center hemodialysis (a process to clean the blood of a patient whose kidneys do not work normally) patient with a documented MRSA (methicillin resistant staphylococcus aureus, antibiotic resistant) infection (Patient #3) of their central venous catheter (CVC) ((tube into a large vein). Findings include: 1. A revised policy dated October 2024, titled “Multi Drug Resistant Organism Management,” indicated for patient infections caused by drug resistant organisms, additional guidance would include temporary additional precautions for MRSA to include patient placement, with as few adjacent stations as possible, PPE (personal protective equipment) including gowns are removed and discarded after care of the patient, and separate patient supplies including stethoscope and blood pressure cuff would be utilized. The policy indicated that antimicrobial resistant bacteria are more common in patients with severe illness and in health care settings, including hemodialysis centers, and can serve as a source for transmission. 2. The clinical record for Patient #3 included a prescription uploaded from Entity 1, a hospital, dated 07/11/2024, indicated Patient #3 was to receive Vancomycin (antibiotic) intravenously (via a vein) for 12 days post dialysis due to a diagnosis of a MRSA infection of Patients’ CVC, for which they receive their hemodialysis treatments. A. The clinical record included a culture (a test to grow organisms to help diagnosis infections) was collected by Entity 1, on 07/10/2024; the culture report identified MRSA. B. The clinical record included a follow up blood culture was collected on 07/29/2024, collected by the dialysis facility, which indicated no growth was detected. C. Treatment Detail Reports dated 07/12/2024, 07/15/2024, 07/17/2024, and 07/19/2024 indicated PCT 3 changed Patients’ CVC dressing on these dates. The Treatment Detail Reports indicated Patient #3 received their hemodialysis (HD) treatment at station 6 on 07/12/2024, at station 1 on 07/15/2024, at station 7 on 07/17/2024 which were each adjacent to other stations. A Treatment Detail Report from 07/19/2024 indicated Patient #3 received their HD treatment at station 12, the isolation room. The Treatment Detail Reports failed to evidence the precautions taken for the known MRSA infection. D. The culture report, dated 08/28/2024, identified positive growth from the right arm was collected on 08/26/2024. E. A nursing note titled, “Patient Note” and dated 07/12/2024, indicated Patient arrived at the dialysis facility, from a recent hospitalization, with a Vancomycin order. The note indicated Patient’s nephrologist (kidney doctor) reviewed the order for the Vancomycin. F. A nursing note titled, “Patient Note” and dated 07/19/2024, indicated Patient’s nephrologist read the Vancomycin order from the hospital. G. An Infection Snapshot Report dated 07/19/2024 to 07/26/2024 indicated Patient received Vancomycin for an infected exit site infection of the CVC with patient symptoms of purulent drainage (fluid from a wound that normally indicates infection) and chills. H. A Nursing Note, titled, “Patient Note,” dated 08/26/2024 indicated the patient was hospitalized due to an infectious emboli (clot) and was septic (severe response to an infection). I. A prescription from Entity 1, dated 09/05/2024, indicated Patient was to receive Vancomycin intravenously during the last hour of dialysis until 09/26/2024 for diagnosis of MRSA bacteremia (bacteria in the blood). J. An Infection Snapshot Report dated 09/09/2024 to 09/27/2024 indicated Patient received Vancomycin for a systemic (affecting the whole body) infection of staphylococcus aureus (a type of bacteria). K. The clinical record failed to evidence follow up culture(s) after informed of the MRSA bacteremia diagnosis as documented on the 9/05/2024 prescription. L. The clinical record failed to evidence interventions in place for the dialysis clinic staff, during the provision of care for Patient #3, with a diagnosed MRSA infection, beginning 7/10/2024. 3. During an interview on 12/30/2024, beginning at 8:40 AM, RN 1 indicated MRSA precautions are standard precautions. 4. During an interview on 12/30/2024, beginning at 1:50 PM, the Administrator indicated the facility had a MRSA policy but was unsure of the guidelines. During a follow up interview on 12/30/2024, beginning at 2:40 PM, the Administrator indicated there was not documentation of interventions and or special precautions used after their were aware and during the time of Patient’s active MRSA infection. The Administrator was unable to verbalize the precautions taken by the staff during this time or the precautions that should have been in place. 5. During an interview on 12/30/2024, beginning at 2:00 PM, the Medical Director indicated MRSA protocols would include using the isolation room, dedicated gloves and PPE gowns for the staff to care for the MRSA patient, repeat cultures and monitoring follow up.”

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure PCT 3 administered the correct hemodialysis [HD] (a process to clean the blood of a patient whose kidneys do not work normally) prescription in 1 (Patient 12) of 5 active in-center hemodialysis [HD] prescriptions reviewed with the RN Clinical Coordinator, while patients were receiving HD. Findings include: A job description dated, 04/2023 and titled “Patient Care Technician ICHD [In-Center Hemodialysis]Expert” indicated the PCT’s essential function would include, but not limited to, a review of the dialysis prescription and initiation of dialysis. An undated job description titled “Clinical Coordinator ICHD Advanced” indicated essential functions would include, but not limited to, monitoring direct patient care administered by the PCT’s. During an observation on 12/30/24, beginning at 1:44 PM, Patient #12, at station #2, was receiving the dialysate bath of 2K (Potassium) 2.5Ca (Calcium). The electronic medical record evidenced the most recent dialysis prescription was dated 12/18/2024 and indicated the dialysis bath prescribed was 3K 2.5 Ca. A Treatment Detail Report dated 12/30/2024 indicated at 1:25 PM a 2K 2.5 Ca dialysate bath was initiated on Patient #12 by PCT 3. During an interview on 12/30/2024 beginning at 1:46 PM, RN 1 indicated Patient did not receive the correct dialysis bath. RN 1 indicated PCT 3 entered the dialysis prescription incorrectly and initiated treatment.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 47022 Based on record review and interview, the dialysis facility failed to evidence they tracked infections to identify trends and established baseline information in infection incidence in 1 of 1 facility. Findings include: 1. A revised policy dated April 2021, titled, “Continuous Quality Improvement Program,” indicated facility administrators would conduct period Facility Health Meetings (FHM) also known as QAPI (quality assessment and performance improvement to review issues and indicators regarding the facility’s performance are conducted monthly. The policy indicated written documentation and plans of action would be documented and quality improvement meeting minutes would be provided upon request to Center for Medicare Services. The policy indicated the facility would measure, analyze and track quality indicators and would include but not limited to the following: infection control including incidence of infections. The policy indicated the infection control monitoring would be reflected in the meeting minutes. 2. The QAPI binder included an ICMR (Indiana Council on Medical Research) (Hospital Infection Control Guidelines) Infection Dashboard from January 2024 to October 2024, indicated the facility did not have blood stream infections, nor access related blood stream infection, nor local access site infection, nor vascular access infections, and no intravenous antibiotic were started. The QAPI binder had no further infections documented. 3. A Nursing Note from Entity 1, a hospital, dated 07/07/2024, indicated Patient #3, in-center hemodialysis (ICHD) patient, was admitted on 07/07/2024 and the dialysis catheter had foul, purulent (drainage indicative of infection) drainage from the insertion site and cultures (a test to grow microorganisms to help diagnosis infection) were collected. A Prescription dated 07/11/2024 from Entity 1, indicated vancomycin (an antibiotic) was to be given intravenously (through a vein) after hemodialysis due to a hemodialysis catheter MRSA (methicillin resistant staphylococcus aureus) (drug resistant) infection. A Prescription dated 09/05/2024 from Entity 1, indicated vancomycin was to be given intravenously during the last hour of hemodialysis due to a diagnosis of MRSA bacteremia (infection of the blood). 4. An Infection Snapshot Report, dated 08/01/2024 to 08/31/2024, for Patient #14, a peritoneal dialysis patient (dialysis through an abdominal tube), indicated Patient was prescribed Cephalexin (an antibiotic) for a localized exit site infection of the peritoneal dialysis catheter with symptoms that included proud flesh (excessive formation of tissue that protrudes above a wound’s surface and appears beefy red with a moist surface). A nursing note titled, “Patient Note,” dated 08/28/2024, indicated the patient’s exit site had a small amount granulation tissue and mild redness and was started on cephalexin. During an interview on 12/31/2024, beginning at 12:15 PM, the Regional Clinical Manager,Corporate Person 1, indicated there were not documented peritoneal catheter infections or peritonitis (inflammation of the lining of the abdomen) for the QAPI program. 5. An Infection Snapshot Report, dated 08/01/2024 to 08/31/2024, for Patient #4, a peritoneal dialysis patient, indicated cephalexin was prescribed for a suspected infection associated with the genitourinary system. 6. An Infection Snapshot Report, dated 11/29/2024 to 12/13/2024, for Patient #7, an ICHD patient, indicated levofloxacin (antibiotic) was prescribed 04/05/2024.The Infection Snapshot Report failed to evidence the reason the antibiotic was prescribed. During an interview on 12/31/2024, beginning at 12:15 PM, Corporate Person 1 indicated Patient was prescribed levofloxacin for a urinary tract infection. 7. An Infection Snapshot Report dated 11/29/2024 to 12/31/2024, for Patient #15, an ICHD patient, indicated cephalexin was prescribed 12/13/2024 to 12/16/2024. The Infection Snapshot Report failed to evidence the reason the antibiotic was prescribed. 8. A Hospitalization Log indicated Patient #3 was hospitalized 07/07/2024 with an access infection and 08/25/24 with a blood stream infection. 9. A Hospitalization Log indicated Patient #2 was hospitalized 11/17/2024 with a wound infection. 10. During an interview on 12/31/2024, beginning at 12:15 PM, Corporate Person 1 indicated the Facility Infection Manager Monthly checklist dated August 2024 indicated blood stream infections were tracked and an infection log was optional and was not completed. 11. During an interview on 12/26/2024, beginning at 3:00 PM, the Administrator indicated there was not a facility infection log and documentation of dialysis related infections would be in the QAPI binder and non-dialysis related infections would be in the patient’s clinical record. 12. During an interview on 12/27/2024, beginning at 2:30 PM, Corporate Person 1 indicated infections, dialysis and non-dialysis related) are documented, the facility did not have an infection log and infections would be documented in QAPI and discussed at monthly QAPI meetings. Corporate Person 1 indicated the blood stream infection for Patient #3 was not included on the facility’s blood stream infection report due to was diagnosed while admitted in the hospital and indicated the blood stream infection would be on the QAPI infections documentation. 12. During a follow up interview on 12/31/2024, beginning at 12:15 PM, the Administrator indicated there was not documentation of QAPI meeting minutes that would include infections that were discussed. 13. A review of Huddles completed from 06/07/2024 to 12/13/2024 failed to evidence documentation infection review was completed. 14. During a follow up interview during the QAPI review on 12/31/2024 beginning at 12:15 PM, Corporate Person 1 indicated dialysis related and non-dialysis related infections are documented in each patient’s individual charts, andinfections are discussed weekly at huddle meetings. Corporate Person 1 indicated infections are determined by diagnosis or if a patient were on antibiotics. Corporate Person 1 indicated trends for infections are not monitored. 15. During a follow up interview on 12/31/2024, beginning at 1:00 PM, Corporate Person 1 indicated a culture would be needed to confirm a peritoneal catheter infection even if antibiotics were given for redness at the insertion site in order to be added to the peritoneal catheter infection tracking ICMR Report. Corporate Person 1 indicated the facility would not identify trends of nondialysis related infection and a urinary tract infection would not be tracked.”