Davita Terre Haute 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: 48387 Based on record review and interviews the facility failed to update the patient treatment list in the emergency preparedness binder every month for 1 of 1 facility binder reviewed. Findings include: 1. A 04-2024 revised policy titled “Facility Emergency Management Plan” indicated that the evacuation kit should contain a copy of each patient’s treatment orders and medication list, which should be updated monthly. 2. During the flash tour on 09/10/2024, the Evacuation Kit in the Home dialysis treatment area contained an August 1, 2024, patient treatment order and medication list. The facility failed to update treatment orders and medication lists every 30 days. 3. During an interview on 09/10/2024 at 11:05 AM, RN 1 indicated that the Emergency patient list should be updated monthly, and it hadn’t been checked this month.”

“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 staff failed to perform hand hygiene for 3 of 3 central venous catheter (CVC) observations (Patients #11, #12, #20); and failed to perform hand hygiene after removing gloves and before touching clean items for 5 of 12 patient care observations. treatment floor observations.(RN 5, PCT 2, 3, 4, 5) Findings include: 1. An April 2023 policy titled “Infection Control for Dialysis Facilities” The policy indicated that staff members are required to perform hand hygiene before and immediately after removing gloves, as well as before touching clean areas and supplies. 2. During an observation on 09/10/2024 at 3:30 PM, with gloved hands, Patient Care Technician (PCT) 2 removed Patient 11’s old CVC dressing, cleaned the CVC exit site on Patient #11, and then applied a sterile dressing to the CVC exit site. PCT 2 then cleaned CVC ports, removed gloves, and touched the computer. PCT 2 failed to change gloves and perform hand hygiene after removing the old dressing and before cleaning the CVC exit site. PCT 2 failed to change gloves and perform hand hygiene before cleaning CVC ports and failed to perform hand hygiene before touching the computer. 3. During an observation on 09/10/2024 at 2:40 PM, PCT 3 touched the computer mouse and then touched Patient #6’s dialysis machine without performing hand hygiene or gloving. 4. During an observation on 09/10/2024 at 3:50 PM, PCT 3 removed Patient #12 old CVC dressing and cleaned the CVC exit site. PCT 3 failed to change gloves and perform hand hygiene after removing Patient #12’s old dressing and before cleaning the CVC exit site. 5. During an observation on 09/10/2024 at 1:25 PM, PCT 3 gloved hand touched Patient # 15’s dialysis machine monitor, then touched the computer cart and returned to the dialysis machine. PCT 3 failed to perform hand hygiene or glove change after touching the dialysis machine and before or after touching the computer, or after touching the computer and before touching the dialysis machine. 6. During an observation on 09/10/2024 at 2:05 PM, PCT 2 used a gloved hand to touch the dialysis machine, left the station #3 area to collect their stethoscope and clean supplies, then returned to station #3 to provide care to Patient #14. PCT failed to change gloves and perform hand hygiene between touching the dialysis machine, and collecting clean supplies and before providing care to the patient. 7.During a random observation on 09/10/2024 at 3:15 PM, PCT 2, with gloved hands, touched the dialysis machine screen at station #13, then went to station #12 and touched the dialysis machine screen. PCT failed to perform glove change and hand hygiene. 8. During a random observation on 09/10/2024 at 3:17 PM, PCT 2 touched the dialysis machine, then removed one glove, left Station #13 with one hand gloved on, collected the clean supplies, and returned to Station #13, placed the glove on ungloved hand and provided care to the Patient at Station #13. PCT 2 failed to remove gloves and perform hand hygiene after touching the dialysis machine, before collecting clean supplies, and before donning gloves. 9. During a random observation on 09/11/2024 at 11:25 AM, PCT 5 provided care to Patient # 22 and removed gloves. PCT 5 failed to perform hand hygiene after removing gloves. 10. During an observation on 09/12/2024 at 10:10 AM, PCT 4, with gloved hands, emptied the prime waste receptacle and then returned to clean the front of the dialysis machine; PCT 4 failed to change gloves and perform hand hygiene after emptying prime waste and before continuing to clean machine. 11. During an interview on 09/12/2024 at 9:50 AM, PCT 1 indicated hand hygiene should be done after glove change, after touching the computer, and between patients; glove change and hand hygiene should be done when going from the computer to the dialysis machine and from the dialysis machine to the computer. She indicated staff should always have both hands gloved; they are not allowed to wear a glove, on one hand, to document on the dialysis machine and a non-gloved hand to chart on the computer. 12. During an interview on 09/12/2024 at 11:20 AM, Facility Administrator (FA) indicated glove changes should be done between dirty to clean patient care, clean to dirty patient care, between stations, and from a station area to a clean area. She indicated hand hygiene should be done between gloving. 38262 13. During an observation on 09/11/2024 at 10:30 AM, Registered Nurse (RN) 5 removed her gloves after flushing Patient #20’s CVC bloodline. She then retrieved a normal saline syringe from a clean area. RN 5 failed to perform hand hygiene after removing her gloves and before retrieving items from a clean area. 14. During an interview on 09/11/2024 at 11:36 AM, RN 5 stated she received training on when to perform hand hygiene and that it should be done after removing gloves. 15. During an interview on 09/11/2024 at 3:00 PM, Registered Nurse (RN) 1 indicated hand hygiene should be done between gloving and gloves should be changed between patients. 16. During an interview on 09/11/2024 at 4:30 PM the Facility Administrator (FA) and the Manager of Clinical Services (MCS)stated RN 5 received training on hand hygiene and should know to perform hand hygiene after removing gloves. 17. During an interview on 09/17/2024 at 9:04 AM, the Medical Director stated the expectation was for staff to follow facility policy regarding infection control and hand hygiene.”

“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 staff failed to follow infection control procedures when cleaning and disinfecting contaminated equipment and work surfaces for 5 of 12 staff observation. (PCTs 1, 2, 3, 4, FA) Findings include: 1. A revised April 2023 policy titled “Infection Control for Dialysis Facilities” indicated staff are to clean and disinfect all equipment (stethoscopes, blood pressure cuffs, etc.), TV monitors, tray tables, dialysis machines, treatment chairs, countertops, wall boxes (frames recessed into the wall), drain and water supply lines, and work surfaces at the end of each treatment. A 1:10 (1-1/2 cups of bleach in a gallon of water) bleach solution should be used on visible blood or blood spills. A 1:100 (1/4 cup of bleach in a gallon of water) bleach solution should be used for routine disinfection of environmental surfaces. 48387 2. During Flash Tour on 09/10/2024 at 10:08 AM, blood was observed found on 4 of the 6 gray rolling carts used for sharp containers, and a quarter-size blood spot was observed on the floor in front of the large biohazard trash container. 3. During an observation on 09/10/2024 at 1:25 PM, Patient Care Technician (PCT) 3 used a stethoscope on Patient #15 and then placed the stethoscope around the his neck. PCT 3 failed to clean or disinfect his stethoscope after use. 4. During an observation on 09/10/2024 at 2:05 PM, PCT 2 used a stethoscope on Patient #14 and then placed the stethoscope around their neck. PCT 2 failed to clean or disinfect his stethoscope after use. 5. During an observation on 09/10/2024 at 2:40 PM, the Facility Administrator (FA), while working as the treatment floor nurse, used a stethoscope on Patient #6 and then placed the stethoscope around their neck. The FA failed to clean or disinfect his stethoscope after use. 6. During a random observation on 09/11/2024 at 11:30 AM, blood was found on 4 of the 6 gray rolling carts used to hold sharp containers. 7. During an observation on 09/11/2024 at 10:52 AM, PCT 1 disinfected the seat and front-facing back part of the treatment chair at station 2. PCT 1 did not fully recline the treatment chair to disinfect deeper into the seat. PCT 1 did not disinfect the countertop located directly behind the treatment chair or the wall box. During an interview on 09/11/2024 at 10:53 AM, PCT 1 stated she fully reclines the chair by pulling up on the footrest to bring the back of the chair down to a reclining position. She stated that the footrest doesn’t always raise, preventing the chair from reclining. She stated the chair at station 2 had been repaired in the past. 8. During a random observation on 09/12/2024 at 8:48 AM, blood was observed on 4 of the 6 gray rolling carts used to hold sharp containers. 9. During an observation on 09/12/2024 at 10:10 AM, PCT 4 cleaned the front of the dialysis machine in Station #1, the seat and lower back of the dialysis chair, and the blood pressure cuff with one bleach cloth. PCT 4 failed to clean the sides and top of the dialysis machine; tubes running from the machine to the blood pressure cuff to the wall connect; failed to open and recline the chair to clean sides and footrest; and failed to clean the TV and wall box. 10. During an interview on 09/12/2024 at 9:50 AM, PCT 1 indicated that the cleaning crew comes in every night and cleans, which includes mopping. PCT 1 indicated sharps containers and gray carts should be wiped down nightly. PCT 1 indicated she just changed her sharps container two nights ago; she went to that sharp container to look at it, and a blood run was found on the outside of the sharps container gray rolling cart. PCT 1 acknowledged blood, then left to assist other PCT. 11. During an interview on 09/12/2024 at 10:15, PCT 1 indicated dialysis chairs should be reclined, and sides should be opened for cleaning between patients. PCT 1 demonstrated the chair reclining and the sides opened to clean on Station #1 chair. 12. During an interview on 09/12/2024 at 11:00 AM, PCT 1 indicated stethoscopes are placed around the staff neck and should be cleaned before and after use on a patient. 13. During an interview on 09/12/2024 at 11:20 AM, the FA indicated the cleaning of the station between patients should include oxygen equipment if used by prior patients; television, dialysis chair, which should be laid back, and sides should be opened to clean; dialysis machines top, front, sides, and ledge at the bottom; blood pressure cuffs and line from blood pressure cuff to dialysis machine; and wall box. She also indicated that the wall box build-up should be cleaned off on Sunday, Bleach Day. FA indicated if stethoscopes are worn around the staff’s neck, they should be cleaned before and after use on a patient. FA indicated there is no delegated person to clean sharps containers; staff should be cleaning blood off of sharp containers and carts if they see it. FA indicated she worked the floor on 09/10/2024 and did not notice the blood on the floor. She indicated the cleaning crew did not clean the floors on 09/09/2024 night, so the blood had not been cleaned up from the day before.”

“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 facility staff failed to apply an aseptic technique when preparing and administrating intravenous medications for 2 of 2 medication preparation observations. (RN 1, PCT 1) Findings include: 1. A revised October 2023 policy titled “Medication Policy” indicated that all teammates should use an aseptic technique, such as wiping the stopper with alcohol, to prevent contamination of drugs during preparation. 2. During an observation on 09/11/2024 at 1:50 PM, Registered Nurse 1 cleaned Patient #14’s arm, then touched the insertion site prior to inserting a butterfly needle ( a medical device used to draw blood or administer medications or intravenous (IV) fluids into a vein) to collect labs and administer medication without disinfecting the site again. 38262 3. During an observation on 09/12/2024 at 9:30 AM, Patient Care Technician (PCT) 1 removed a 10 cubic centimeter (cc) needled syringe from the packet and inserted the needle into the Heparin (medication to prevent clotting) vial without wiping the stopper with alcohol. PCT 1 then opened a second syringe packet and withdrew Heparin from the same vial without cleaning the stopper with alcohol between uses. PCT 1 failed to apply a proper aseptic technique during medication preparation. During an interview on 09/12/2024 at 11:00 AM, PCT 1 stated before drawing up Heparin from a vial into the syringe the stopper to the vial should be cleaned with alcohol. During an interview on 09/16/2024 at 9:45 AM, the Facility Administrator stated staff should wipe off the stopper to the Heparin vial with alcohol each time they draw up medication from the vial.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 48387 Based on observation, record review, and interview, the staff failed to provide aseptic site care to patients with Central Venous Catheters (CVC), affecting 2 of 2 Patient Care Technicians (PCT) observed providing CVC care (PCT 2, PCT 3) Findings include: 1. A revised 10-2024 policy titled “Central Venous Catheter with Clearguard HD Antimicrobial End Caps” indicated staff should secure patients’ clothes away CVC exit site to minimize the risk of cross-contamination. When disconnecting CVC from treatment, an aseptic technique should be used. 2. During an observation on 09/10/2024 at 3:30 PM, PCT 2 removed Patient #11’s cleaned CVC exit site then allowed Patient #11 clothes to lay directly on the exit site. Staff failed to provide aseptic care to CVC site. 3. During an observation on 09/10/2024 at 3:25 PM, PCT 3 disconnected Patient #13’s blood lines without disinfecting connections. Staff failed to provided aseptic technique during CVC care. 4. During an interview on 09/12/2024 at 11:20 AM, the Facility Administrator (FA) indicated that the CVC site should not be touched after cleaning the exit site and before applying new dressing; this includes patient clothes.”

“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: 48387 Based on record review and interview, the Registered Nurses (RN) failed to accurately document patient assessment times, affecting 5 of 7 in-center record reviews (Patient #3,#4, #5, #10, #18); the facility failed to ensure staff followed Heparin (blood clotting) prescribed orders for 1 of 1 in-center record reviews with Heparin pump. (Patient # 18), and the dialysis facility failed to ensure expired chlorine test strips were discarded and accurate testing of chlorine levels was collected, creating the potential to affect all 68 in-center dialysis patients. Findings include: 1. 04/2024 revised policy titled “ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” indicates the nurse’s is responsible for reviewing documentation for accuracy. 2. A 10/2023 revised policy titled “Medication Policy” Indicates medications are administered as prescribed and then documented in the patient’s medical record; no medications are given without an order from the physician; before giving medication, verify the physician order. 3. A review of Patient #3’s clinical record evidenced the following: A Treatment Detail Report dated 08/23/2024 indicates that RN 7 assessed Patient #3’s baseline four times during the patient’s treatment but failed to document until 4 hours and 29 minutes post-treatment, using the same timestamp of 19:04 for all four entries. A Treatment Detail Report dated 08/30/2024 indicates that RN 7 assessed Patient #3’s baseline five times during the patient’s treatment but failed to document until 3 hours and 12 minutes post-treatment, using the same timestamp of 18:17 for all four entries. A Treatment Detail Report dated 09/02/2024 indicates that RN 7 assessed Patient #3’s baseline six times during the patient’s treatment but failed to document until 1 hour and 37 minutes post-treatment, using the same timestamp of 18:01 for all six entries. A Treatment Detail Report dated 09/04/2024 indicates that RN 7 assessed Patient #3’s baseline six times during the patient’s treatment but failed to document until 3 hours and 37 minutes post-treatment, using the same timestamp of 18:01 for all six entries. A Treatment Detail Report dated 09/06/2024 indicates that RN 7 assessed Patient #3’s baseline five times during the patient’s treatment but failed to document until 2 hours and 30 minutes post-treatment, using the same timestamp of 17:57 for all five entries. 4. A review of Patient #10’s clinical record evidenced the following: A Treatment Detail Report dated 08/22/2024 evidenced Patient #10’s BP reading of 68/53 at 5:29 AM. RN 7 reviewed the low blood pressure reading at 9:24 AM, 3 hours and 55 minutes later. 5. A review of Patient #18’s clinical record evidenced the following: A Treatment Detail Report dated 08/21/2024 indicates a medication administration section that indicated the Heparin pump was stopped at 15:45; the treatment ended at 15:48. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 08/23/2024 indicates that RN 7 assessed Patient #18’s baseline two times during the patient’s treatment but failed to document until 40 minutes post-treatment, using the same timestamp of 20:07 for both entries. The report also included a medication administration section that indicated the Heparin pump was stopped at 19:27; the treatment ended at 18:55. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 08/26/2024 indicates that RN 7 assessed Patient #18’s baseline two times during the patient’s treatment but failed to document until 47 minutes post-treatment, using the same timestamp of 19:42 for both entries. The report also includes a medication administration section that indicated the Heparin pump was stopped at 18:57; the treatment ended at 18:55. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 08/28/2024 included a medication administration section that indicated the Heparin pump was stopped at 19:24; the treatment ended at 19:21. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 09/02/2024 indicates that RN 7 assessed Patient #18’s baseline two times during the patient’s treatment but failed to document until 2 hours and 15 minutes post-treatment, using the same timestamp of 18:01 for both entries. The report also included a medication administration section that indicated the Heparin pump was stopped at 15:53; the treatment ended at 15:46. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 09/04/2024 indicates that RN 5 assessed Patient #18’s baseline four times during the patient’s treatment but failed to document until 1 hour and 04 minutes post-treatment, using the same timestamp of 16:28 for both entries. The report also included a medication administration section that indicated the Heparin pump was stopped at 15:22; the treatment ended at 15:25. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 09/06/2024 included a medication administration section that indicated the Heparin pump was stopped at 14:31; the treatment ended at 14:31. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 09/09/2024 included a medication administration section that indicated the Heparin pump was stopped at 19:28; the treatment ended at 19:28. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. A Treatment Detail Report dated 09/11/2024 included a medication administration section that indicated the Heparin pump was stopped at 19:40; the treatment ended at 19:44. The facility failed to stop the Heparin 30 min before the end of treatment as ordered. 6. A review of Patient #4’s Treatment Detail Report dated 08/27/2024 indicated RN 7 assessed Patient #4’s baseline four times during the patient’s treatment. RN 7 failed to document until 1 hour and 44 minutes post-treatment, using the same timestamp of 17:51 PM for all four entries. 7. A review of Patient #5’s clinical record evidenced the following: A Treatment Detail Report dated 09/04/2024 indicated RN 7 assessed Patient #5’s baseline three times during the patient’s treatment. RN 7 failed to document until 3 hours and 17 minutes post-treatment, using the same timestamp of 11:12 AM for all three entries. A Treatment Detail Report dated 09/06/2024 indicated RN 7 assessed Patient #5’s baseline three times during the patient’s treatment. RN 7 failed to document until 2 hours and 42 minutes post-treatment, using the same timestamp of 12:57 PM for all three entries. 38262 8. During an interview on 09/16/2024 at 2:45 PM, RN 7 indicated his documentation is done after the patient leaves the station, and he doesn’t take the time to document during treatment. He indicated that the Heparin order for Patient #18 is incorrect in the patient’s medical chart, and Heparin for Patient #18 should be given through the end of treatment. RN 7 could not provide a physician order for Heparin to be given until treatment ends. 9. During an interview on 09/16/2024 at 3:20 PM, Facility Administrator, indicated RN should not be documenting after treatment is completed; staff should be documenting in real-time. 10. A document, titled “Ultra-Low (Trademark) Total Chlorine Test Strips” collected from the internet indicates user should not use test strip after the expiration date. https://rpc-rabrenco.com/ifu/ifu-k100-0118-ultra-low-total-chlorine-test-strips-instructions-for-use 11. During the flash tour on 09/10/2024, Patient Care Technician (PCT) 1 read the expiration date on the chlorine test strip as 08/31/2024. 12. In an interview on 09/10/2024 at 9:45 AM, PCT 1 indicated the expired chlorine test strips were used to test the chlorine in water system that supplies water to all in-center dialysis machines. 13. During an interview on 09/11/2024 at 9:50 AM, Biomed Chief Technician indicated the RPC chlorine strips in water treatment room on 09/10/2024 were expired. He indicated the expiration date should be checked during each use of strips.”