Davita Independence Dialysis Center

“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: 50529 Based on observation, policy review, and interview, the End Stage Renal Disease (ESRD) facility failed to ensure patients washed their hands or performed hand hygiene after holding their dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) access site (a surgically created entry point into the bloodstream) after treatment on 1 of 2 observation days. This deficient practice provided a mode of contamination with the potential spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 21 patients that received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...Patients and caregivers will be encouraged to...Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis ...Perform hand hygiene after treatment before leaving treatment area ... this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites ...” An observation at station #5 on 09/17/25 from 10:24 AM to 10:30 AM, showed that Staff E, Certified Clinical Hemodialysis Technician (CCHT) failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites. An observation at station #11 on 09/17/25 at 1:17 PM, showed that Staff F, Patient Care Technician (PCT) failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites. An observation at station #12 on 09/17/25 at 2:32 PM, showed that Staff F, PCT, failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites. During an interview on 09/17/25 at 3:20 PM, Staff F, PCT, stated that it is the expectation of the staff to offer hand sanitizer to patients who have held their sites post treatment to reduce risk of cross contamination of germs and bacteria. During an interview on 09/18/25 at 1:20 PM, Staff A, Facility Administrator, confirmed that the facility’s policy is to be followed for hand hygiene when providing care and that failure to do so could lead to infection and/or other negative outcomes for patients, staff, and visitors.”

“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: 50529 Based on policy review, observation, and interview the End Stage Renal Disease (ESRD) facility failed to ensure that clean supplies were stored in a designated area at a sufficient distance to avoid contamination with blood and/or other bodily fluids on 2 of 2 observation days. This deficient practice has the potential to increase the risk of infection that could negatively impact the health and well-being of the 21 patients who receive treatments at this facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...Supplies will be stored in a manner that maintains their integrity ...clean supplies in the patient treatment area ...is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood ...Disposable gloves and alcohol based hand rub containers may be stored on the chair side carts but not stored on counters where terminals are mounted ...” An observation on 09/17/25 at 10:32 AM, and again on 09/18/25 at 2:22 PM, showed a box of clean gloves stored on the backwall behind Station #4 and two boxes of gloves on the backwall between Station #10 and #11 in the splash zone (the area around the dialysis station where blood or other bodily fluids could potentially splash or spread during treatment). During an interview on 09/18/25 at 2:22 PM, Staff A, Facility Administrator, confirmed that it was against facility policy to store gloves on the backwalls due to the increased possibility for contamination.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50529 Based on policy review, record review, and interview, the End Stage Renal Disease (ESRD) facility failed to ensure that staff notified a licensed nurse for changes to dialysate flow rate (DFR) or blood flow rate (BFR) and that a licensed nurse assessment included a review of the patient treatment to verify the dialysis prescription was provided as ordered for 5 (Patient 1, 2, 3, 4, and 5) of 5 sampled patients. This deficient practice increases the risk of inadequate treatment outcomes that could negatively impact the health and well-being of the 21 patients receiving treatment at this facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised April 2024, showed, “ ...The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ...The assessment includes ...Review of patient reports, data collection ...response to treatment, verification of prescription including machine parameters ...review of documentation for accuracy, completion and patient data ...prescription components are confirmed by a licensed nurse ...Prescription components include ...Blood flow rate ....Dialysate flow rate ...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ...” Patient 1 Review of Patient 1’s treatment flowsheet records, dated 09/01/25 through 09/12/25, showed the prescribed blood flow rate (BFR) of 400 milliliters per min (mL/min) was not provided as ordered for 1 of 7 treatments reviewed. On 09/12/25 at 5:03 AM, Staff D, Registered Nurse (RN), initiated Patient 1’s treatment with a BFR of 200 mL/min. The BFR remained at 200 mL/min until the end of treatment at 9:11 AM. Staff D failed to document a justifiable rationale for the change to the prescribed BFR as required per facility policy. Patient 2 Review of Patient 2’s treatment flowsheet records, dated 09/03/25 through 09/12/25, showed the prescribed blood flow rate (BFR) of 400 milliliters per min (mL/min) was not provided as ordered for 1 of 5 treatments reviewed. On 09/03/25 at 7:57 AM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), documented a BFR of 350 mL/min. The BFR remained at 350 mL/min for 83 minutes until 9:20 AM. Documentation failed to show evidence that Staff E notified a RN of the decrease to the BFR or a documented rationale for the change to the BFR. Further review failed to show a RN assessed the BFR for intervention nor documented that the prescribed treatment could be provided as ordered. Patient 3 Review of Patient 3’s treatment flowsheet records, dated 09/03/25 through 09/12/25, showed the prescribed blood flow rate (BFR) of 450 milliliters per min (mL/min) was not provided as ordered for 3 of 5 treatments reviewed. On 09/03/25 at 5:48 AM until end of treatment at 8:35 AM, patient care technicians documented a BFR of 400 mL/min. Documentation failed to show evidence that staff notified a RN of the decrease to the BFR or a documented rationale for the change to the BFR. Further review failed to show that a RN assessed the BFR for intervention nor documented that the prescribed treatment could be provided as ordered. On 09/08/25 at 5:48 AM until end of treatment at 8:31 AM, patient care technicians documented a BFR of 400 mL/min. Documentation failed to show evidence that staff notified a RN of the decrease to the BFR or a documented rationale for the change to the BFR. Further review failed to show that a RN assessed the BFR for intervention nor documented that the prescribed treatment could be provided as ordered. On 09/10/25 at 5:10 AM until end of treatment at 8:10 AM, Staff E and Staff G, CCHT, documented a BFR of 400 mL/min. Documentation failed to show evidence that staff notified a RN of the decrease to the BFR or a documented rationale for the change to the BFR. Further review failed to show that a RN assessed the BFR for intervention nor documented that the prescribed treatment could be provided as ordered. Patient 4 Review of Patient 4’s treatment flowsheet records, dated 09/01/25 through 09/15/25, showed the prescribed blood flow rate (BFR) of 400 (mL/min) was not provided as ordered for 1 of 7 treatments reviewed. On 09/15/25 at 6:59 AM, Staff D, RN, initiated Patient 4’s treatment with a BFR of 350 mL/min. Further review showed the BFR remained at 350 mL/min until the end of treatment at 10:35 AM. Documentation failed to show evidence that Staff D provided any interventions or documented rationale for the change to the prescribed BFR. Patient 5 Review of Patient 5’s treatment flowsheet records, dated 09/05/25 through 09/15/25, showed the prescribed dialysate flow rate (DFR) of 600 (mL/min) was not provided as ordered for 1 of 5 treatments reviewed. On 09/15/25 from 10:20 AM until end of treatment at 12:53 PM, patient care technicians documented a DFR of 500 mL/min. Documentation failed to show evidence that staff notified a RN of change to the DFR or documented a rationale for the change to the DFR. Further review failed to show evidence that a RN evaluated the patient treatment to ensure the prescribed DFR was proved as ordered. During an interview on 09/18/25 at 1:20 PM, Staff A, Facility Administrator, stated that it is the expectation of staff to follow all policies and procedures for direct patient care. All patients are expected to run per their individualized hemodialysis orders unless approved modifications have been made by the physician.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 50529 Based on policy review, record review, and interview, the End Stage Renal Disease (ESRD) facility failed to ensure staff notified a licensed nurse of out of parameter patient weights and blood pressures (BP) and that nursing staff assessed and monitored patient fluid status for 5 (Patient 1,2, 3, 4, and 5) of 5 sampled patients. This deficient practice posed an increased risk for complications, including heart failure and other adverse outcomes that could negatively impact the health and well-being of the 21 patients who receive treatments at this facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”, revised April 2024, showed, “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse ... Measurement of Blood Pressure (BP) ... Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flowsheet ... Patient weight ... Abnormal findings or findings ouside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy) ... All findings, interventions and patient response will be documented in the patient’s medical record ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... if patient is above or below 1 kg from the target weight ... systolic [blood pressure] greater than 180 mm/Hg or less than 90 mm/Hg...diastolic [blood pressure] greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings ...” Patient 1 On 09/01/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was documented as 183/136 and sitting BP was 181/132. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the lowest BP was 150/114 and highest BP was 175/126. Further review failed to show documented evidence that an RN addressed the abnormal BPs, provided interventions during treatment, or notified a physician of the abnormal BPs. On 09/01/25, Patient 1’s treatment sheet showed a prescribed EDW of 90 kg. The post weight was documented as 91.3 kg (1.3 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/02/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was documented as 162/131 and sitting BP was 163/126. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 for the entire treatment. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/03/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was documented as 185/139 and sitting BP was 186/139. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 for the entire treatment. Patient 1’s post treatment sitting BP was 186/139 and the standing BP was 193/128. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/03/25, Patient 1’s treatment sheet showed a prescribed EDW of 90 kg. The post weight was documented as 94.0 kg (4.0 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/05/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was documented as 177/137 and sitting BP was 181/136. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 from 6:23 AM - 9:02 AM (3 hours 19 minutes.) Patient 1’s post treatment sitting BP was 161/114 and the standing BP was 154/115. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/05/25, Patient 1’s treatment sheet showed a prescribed EDW of 90 kg. The post weight was documented as 100.9 kg (10.9 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/09/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was documented as 202/148 and sitting BP was 209/164. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 from 9:10 AM - 12:47 PM (3 hours 37 minutes.) Patient 1’s post treatment sitting BP was 171/119 and the standing BP was 178/126. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/10/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment sitting BP was 192/128. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 from 4:55 AM - 9:00 AM (4 hours 5 minutes.) Patient 1’s post treatment sitting BP was 176/109. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/10/25, Patient 1’s treatment sheet showed a prescribed EDW of 90 kg. The post weight was documented as 106.6 kg (16.6 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/12/25, Patient 1’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment sitting BP was 170/119. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Review of blood pressures throughout treatment showed the diastolic BP >110 from 5:03 AM - 9:11 AM (4 hours 8 minutes.) Patient 1’s post treatment sitting BP was 180/125. Further review failed to show documented evidence that an RN addressed or provided interventions for the elevated BPs. On 09/12/25, Patient 1’s treatment sheet showed a prescribed EDW of 90 kg. The post weight was documented as 104.7 kg (14.7 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. Patient 2 On 09/08/25, Patient 2’s treatment sheet showed a prescribed EDW of 109.0 kg. The post weight was documented as 110.6 kg (1.6 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/12/25, Patient 2’s treatment sheet showed a prescribed EDW of 109.0 kg. The post weight was documented as 113.9 kg (3.9 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. Patient 3 On 09/03/25, Patient 3’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was 215/104 and sitting BP was 203/112. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. On 09/08/25, Patient 3’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was 209/131 and sitting BP was 183/109. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. On 09/10/25, Patient 3’s flowsheet “Treatment Parameter Orders” showed that treatment is not to be initiated, and a nurse notified for a systolic blood pressure (SBP) above 210 mmHg or below 80 mmHg and/or a diastolic blood pressure (DSP) above 110 mmHg or below 40 mmHg. Patient 1’s pretreatment standing BP was 219/141 and sitting BP was 228/131. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs prior to initiating treatment. Further review showed that for 30 minutes from 4:40 AM until 5:10 AM and from 7:40 AM until 8:25 AM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), documented Patient 3’s systolic BP as greater than 200 and diastolic BP as greater than 100. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs. On 09/15/25 from 4:40 AM until 5:10 AM, 6:41 AM, 7:39 AM and 8:25 AM, Staff D, RN and Staff E, CCHT documented Patient 3’s SBP as greater than 200 and DBP as greater than 100. Further review failed to show evidence that an RN was notified or that an RN assessed, evaluated, or provided interventions for the abnormal BPs. Patient 4 On 09/01/25, Patient 4’s treatment sheet showed a prescribed EDW of 82.5 kg. The post weight was documented as 84.7 kg (2.2 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/15/25, Patient 2’s treatment sheet showed a prescribed EDW of 82.5.0 kg. The post weight was documented as 80.0 kg (2.2 kg under EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. Patient 5 On 09/10/25, Patient 5’s treatment sheet showed a prescribed EDW of 88.3 kg. The post weight was documented as 89.6 kg (1.3 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/12/25, Patient 5’s treatment sheet showed a prescribed EDW of 88.3 kg. The post weight was documented as 90.0 kg (1.7 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. On 09/12/25, Patient 5’s treatment sheet showed a prescribed EDW of 88.3 kg. The post weight was documented as 89.9 kg (1.6 kg over EDW). Documentation failed to show evidence that an RN was notified of a post weight >1.0 or that an RN assessed the patient’s fluid status post treatment as required per facility policy. During an interview on 09/18/25 at 1:20 PM, Staff A, Facility Administrator, stated that it is the expectation of staff to follow all policies and procedures for direct patient care and monitoring. Staff A confirmed that technicians are to report any abnormal findings outside of patient baseline, BPs outside of parameters, falls, hospitalizations, new symptoms, and unachieved target weights. Nurses should notify the physician of any abnormal data from baseline, BPs outside of parameters, falls, hospitalizations, new symptoms/complaints, access issues, AMAs, and any patients above or below their target weight by 1kg.”