Davita Wyandotte West Dialysis

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure staff followed infection control policies regarding hand hygiene during 1 of 2 observations of medication administration. This deficient practice provides a mode for cross contamination of infectious pathogens (micro-organisms that can cause disease) that could negatively impact the health and well-being of any patient receiving services in this facility. Findings include: A facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, revealed, “1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e. [id est, that is], plugging/unplugging acid/bicarb [bicarbonate] lines form [sic] dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” On 07/21/2025 at 4:02 PM Registered Nurse (RN) #10 was observed administering parenteral (outside the gastrointestinal tract) medications. The observation revealed after preparing the medication RN #10 entered Patient Treatment Station #5, donned gloves, and administered the medication. RN #10 failed to perform hand hygiene upon entering the patient treatment station and prior to donning gloves. During an interview on 07/21/2025 at 4:24 PM, RN #10 stated her practice was to perform hand hygiene when entering and leaving the patient treatment stations and when changing gloves. RN #10 stated that she did not realize that she did not perform hand hygiene upon entering the patient treatment station and prior to donning gloves. During an interview on 07/22/2025 at 4:00 PM, the Medical Director confirmed that it was the facility’s expectation that staff follow the infection control policy.”

“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: 50873 Based on interview, record review, and facility policy review, the facility failed to monitor patients during dialysis treatments and failed to report abnormal findings to the licensed nurse per the facility policy for 7 (Patients #1, #2, #3, #4, #5, #6, and #7) of 7 sampled patients reviewed for monitoring of dialysis treatments. This deficient practice has the potential for a change in patient condition to go unnoticed or unadressed and places the health, safety, and well-being of any patient receiving services at this facility at risk for harm. Findings include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, revealed the section titled, “Intradialytic Data Collection/Assessment,” included, “9. Intradialytic treatment monitoring and data collection which may be performed by the PCT [Patient Care Technician] or licensed nurse includes: a. Vital signs and treatment monitoring,” including, “iii. Non-nocturnal treatments are completed at least every thirty (30) minutes.” The section titled, “Abnormal Findings,” revealed, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time.” The policy also indicated, “Blood Pressure-Intradialytic: - Systolic [the top number of the blood pressure reading] greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg - Diastolic [the bottom number of the blood pressure reading] greater than or equal to 100 mm/Hg or less than 50 mm/Hg.” The policy also indicated, “Heart or Pulse Rate Pre/Intra/Post: - Less than 60 beats per minute [BPM] or greater than 100 beats per minute and/or an irregular heart beat.” Patient #1’s “Treatment Details Report” dated 07/16/2025, revealed no evidence the patient was monitored from 8:00 AM until 9:00 AM. Patient #2’s “Treatment Details Report” dated 07/07/2025, revealed the patient’s blood pressure (BP) documented by Patient Care Technician (PCT) #5 at 7:55 AM was 161/103 mm/Hg. The report revealed there was no documentation to indicate a licensed nurse was notified of Patient #2’s elevated BP. A “Treatment Details Report” for Patient #2, dated 07/10/2025, revealed that PCT #1 took blood pressure readings of 164/105 mm/Hg at 6:55 AM and 174/107 mm/Hg at 8:27 AM; that PCT #3 took blood pressure readings of 174/112 mm/Hg at 7:25 AM and 157/117 mm/Hg at 7:55 AM; and that PCT #8 took a blood pressure reading of 155/108 at 8:33 AM. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient #2 dated 07/16/2025 revealed that PCT #1 took blood pressure readings of 172/109 at 5:59 AM, 174/113 mm/Hg at 6:49 AM, 198/127 mm/Hg at 6:59 AM, and 188/115 mm/Hg at 7:29 AM and that PCT #3 took a blood pressure reading of 191/107 mm/Hg at 8:12 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #2, dated 07/16/2025, revealed that PCT #6 took blood pressure readings of 185/115 mm/Hg at 7:10 AM and 161/102 mm/Hg at 8:40 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #3, dated 07/11/2025, revealed that PCT #5 took a blood pressure reading of 121/47 mm/Hg at 1:56 PM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #4, dated 07/07/2025, revealed that PCT #9 took a blood pressure reading of 180/110 mm/Hg at 8:47 AM, and PCT #7 took a blood pressure reading of 173/101 mm/Hg at 9:47 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #4, dated 07/14/2025, revealed that PCT #7 took blood pressure readings of 176/109 mm/Hg at 9:15 AM, 180/106 mm/Hg at 9:45 AM, 177/100 mm/Hg at 10:15 AM, and 175/101 mm/Hg at 10:45 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #5, dated 07/17/2025, revealed that PCT #8 took a blood pressure reading of 119/100 mm/Hg at 7:57 AM, and PCT #15 took a blood pressure reading of 157/40 mm/Hg at 8:52 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient #6, dated 07/10/2025, revealed that PCT #1 took a blood pressure reading of 106/45 mm/Hg at 10:58 AM, and PCT #2 took a blood pressure of 78/51 mm/Hg at 12:29 PM and a heart rate of 104 BPM at 12:37 PM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #6, dated 07/12/2025, revealed there was no evidence of patient monitoring from 10:32 AM until 11:32 PM (1 hour). A “Treatment Details Report” for Patient #6, dated 07/17/2025, revealed that PCT #2 took blood pressure readings of 104/48 mm/Hg at 12:16 PM and 111/43 mm/Hg at 1:16 PM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #6, dated 07/19/2025, revealed that PCT #5 took a blood pressure reading of 106/46 mm/Hg at 12:47 PM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #7, dated 07/15/2025, revealed there was no evidence of patient monitoring from 12:34 PM until 1:36 PM (1 hour and 2 minutes). A “Treatment Details Report” for Patient #7, dated 07/15/2025, revealed PCT #5 took a blood pressure reading of 172/111 mm/Hg at 11:34 AM. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient #7, dated 07/19/2025, revealed that PCT #5 took a pre-treatment blood pressure reading of 125/104 mm/Hg and a heart rate of 105 BPM at 12:13 PM. The report revealed there was no evidence of notification to the RN of the out-of-range blood pressure reading. On 07/22/2025 at 12:44 PM, the Facility Administrator (FA) confirmed that the facility’s expectation was for PCTs to notify the RNs of out-of-range vital signs per the facility policy and document the notification. The FA confirmed that the facility’s expectation was that patient monitoring occurred every 30 minutes during treatment and was documented, including the patient’s blood pressure, heart rate, blood flow rate, dialysate flow rate, needle pressures, patient’s access and face visualized, the heparin pump, and any patient notes. On 07/22/2025 at 2:20 PM, RN #12 stated PCTs should notify the RNs of out-of-range vital signs and document the notification. On 07/23/2025 at 3:23 PM, PCT #5 indicated that patient monitoring was to occur every 30 minutes or more if needed. PCT #5 stated, “When in doubt check with a nurse.” PCT #5 stated the reporting parameters for vital signs that the PCT should report to the RN included a systolic blood pressure greater than 180 or less than 90, a diastolic blood pressure greater than 100 or less than 50, and a heart rate below 60 and greater than 100. PCT #5 stated RN notification should be documented.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to ensure dialysis prescriptions were followed for 5 (Patients #1, #2, #5, #6, and #7) of 7 sampled patients reviewed. Specifically, prescribed ultrafiltration (UF) rates were not followed for Patients #2, #5, and #7, and prescribed blood flow rates (BFR) were not followed for Patients #1, #2, #5, and #6. This deficient practice has the potential to affect the effectiveness of the dialysis treatment which could negatively impact the health and well-being of any patient receiving services at this facility. Findings include: 1. Ultrafiltration Rates A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, indicated “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR [ultrafiltration rate] and Max [maximum] UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb [bicarbonate]) and settings j. Heparinization (intradialytic infusion setting).” The policy revealed the section titled, “Intradialytic Data Collection/Assessment,” indicated, “iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures.” The policy also indicated, “10. 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.” A “Treatment Details Report” for Patient #2 on 07/07/2025 indicated a prescribed maximum UFR of 13 mL/kg/hr (milliliters per kilogram per hour) in the “Pre-Treatment Fluid Calculation” section. The “Post Treatment Weight” section of the Treatment Details Report revealed the treatment UFR was 13.5 mL/kg/hr. The report revealed there was no documentation to explain this deviation from the prescribed maximum UFR. A “Treatment Details Report” for Patient #2 on 07/18/2025 indicated a prescribed maximum UFR of 13 mL/kg/hr in the “Pre-Treatment Fluid Calculation” section. The “Post Treatment Weight” section of the Treatment Details Report revealed the treatment UFR was 15.2 mL/kg/hr. The report revealed there was no documentation to explain this deviation from the prescribed maximum UFR. A “Treatment Details Report” for Patient #5 on 07/19/2025 indicated a prescribed maximum UFR of 13 mL/kg/hr in the “Pre-Treatment Fluid Calculation” section. The “Post Treatment Weight” section of the Treatment Details Report revealed the treatment UFR was 14.7 mL/kg/hr. The report revealed there was no documentation to explain this deviation from the prescribed maximum UFR. A “Treatment Details Report” for Patient #7 on 07/19/2025 indicated a prescribed maximum UFR of 13 mL/kg/hr in the “Pre-Treatment Fluid Calculation” section. The “Post Treatment Weight” section of the Treatment Details Report revealed the treatment UFR was 16 mL/kg/hr. The report revealed there was no documentation to explain this deviation from the prescribed maximum UFR. On 07/23/2025 at 6:40 PM, the Facility Administrator confirmed the expectation that the UFR should not exceed the ordered maximum UFR without a provider order to do so. 2. Prescribed BFR A “Treatment Details Report” for Patient #1 on 07/11/2025 indicated a prescribed BFR of 450 ml/min (milliliters per minute) in the “Dialysis Prescription” section. The “Intradialytic Vitals Stat Line” section of the Treatment Details Report revealed the treatment was run at a BFR of 400 ml/min from 6:31 AM until 9:01 AM. The record revealed there was no evidence of a rationale as to why the treatment deviated from the prescription. A “Treatment Details Report” for Patient #2 on 07/18/2025 indicated a prescribed BFR of 400 ml/min under the “Dialysis Prescription” section. The “Intradialytic Vitals Stat Line” section of the Treatment Details Report revealed the treatment was run at a BFR of 350 ml/min from 6:29 AM until 8:12 AM. The record revealed there was no evidence of a rationale as to why the treatment deviated from the prescription. A “Treatment Details Report” for Patient #5 on 07/07/2025 indicated a prescribed BFR of 400 ml/min under the “Dialysis Prescription” section. The “Intradialytic Vitals Stat Line” section of the Treatment Details Report revealed the treatment was run at a BFR of 350 ml/min from 4:23 PM until 4:51 PM then changed to 300 ml/min at 4:51 PM until 6:15 PM. The record revealed there was no evidence of a rationale as to why the treatment deviated from the prescription. A “Treatment Details Report” for Patient #5 on 07/17/2025 indicated a prescribed BFR of 400 ml/min under the “Dialysis Prescription” section. The “Intradialytic Vitals Stat Line” section of the Treatment Details Report revealed the treatment was run at a BFR of 350 ml/min from 6:56 AM until 8:26 AM. The report revealed there was no evidence of a rationale as to why the treatment deviated from the prescription. A “Treatment Details Report” for Patient #6 on 07/08/2025 indicated a prescribed BFR of 450 ml/min under the “Dialysis Prescription” section. The “Intradialytic Vitals Stat Line” section of the Treatment Details Report revealed the treatment was run at a BFR of 400 ml/min from 11:50 AM until 1:06 PM. The report revealed there was no evidence of a rationale as to why the treatment deviated from the prescription. On 07/22/2025 at 4:00 PM, the Medical Director stated if staff were unable to achieve the prescribed BFR they should document a rationale or notify the provider. On 07/23/2025 at 3:23 PM, Patient Care Technician (PCT) #5 stated if the BFR was incorrect for a patient, staff should check the prescription, notify the registered nurse, correct the BFR, and document. On 07/23/2025 at 6:40 PM, the Facility Administrator confirmed that the expectation was for the BFR to be run as prescribed and if it deviated from the prescription there should be a documented rationale.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to provide vascular access monitoring per the facility policy for 1 of 2 observations of the initiation of dialysis with an arteriovenous fistula (AVF) or graft (AVG) and 1 of 2 observations of the initiation of dialysis with a central venous catheter (CVC). The failure of the facility to follow it’s policies and procedures for the management of vascular access has the potential to lead to poor infection control practices that may lead to vascular access infections or other adverse events that could negatively impact the health and well-being of any patient receiving services in this facility. Findings included: A facility policy titled, “Central Venous Catheter (CVC) with [Trade Name] HD [Hemodialysis] Antimicrobial End Caps Procedure,” revised 04/2025, revealed a table with a heading titled, “Procedure,” that indicated, “16. Verify both catheter clamps are closed. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads, and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried. 17. Attach sterile 10 ml [milliliter] syringes to the arterial and venous limbs. 18. Open the catheter clamps. Aspirate an amount greater than the catheter limb lumens, generally about 5 ml from each limb.” A facility policy titled, “AV Fistula or Graft Cannulation With [Trade Name] or [Trade Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised 04/2025, revealed a table with a heading titled, “Procedure,” that indicated, “10. While maintaining aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.” The policy continued, “13. Do not palpate insertion site once area has been prepped.” Under the heading titled, “Rationale,” the policy indicated, “13. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” On 07/21/2025 at 3:11 PM, Patient Care Technician (PCT) #1 was observed in Patient Treatment Station #2 initiating dialysis treatment for a patient with an AVF or AVG. The observation revealed PCT #1 failed to reapply antiseptic after touching the access site and prior to cannulation. On 07/21/2025 at 4:10 PM, PCT #1 was observed in Patient Treatment Station #7 initiating dialysis treatment for a patient with a CVC. The observation revealed PCT #1 failed to clean the CVC hubs prior to attaching the syringes. During an interview on 07/21/2025 at 4:28 PM, PCT #1 stated the CVC hubs should be scrubbed prior to connecting the syringes. PCT #1 stated if skin was touched it had to be recleaned. PCT #1 stated they were nervous and were trying to determine where to cannulate as there had previously been trouble with access. During an interview on 07/22/2025 at 6:40 PM, the Facility Administrator confirmed that the facility policy was to be followed when staff initiated treatment with a CVC, AVF, or AVG.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview and facility document and policy review, the facility Quality Assurance and Performance Improvement (QAPI) Committee failed to measure, analyze, and track quality indicators for mortality. This failure had the potential to affect all 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Continuous Quality Improvement Program,” revised 04/2021, revealed, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance.” The policy specified, “The program must include, but not be limited to, the following,” including, “Mortality - review of deaths.” A facility document titled, “Facility Health Meeting,” dated 07/2025, revealed a “Mortality” graph that included measurement data for deaths for the timeframe from July 2024 through July 2025. The document included metrics/information regarding the causes of deaths including cardiac deaths, infection deaths, and other deaths, as well as the total number of deaths. The document revealed: Four deaths in December 2024 with the causes being: one, “cardiac;” one, “other;” and two, “unknown reason.” Two deaths in March 2025, and the causes of death were not documented. Two deaths in April 2025, the cause of one death was “unknown” and the other cause was not documented. One death in May 2025 with the cause of death not documented, for a total of nine patient deaths. Further review revealed there was no evidence the facility was tracking, trending, or analyzing potential contributing factors to patients’ deaths. During an interview on 07/24/2025 at 10:00 AM, the Facility Administrator confirmed there was no evidence of the analysis of mortality data and potential contributing factors in the facility’s QAPI documents.”