Davita Maize 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: 35949 Based on observations, interviews, and facility policy review, the facility staff failed to perform hand hygiene prior to the application of gloves and immediately after the removal of gloves. This deficient practice has the potential to affect the 80 patients who received services at the facility. Findings Included: Review of the facility policy titled, “Infection Control for Dialysis Facilities,” with a revision date of April 2023, revealed, “Hand Hygiene 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, f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” During an observation of the treatment area on 02/29/24 at 11:45 AM, Patient Care Technician (PCT) 6 applied gloves without performing hand hygiene. During an observation of the treatment area on 02/29/24 at 4:02 PM, PCT 6 removed and discarded a pair of gloves she had on, then put on a new pair of gloves, without performing hand hygiene. During an interview on 02/29/24 at 11:55 AM, the Manager of Clinical Services confirmed staff were trained and expected to perform hand hygiene before they touched patient care supplies and equipment, before patient contact, and after the removal of gloves. During an interview on 02/29/24 at 12:51 PM, the Facility Administrator confirmed staff were trained and expected to perform hand hygiene before they touched patient care supplies and equipment, before patient contact, and after the removal of gloves. During an interview on 02/29/24 at 5:31 PM, PCT 6 stated she was trained to perform hand hygiene after the removal of gloves, and before she touched patients, patient care equipment and supplies.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 35949 Based on record reviews, interviews, and facility policy review, the facility failed to complete an initial comprehensive assessment conducted by all members of the interdisciplinary team within 30 calendar days after admission for 1 (Patient 6) of 8 sampled patients. This deficient practice has the potential to affect all new patients who receive services at the facility. Findings Included: Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” with a revision date of July 2023, revealed, “Assessment: 1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD [end stage renal disease] licensure regulations, treating the patient for ESRD, a social worker, and a dietician.” The policy specified, “4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” Review of Patient 6’s “Patient Summary Report,” revealed the facility admitted the patient on 01/18/24. Review of Patient 6’s “Comprehensive Encounter,” revealed the patient’s initial comprehensive assessment was completed on 02/26/24. During an interview on 02/28/24 at 1:23 PM, Registered Nurse (RN) 3 stated she was not aware the initial comprehensive assessment was not completed within 30 days. RN 3 acknowledged she was aware of the requirement and facility policy that indicated for the initial comprehensive assessment should be completed within 30 days of the patient’s admission date. During an interview on 02/28/24 at 4:00 PM, the Medical Director stated he was not sure why Patient 6’s initial comprehensive assessment was not completed within 30 days of the patient’s admission date. The Medical Director stated the facility policy should be followed and the initial comprehensive assessment should be completed within 30 days of a patient’s admission. During a telephone interview on 02/29/24 at 8:15 AM, the Medical Director stated he contacted Patient 6’s physician regarding the late assessment and stated it was a “mistake” that the initial comprehensive assessment was not completed within 30 days of the patient’s admission per the facility policy.”