Davita Manhattan 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: 50529 Based on observation, policy review, and interview, the 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. This deficient practice provided a mode of contamination with the potential spread of dangerous pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 53 patients that received dialysis treatments at the facility. Findings include: Review of a policy, “Infection Control for Dialysis Facilities,” dated 04/2023, showed, “ ...2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving the treatment area. 3. Use of an alcohol-based hand rub may be substituted for handwashing ...” An observation of the treatment floor on 02/11/25 at 9:23 AM, showed Staff C, Registered Nurse (RN) failed to offer hand sanitizer or remind a patient to wash their hands after holding the access site (site where needles were removed) after treatment. During interview on 02/11/25 at 9:23 AM, Staff A, Facility Administrator, stated that the facility does not have a good habit of encouraging hand hygiene and the expectation is that staff follow policy and procedure to decrease the possible spread of infectious pathogens. During an interview on 02/11/25 at 11:33 AM, Patient 3 stated that he/she was unable to recall being informed of and/or educated on facility policy for washing access site prior to treatment and performing hand hygiene post treatment. An observation of the treatment floor on 02/13/25 at 10:48 AM, showed Staff F, Patient Care Technician (PCT), discharged a patient without encouraging hand washing or providing hand sanitizer after treatment. An observation of the treatment floor on 02/13/25 at 10:29 AM, showed Staff E, (PCT) escorted a patient off of the treatment floor after treatment. The patient did not wash his/her hands or use hand sanitizer and Staff E failed to encourage hand washing or use of hand sanitizer prior to the patient leaving the facility.”

“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: 50529 Based on observation, policy review, and interview, the facility failed to ensure staff disinfected all dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) equipment and other surfaces that could be potentially contaminated with patient’s blood after a dialysis treatment. This deficient practice provided a mode of potential transmission of bloodborne pathogens (organisms that may cause disease or infection), which could negatively impact the health and well-being of the 53 patients who received dialysis treatment at the facility. Finding Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” dated 04/2023, showed, “ ...12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials ...i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfectant should be applied so surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time ...a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel...15. The chair side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas. a. Wipe-able keyboard covers or medical grade keyboards are to be utilized. b. The chair side cart components will be cleaned at the end of each treatment day...” An observation of the treatment floor on 02/11/25 from 8:41 AM - 9:33 AM, showed Staff E, Patient Care Technician (PCT), failed to recline a dialysis chair to ensure complete disinfection after a patient treatment and failed to disinfect the counter behind the dialysis machine as required per facility policy. An observation of the treatment floor on 02/11/25 at 10:20 AM, showed dirty computer work stations that are located between patient dialysis stations. The computer work stations are considered part of the dialysis station and should be disinfected per facility policy. An observation of the treatment floor on 02/13/25 at 11:04 AM, showed Staff H, PCT, failed to use enough disinfectant to ensure that wiped surfaces were visibly wet, failed to recline the dialysis chair to ensure all surface areas were disinfected, and failed to disinfect the counter behind the dialysis station where the patient’s belongings are stored. During an interview on 02/11/25 at 12:05 PM Staff A, Facility Administrator, stated that the expectation for cleaning and disinfecting a dialysis station should be done per facility policy and procedure. Staff A stated not following policy could lead to harmful spread of infectious pathogens that negatively affect the care patients received.”

“PR-INFORMED OF PT CARE POLICIES CFR(s): 494.70(a)(8) The patient has the right to- (8) Be informed of facility policies regarding patient care, including, but not limited to, isolation of patients; This Standard is not met as evidenced by: 50529 Based on medical record review, policy review, and interview, the facility failed to ensure 5 of 5 sampled patients (Patient 1, 2, 3, 4, and-5) were informed of facility policy and procedure for the discontinuation of dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatment and evacuation plans in case of an emergency. This deficient practice could inhibit safe treatment disconnection and evacuation of patients during an emergency and has the potential to negatively impact the health and well-being of the 53 patients who received dialysis treatments at the facility. Findings Include: Review of a document titled, “Facility Emergency Management Plan,” revised 04/2024, showed that Emergency Training and Education should be provided to patients upon admission to the facility, quarterly (every 3 months) for fire safety preparedness and emergency take-off procedures, and annually. Admission and Annual Emergency Training and Education includes the following: “ ...Facility specific emergency response procedures ...Fire safety ...Disconnection from dialysis machine ...Emergency equipment as applicable ...Where to go if an emergency occurs, to include emergency evacuation route(s) and shelter in place location(s) ...What to do if an emergency occurs away from the facility ...Provide local emergency and hazard preparedness information ...Copies of dialysis treatment records ...Medication list ...Medical records ...Immunizations ...Facility dietitian will provide patients with three (3) day emergency diet to follow at home and away from facility ...Alternate transportation arrangements ...Where to go in an emergency ...Who to call in an emergency ...” Review of sampled patient charts showed 5 of 5 patients, (Patient 1, 2, 3, 4, and 5) failed to show documented evidence that patients were provided with information of the facility’s emergency preparedness policies and procedures that could be verified by patient signature of receipt and understanding. During an interview on 02/11/25 at 11:33 AM, Patient 3 stated that he/she could not recall receiving the facility’s procedure for evacuation or emergency preparedness procedures. Patient 3 stated that he/she was not capable of doing much and that physical limitations may have been the cause for forgetfulness regarding evacuation procedures. During an interview on 02/11/25 at 12:05 PM, Staff A, Facility Administrator (FA), stated that the facility failed to provide patients with evacuation procedures and/or was unable to provide documented evidence that emergency preparedness education and training was provided to patients with a signed attestation. Staff A stated that failure to provide patients with emergency procedures education could put patients at risk for delayed and complicated evacuation in an emergency and could lead to possible patient injury or harm. During a phone interview on 02/13/25 at 2:11 PM, Staff K, Medical Director, stated that it is expected that all patients receive information and ongoing education on emergency preparedness training, emergency disconnection, and evacuation procedures. Staff K stated that failure to provide such education and training could potentially complicate and cause further harm or injury in a crisis.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to ensure pre-treatment data collection to verify vascular access status (an assessment of the site used to enter the patients’ bloodstream to verify blood flow or identify other concerns), was completed prior to treatment initiation. This deficient practice placed patients at risk for unidentified vascular access issues which could negatively impact the health and well-being of the 45 patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, “ revised April 2024, showed, “ ...1. Patient data will be obtained and documented by the patient care technician (PCT) or a license nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of patient temperature ...vi. Vascular access status...” Review of a policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised October 2022, showed, “ ...4. Prior to auscultating [listening] a bruit [sound of blood flowing through the vascular access] with a stethoscope, clean the diaphragm of the stethoscope first with an alcohol prep pad ... 5. Perform inspection, auscultation and palpation [examination by touch/feel] on entire length of access. Determine presence of bruit and thrill [vibration felt from blood flow within the vascular access]. 5. The presence of a bruit and thrill indicates flow through the access. 6. If bruit or thrill is not present or if signs and symptoms of infection are present, do not cannulate [inserting a needle into the vascular access]...” An observation of the treatment floor on 02/11/25 at 07:49 AM, showed that when Staff D, Patient Care Technician (PCT) auscultated a patient’s vascular access prior to treatment initiation, the patient stated that no one had ever listened to his/her vascular access before. During an interview on 02/11/25 at 11:44 AM, Staff F, PCT, stated that staff are expected to follow policies and procedures that are taught upon hire and annually. Staff F stated that prior to treatment initiation a patient’s access should be assessed for a positive thrill and bruit. Staff F stated that failure to perform the assessment could result in access complications, additional surgeries, and negatively impact the patient’s life because the vascular access is, “their lifeline.” An observation of the treatment floor at Station 4 on 02/12/25 at 10:35 AM, showed Staff J, (PCT) did not perform an access status assessment prior to cannulation and treatment initiation as required per facility policy. An observation of the treatment floor at Station 8 on 02/12/25 at 10:49 AM, showed Staff E, (PCT) did not perform an access status assessment prior to cannulation and treatment initiation as required per facility policy. During an interview on 02/13/25 at 12:30 PM, Staff A, Facility Administrator (FA) stated that staff is expected to initiate patient treatments per facility policies and procedures. Staff A stated that failure to follow policy and procedure could lead to cannulation of a thrombosed (clotted) vascular access, patient complications, and injury/harm/hospitalization.”