Davita Air Capital 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: 35949 Based on observations, interviews, and policy review, the facility failed to ensure staff changed their gloves and performed hand hygiene during central venous catheter (CVC) exit site care for 2 (Patient 7 and Patient 8) of 8 sampled patients. This deficient practice has the potential to place patients at risk for infection. Findings Include: Review of the facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD [hemodialysis] Antimicrobial End Caps Procedure” with an origination date of April 2019, revealed “1. Perform hand hygiene per procedure.” Per the policy, “4. Remove old dressing and discard.” and “7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove.” During an observation on 05/15/24 at 11:27 AM, Registered Nurse (RN) 5 performed CVC exit site care. Once RN 5 removed the old dressing, she did not remove her gloves and perform hand hygiene, and proceeded to clean the area around the CVC exit site. During an interview on 05/15/24 at 3:05 PM, RN 5 stated that she did not perform hand hygiene and change her gloves after she removed the CVC dressing during care for Patient 7. During an observation on 05/16/24 at 10:21 AM, Patient Care Technician (PCT) 11 performed CVC exit site care for Patient 8. Once PCT 11 removed the old dressing, he did not remove his gloves and perform hand hygiene, and proceeded to clean the area around the CVC exit site. During an interview on 05/16/24 at 11:23 AM, PCT 11 stated that the expectation would be to remove gloves and perform hand hygiene after the CVC dressing was removed. PCT 11 acknowledged that he did not remove his gloves and perform hand hygiene when he completed CVC exit site care for Patient 8. During an interview on 05/17/24 at 8:35 AM, the Facility Administrator stated that he expected staff to perform hand hygiene and change their gloves after removal of the CVC dressing during CVC exit site care. During an interview on 05/17/24 at 8:52 AM, the Medical Director stated he expected staff to perform hand hygiene and change their gloves after removal of the CVC dressing during CVC exit site care.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 35949 Based on observations, interviews, and policy review, the facility failed to disinfect objects before removing them from the patient treatment station in 3 (patient treatment stations 1, 2, and 3) of 3 patient treatment stations observed. This deficient practice has the potential to place patients at risk for infections. Findings Include: Review of the facility policy titled “Infection Control for Dialysis Facilities” last revised in October 2021, revealed, “...49. The outside surfaces of all equipment will be wiped with a bleach solution prior to removal from treatment area.” During an observation on 05/15/24 at 8:56 AM, Patient Care Technician (PCT) 9 discontinued the dialysis treatment that was performed in patient treatment station 2. At 9:33 AM, without disinfecting the sharps container, Certified Clinical Hemodialysis Technician (CCHT) 8 removed the sharps container from the patient treatment station. During an observation on 05/15/24 at 9:35 AM, CCHT 8 discontinued the dialysis treatment that was performed in patient treatment station 3. At 9:49 AM, without disinfecting the sharps container, PCT 9 removed the sharps container from the patient treatment station. During an observation on 05/15/24 at 11:34 AM, Registered Nurse (RN) 5 discontinued the dialysis treatment that was performed in patient treatment station 1. At 11:47 AM, without disinfecting the sharps container, RN 5 removed the sharps container from the patient treatment station. During an interview on 05/15/24 at 9:50 AM, PCT 9 stated the practice at the facility was to clean any visible residue off the sharp containers. Per PCT 9, she was unsure if the sharps containers should be cleaned when brought out of the patient treatment station. During an interview on 05/15/24 at 10:13 AM, CCHT 8 stated that the sharps containers were only cleaned when visibly soiled and at the end of the treatment day. During an interview on 05/15/24 at 10:27 AM, RN 4 stated that the sharps containers would be disinfected, along with the patient treatment station, at the completion of each patient treatment and at the end of the day. During an interview on 05/17/24 at 8:35 AM, the Facility Administrator stated that the sharps containers should be disinfected each time the container was taken out of the patient treatment station, per the facility policy. During an interview on 05/17/24 at 8:52 AM, the Medical Director stated that the sharps containers not being disinfected when taken out of the patient treatment station was outside of the facility expectations.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 35949 Based on observations, interview, document review, and facility policy review, the End Stage Renal Dialysis (ESRD) facility failed to ensure the 6 of 6 oxygen tanks were properly stored. This deficient practice has the potential to place patient and staff at risk for harm. Findings Include: Review of a facility policy titled, “Physical Environment,” last revised in April 2018, revealed, “10. The dialysis facility will store supplies in a manner that is consistent with fire safety and other appropriate regulations.” Review of an undated typed document from the “Office of the State Fire Marshal - Fire Prevention Division” document review, provided by the Facility Administrator, revealed “Freestanding cylinders shall be properly chained or in a cylinder stand or cart.” During observation on 05/14/24 at 10:00 AM and 11:22 AM, six oxygen tanks were unsecured and stored in the conference room. During an interview on 05/14/24 at 11:22 AM, the Facility Administrator stated that the oxygen tanks were “just delivered” and the facility’s process was to store oxygen tanks in another location. During an interview on 05/17/24 at 9:01 AM, the Medical Director stated that oxygen tanks should be stored in a manner to prevent them from falling over.”