Davita Free State 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 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 and between glove changes on 2 of 3 observation day. 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 66 patients that received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...will perform hand hygiene ...prior to gloving and immediately after removal of gloves ...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 ...Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites ...” During an observation at station #15 on 09/23/25 at 10:04 AM, Staff G, Certified Clinical Hemodialysis Technician (CCHT), failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites and before leaving the clinic. During an observation at station #8 on 09/23/25 at 10:40 AM, Staff I, CCHT, failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites and before leaving the clinic. During an observation at station #15 on 09/24/25 at 2:41 PM, Staff G, CCHT, failed to offer/provide hand sanitizer to patient or encourage hand washing after holding access sites. During an observation at station #8 on 09/24/25 at 2:39 PM, Staff K, Patient Care Technician (PCT), failed to perform hand hygiene in between glove changes while cleaning and disinfecting the dialysis station. During an interview on 09/24/25 at 2:16 PM, Staff J, CCHT, stated that it is the expectation of the staff to offer hand sanitizer or suggest hand washing to patients who have held their sites post treatment to reduced risk of cross contamination of germs and bacteria. During an interview on 09/25/25 at 10:15 AM, 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-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. 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 that staff followed its policy and procedures for a patient with a Central Venous Catheter (CVC) (an access site to the bloodstream that utilizes a tube inserted into a large vein that leads directly to the heart). This deficient practice places any patient with a CVC at risk for increased instance of bloodstream infections, cross contamination, air embolus, and other adverse outcomes. Findings Include: Review of a policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” revised 04/2025, showed that prior to treatment initiation, the patient should be placed in a supine (laying on back) position, as flat as possible. The supine position increases blood flow through the catheter and decreases the risk of an air embolism (a dangerous condition in which air enters the bloodstream.) The CVC site is to be assessed for signs and symptoms of infection or physical damage to the CVC such as cuff migration, cracks, or leaks. Physical damage to the CVC could cause harm to the patient due to misalignment of the catheter, air embolism, and possible contamination. If signs of infection or CVC damage is noted, it must be reported to the RN/physician for further follow-up. After access assessment, the CVC site is to be cleaned, and a sterile dressing applied. During an observation at station #15 on 09/23/25 at 10:42 AM, Staff G, Certified Clinical Hemodialysis Technician (CCHT), failed to place a patient with a CVC in the supine position and failed to provide CVC care and assessment prior to initiating treatment as required per policy. During an interview on 09/25/25 at 10:15 AM, Staff A, Facility Administrator, stated that it is the expectation of staff to initiate treatments and provided CVC care per facility policy to reduce opportunity for air embolus, cross contamination, and improve capability to achieve optimal blood flow rate.”

“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 record review, policy 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), blood flow rate (BFR), prescribed treatment time, and that a licensed nurse assessment included a review of the patient treatment to verify the dialysis prescription was provided as ordered for 4 (Patient 2, 4, 5, and 7) of 7 sampled patients. This deficient practice has the potential to negatively impact the health and well-being of the 66 patients receiving treatment at this facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised 04/2024, 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 ... Treatment time ... Blood flow rate (BFR) ... Dialysate flow rate (DFR) ... 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 ...” Review of a policy titled, “Prescribed Treatment Time Not Met,” revised 04/2024, showed that the Registered Nurse (RN) will verify that a patient signs the “Early Termination of Treatment Against Medical Advice (AMA)” form any time a patient requests to terminate their treatment earlier than the prescribed run time. The policy goes on to state that the RN will document the event in the patient’s record and will include the amount of time by which the treatment was shortened and any intervention to address the shortened treatment, including recommendations to the patient. The completed copy of the AMA form is to be kept in the patient’s medical record.” Patient 2 Review of Patient 2’s dialysis orders on 09/22/25 showed a prescribed BFR of 450 milliliters per minute (mL/min). On 09/22/25, Patient 2’s BFR was charted at 400mL/min from 1:38 PM until 2:10 PM. Documentation failed to show evidence that an RN was notified of the decrease to the BFR or a rationale for the change to the BFR. Further review failed to show an RN assessed the BFR for intervention nor documented that the prescribed treatment could not be provided as ordered. Patient 4 Review of Patient 4’s dialysis orders on 09/12/25 showed a prescribed treatment time of 3 hours 30 minutes (210 minutes.) On 09/12/25, Patient 4’s treatment duration was charted as 3 hours 18 minutes (198 minutes.) Review of the treatment flowsheet report failed to show a documented rationale why the prescribed treatment time was not provided as ordered or that an Against Medical Advice (AMA) form was completed and signed as required per facility policy. Review of Patient 4’s dialysis orders on 09/17/25 showed a prescribed DFR of 800 mL/min. On 09/17/25 at 5:54 AM until end of treatment at 9:20 AM, staff documented the DFR at 500mL/min. Documentation failed to show evidence that staff notified an RN of the decrease to the DFR or a documented rationale for the change to the DFR. Further review failed to show that an RN documented that the prescribed treatment could not be provided as ordered. Patient 5 Review of Patient 5’s dialysis orders on 09/09/25 until 09/20/25, showed a prescribed BFR of 350 mL/min. On 09/18/25 at 10:42 AM, Staff N, Registered Nurse (RN) initiated treatment with a BFR of 340 mL/min. The BFR remained at 340 mL/min until end of treatment at 2:02 PM. Documentation failed to show evidence of rationale for the decreased BFR or that the RN documented attempts at interventions to address the decreased BFR. The RN failed to document the inability to provide the dialysis prescription as ordered in the medical record. On 09/09/25 at 12:56 PM, Staff N, RN initiated treatment with a BFR of 300 mL/min. The BFR remained at 300 mL/min until 1:21 PM. Documentation failed to show evidence of rationale for the decreased BFR or that the RN documented attempts at interventions to address the decreased BFR. The RN failed to document the inability to provide the dialysis prescriptions as ordered in the medical record. Patient 7 Review of Patient 7’s dialysis order on 09/18/25 showed a prescribed BFR of 400 mL/min. On 09/18/25 at 7:26 AM, Staff J, Certified Clinical Hemodialysis Technician (CCHT), documented the BFR at 350 mL/min. Documentation failed to show evidence that an RN was notified of the decreased BFR or that an RN assessed the patient for intervention for the decreased BFR. At 9:03 AM, Staff M, CCHT, documented the BFR at 300 mL/min. Documentation failed to show a rationale for decreasing the BFR to 300 mL/min or that an RN was notified of the decrease to the BFR. Further review failed to show evidence that an RN reviewed and documented in the medical reason that the patient was unable to obtain the dialysis prescription as ordered. During an interview on 09/24/25 at 10:00 AM, Staff A, Facility Administrator, stated that it is the expectation of staff to follow individualized treatment prescriptions and provide patient dialysis treatments as ordered. Staff A stated that staff are to have patients sign an AMA form if they chose to shorten treatment by 15 minutes or more and physician would be notified.”