Davita Crestview Hills Dialysis

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment for 3 of 3 observations. Failure to thoroughly disinfect all environmental surfaces in the dialysis treatment stations after each treatment had the potential to serve as a vehicle for transmission of infectious disease and negatively impact the safety and well-being of the 48 patients receiving dialysis treatments at this facility. The findings include: Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revised in 04/2023, indicated, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machine; touchscreens; countertops).” Observations of the treatment area on 04/23/2025 with the Facility Administrator (FA) revealed the following: -At 11:35 AM, Certified Clinical Hemodialysis Technician (CCHT) 5 was observed disinfecting Station 7. CCHT5 failed to disinfect the emergency disconnect pack stored on the dialysis machine’s intravenous (IV) pole prongs. -At 12:30 PM, Registered Nurse (RN) 2 was observed disinfecting Station 19. RN2 failed to disinfect the emergency disconnect pack stored on the dialysis machine’s IV pole prongs. -At 1:00 PM, RN2 was observed disinfecting Station 9. RN2 failed to disinfect the emergency disconnect pack stored on the dialysis machine’s IV pole prongs. During an interview on 04/23/2025 at 1:10 PM, CCHT5 stated he did not disinfect the emergency disconnect pack stored on the dialysis machine’s IV pole prongs. CCHT5 stated he was trained and expected to disinfect all surfaces in the treatment station after each patient’s treatment was terminated. During an interview on 04/23/2025 at 1:25 PM, RN2 stated she did not disinfect the emergency disconnect pack stored on the dialysis machine’s IV pole prongs. RN2 stated she was trained and expected to disinfect all surfaces in the treatment station after each patient’s treatment was terminated. During an interview on 04/23/2025 at 1:30 PM, the FA stated staff was trained and expected to disinfect all surfaces in the treatment station after each patient’s treatment was terminated. During an interview on 04/24/2025 at 10:50 AM, the Medical Director stated staff was trained and expected to disinfect all surfaces in the treatment station after each patient’s treatment was terminated.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to secure and restrict access to the water purification and storage system only to authorized personnel who were responsible for monitoring and maintenance of the system. The failure had the likelihood to allow unauthorized personnel access to the water purification and storage system and the potential to negatively impact the safety and well-being of the 48 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Physical Environment,” revised in 04/2018, indicated, “9. Systems to assure patient safety will be in place, such as a method for patients to call for help from the restrooms and exam rooms. Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only. Access limitation does not preclude visitors or tours by individual(s) authorized and supervised by facility personnel.” Review of the facility’s policy titled, “Water Treatment Systems Minimum Component Requirement,” revised in 10/2021, indicated, “2. New and renovated water purification and distribution systems should be located in a secure area that is readily accessible to authorized teammates. A location will be chosen which minimizes the length and complexity of the distribution system. Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system and supply ordering. An exception to this may be made for janitorial services for maintenance of the physical environment. All deliveries made in close proximity to the water treatment system must be supervised.” Observation on 04/21/2025 at 9:00 AM during an environmental tour with the Facility Administrator (FA) revealed the water purification and storage system was located in a general supply storage area without access restriction. During an interview on 04/22/2025 at 11:45 AM, the FA stated that housekeeping staff entered the general supply storage area unescorted to retrieve housekeeping supplies, such as toilet paper. The FA confirmed the housekeeping staff had unrestricted access to the water purification and storage area, in addition to “any teammate,” including those teammates not responsible for monitoring and/or maintenance of the system. During an interview on 04/24/2025 at 10:50 AM, the Medical Director confirmed access to the water purification and storage system should be restricted to those staff responsible for monitoring and maintenance of the water purification and storage system.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis treatment and medication prescription as prescribed by the medical provider for 4 of 5 sampled patients, Patient (P) 1, P3, P4, and P5. Failure to follow the medical providers’ dialysis treatment and medication prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatment and medication for the 48 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in 04/2024, revealed, “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 the 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 [ultrafiltration] Profiling, f. Blood flow rate, g. Dialysate flow rate, h. All accesses evaluated, i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings, j. Heparinization (intradialytic infusion setting).” Further review of the policy revealed, “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.” 1. Review of P1’s treatment sheet, dated 04/01/2025, revealed a prescribed blood flow rate (BFR) of 300 milliliters per minute (mL/min). However, P1’s BFR was documented as 250 mL/min from 12:45 PM until 1:23 PM. There was no rationale documented why the prescribed BFR was not achieved. Review of P1’s treatment sheet, dated 04/08/2025, revealed a prescribed BFR of 300 mL/min. However, P1’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 2. Review of P3’s treatment sheet, dated 04/02/2025, revealed a prescribed hourly infusion of 0.6 milliliters (ml) of heparin (an anticoagulant) with a prescribed stop time of 60 minutes before the end of the treatment. However, P3’s treatment sheet indicated the heparin pump was continually activated until the treatment was terminated at 12:45 PM. There was no rationale documented why the hourly infusion of heparin was not terminated 60 minutes before the end of the treatment. 3. Review of P4’s treatment sheet, dated 04/01/2025, revealed a prescribed blood flow rate (BFR) of 250 milliliters per minute (mL/min) and a prescribed dialysate flow rate (DFR) of 800 mL/min. However, P4’s BFR was documented as 400 mL/min, and the DFR was documented as 610 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR and DFR were not achieved. Review of P4’s treatment sheet, dated 04/03/2025, revealed a prescribed BFR of 250 mL/min. However, P4’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Review of P4’s treatment sheet, dated 04/05/2025, revealed a prescribed BFR of 250 mL/min. However, P4’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Review of P4’s treatment sheet, dated 04/10/2025, revealed a prescribed BFR of 250 mL/min. However, P4’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Review of P4’s treatment sheet, dated 04/17/2025, revealed a prescribed BFR of 250 mL/min. However, P4’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 4. Review of P5’s treatment sheet, dated 04/02/2025, revealed a prescribed hourly infusion of 1 milliliter (ml) of heparin with a prescribed stop time of 60 minutes before the end of the treatment. However, P5’s treatment sheet indicated the heparin pump continued to be activated at 9:00 AM, 21 minutes before the treatment was terminated at 9:21 AM. There was no rationale documented why the hourly infusion of heparin was not terminated 60 minutes before the end of the treatment. Review of P5’s treatment sheet, dated 04/14/2025, revealed a prescribed hourly infusion of an unspecified dose of heparin with a prescribed stop time of 60 minutes before the end of the treatment. However, P5’s treatment sheet indicated the heparin pump was inactivated at 9:02 AM, 30 minutes before the treatment was terminated at 9:32 AM. There was no rationale documented why the hourly infusion of heparin was not terminated 60 minutes before the end of the treatment. Review of P5’s treatment sheet, dated 04/16/2025, revealed a prescribed blood flow rate (BFR) of 420 milliliters/minute and an hourly infusion of 1 ml of heparin with a prescribed stop time of 60 minutes before the end of the treatment. However, P5’s treatment sheet indicated the BFR was documented as 430 mL/min from 8:23 AM until 9:23 AM, and the heparin pump was inactivated at 8:52 AM, 35 minutes before the treatment was terminated at 9:27 AM. There was no rationale documented why the BFR was not achieved, and the hourly infusion of heparin was not terminated 60 minutes before the end of the treatment. During an interview on 04/24/2025 at 11:35 AM, Registered Nurse 3 stated she was trained and expected to document a rationale why a patient’s prescription was not followed and/or achieved. During an interview on 04/24/2025 at 8:10 AM, the Facility Administrator stated staff was trained and expected to document a rationale why a patient’s prescription was not followed and/or achieved. During an interview on 04/24/2025 at 10:50 AM, the Medical Director stated staff was expected to document a rationale why a patient’s prescription was not followed and/or achieved.”