Davita Eastern Kentucky 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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure hand hygiene was performed according to facility policy during 4 of 10 observations of patient care. Findings included: A facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “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 (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine), f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” A facility policy titled, “AV [arteriovenous] Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised 10/2024, indicated, “16. Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation.” 1. During an observation on 02/19/2025 at 10:12 AM, Registered Nurse (RN) #5 entered patient treatment station 10 to perform discontinuation of dialysis for a patient with an arteriovenous fistula (AVF). RN #5 returned the patient’s blood and disconnected the bloodlines from the cannulation needles. The bloodlines were connected to the extracorporeal circuit on the machine. RN #5 removed the first cannulation needle and applied pressure to the insertion site to stop the bleeding. RN #5 then removed the second needle and again held the insertion site. RN #5 did not perform hand hygiene after contact with the dialysis machine when she attached the bloodlines or prior to the removal of the patient’s cannulation needles. In an interview on 02/19/2025 at 12:13 PM, RN #5 stated hand hygiene and glove changes should occur prior to removing the needles after reinfusing the patient’s blood and disconnecting the blood line. RN #5 stated that any time a staff member changed their gloves they should perform hand hygiene. RN #5 stated she did not perform hand hygiene prior to removing the patient’s needles in treatment station because she was overwhelmed. 2. During an observation on 02/19/2025 at 10:47 AM, Patient Care Technician (PCT) #3 entered patient treatment station 6 to initiate dialysis treatment for a patient with an arteriovenous fistula (AVF). PCT #3 palpated the access, cleaned a stethoscope, auscultated the access, cleaned the access with alcohol, applied betadine (an antiseptic), applied a tourniquet, and cannulated the patient’s access. PCT #3 did not perform hand hygiene after she assessed the patient’s access or prior to the cannulation of the patient’s access. In an interview on 02/19/2025 at 2:28 PM, PCT #3 stated she normally performed hand hygiene and changed her gloves after she reinfused the patient’s blood back and before she pulled the needles. PCT #3 stated hand hygiene should be completed and gloves changed after the assessment of the patient’s access and prior to cannulating the patient’s access site. PCT #3 stated she did not change gloves and perform hand hygiene after she assessed the patient’s access in dialysis treatment station #6 or prior to cannulation because she was nervous. 3. During an observation on 02/19/2025 at 10:53 AM, Patient Care Technician (PCT) #1 entered patient treatment station 5 to perform discontinuation of dialysis for a patient with an arteriovenous fistula (AVF). PCT #1 returned the patient’s blood and disconnected the bloodlines from the cannulation needles. The bloodlines were connected to the extracorporeal circuit on the machine. PCT #1 then removed the first cannulation needle. PCT #1 did not perform hand hygiene after contact with the dialysis machine when she attached the bloodlines or prior to the removal of the patient’s cannulation needle. 4. During an observation on 02/19/2025 at 11:40 AM, Patient Care Technician (PCT) #1 entered patient treatment station 2 to perform dialysis treatment initiation for a patient with an arteriovenous fistula (AVF). PCT #1 cleaned the patient’s access with soap and water, cleaned the stethoscope with alcohol, auscultated the access, cleaned the site with antiseptic, applied a tourniquet, and cannulated the access. PCT #1 did not perform hand hygiene after she assessed the patient’s access or prior to cannulation of the access. In an interview on 02/21/2025 at 10:46 AM, the Medical Director confirmed the facility expectation was for staff to perform hand hygiene per policy and that would include after reinfusing a patient’s blood and prior to removing cannulation needles and after assessing a patient’s access and prior to cannulation.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to clean and disinfect hemodialysis treatment stations during 2 of 2 infection control observations. This deficiency had the potential to affect the 25 patients who received hemodialysis treatments in the facility. Findings included: A facility policy titled, “Infection Control for Dialysis Facilities,” revised 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. [exempli gratia, for example], 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)”and “ii. Priming containers are to be emptied prior to disinfection.” 1. During an infection control observation on 02/19/2025 at 10:32 AM, Patient Care Technician #1 cleaned and disinfected dialysis treatment station 2; however, she failed to empty the prime waste receptacle and disinfect the prime waste receptacle, television, and counter behind the station. 2. During an infection control observation on 02/19/2025 at 11:00 AM, Patient Care Technician (PCT) #3 cleaned and disinfected dialysis treatment station 7; however, she failed to disinfect the television and counter behind the station. During an interview on 02/19/2025 at 12:13 PM, Registered Nurse #5 stated the facility expectation was to empty the prime waste receptacle and clean the prime waste receptacle, television, and the counter behind the treatment station. During an interview on 02/19/2025 at 2:28 PM, PCT #3 stated the facility expectation was to clean the television, the shelf behind the treatment station, and the prime waste receptacle between treatments. During an interview on 02/21/2025 at 10:46 AM, the Medical Director stated the facility expectation was to disinfect dialysis treatment stations per policy to include emptying and cleaning the prime waste receptacle, the television, and the shelf behind the machine.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to monitor the fluid status and report abnormal vital signs for 2 (Patient #1 and Patient #4) of 5 sampled patients reviewed for hemodialysis monitoring. Findings included: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated, “11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary.” The policy specified, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time.” Per the policy, “”Blood Pressure [BP] - Intradialytic: *Systolic [the top number of a blood pressure reading] greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg *Diastolic [the bottom number of a blood pressure reading] greater than or equal to 100 mm/Hg or less than 50 mm/Hg” and “Heart or Pulse Rate Pre/Intra/Post: *Less than 60 beats per minute [bpm] or greater than 100 beats per minute and/or an irregular heart beat.” 1. Patient #1’s “Treatment Details Report,” dated 02/03/2025 at 12:04 PM, indicated the patient had a heartrate of 104 bpm and there was no indication a nurse was notified. 2. Patient #4’s “Treatment Details Report,” dated 02/03/2025, indicated the patient had a heartrate of 46 bpm and there was no indication a nurse was notified. Patient #4’s “Treatment Details Report,” dated 02/12/2025, indicated the patient had a heartrate of 44 bpm and there was no indication a nurse was notified. Patient #4’s “Treatment Details Report,” dated 02/14/2025, indicated the patient had a heartrate of 44 bpm and a blood pressure reading of 99/55 mmHg and there was no indication a nurse was notified. During an interview on 02/19/2025 at 12:13 PM, Registered Nurse (RN) #5 stated patient care technicians (PCTs) should report to a nurse if a patient had a blood pressure reading less than 100/60 mmHg, greater than 160/95 mmHg, or a drop in blood pressure greater than 15 mmHg. RN #5 stated once a nurse was notified of an out-of-range vital sign parameter, the nurse should check on the patient, see what interventions, if any, were needed, and document everything that was done. During an interview on 02/19/2025 at 2:28 PM, PCT #3 stated PCTs were to notify the nurse if a patient had any complaints, such as cramping, a blood pressure reading below 90/50 mmHg or above 200/100 mmHg, or a heartrate below 50 bpm or above 100 bpm. PCT #3 stated the nurse should then document any interventions that were done. During an interview on 02/20/2024 at 11:00 AM, the Facility Administrator (FA) stated that when a registered nurse was notified of a patient’s abnormal heartrate, the notification should be documented. The FA stated there should be a follow-up note from the RN to include a recheck of the patient’s heartrate. The FA stated the facility expectation was for a patient’s heartrate below 50 bpm to be reported to the RN and documented. During an interview on 02/21/2025 at 10:46 AM, the Medical Director stated the facility expectation was for PCTs to report out-of-range vital signs to the RNs per facility policy.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview, document review, and facility policy review, the facility failed to track, trend, and analyze the quality indicator information. This deficient practice had the potential to affect all 37 patients who received dialysis treatment at the facility. Findings included: A facility policy titled, “Continuous Quality Improvement Program,” revised 04/2024, indicated, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following: *Patient Safety, including - Review of sentinel events - Review of trends of adverse patient occurrences including falls and blood loss - Review of product, equipment, or medication notices or recalls *Infection Control, including - Incidence of infections - Vaccination rates for Hepatitis B, Influenza, and Pneumococcal *Adequacy of Dialysis *Nutritional Status *Mineral Metabolism and Renal Bone Disease *Anemia Management *Vascular Access *Growth and Capacity *Mortality - review of deaths *Hospitalizations an Emergency Ambulance Transfers *Patient Satisfaction and Grievances, including KDQOL [Kidney Disease Quality of Life] *Other indicators as reflected in the Quality Improvement and Facility Management Meeting form.” The facility “Dashboard Health Outcomes: Mortality,” for the timeframe 02/2024 through 01/2025, revealed no evidence to indicate the facility tracked, trended, or analyzed patients’ deaths that could have been contributed to missed treatments, abnormal laboratory values, or ultrafiltration rates. The facility “Mortality Improvement Plans [IP],” dated 01/2025, indicated “No IP / Comment.” During an interview on 02/20/2025 at 3:00 PM, the Facility Administrator (FA) stated the Mortality Improvement Plan was the document in which the facility trended, analyzed, and documented their action plans for the previous 12 months. The FA confirmed there was no documentation to review. The FA stated the facility did not track, trend, or analyze potential contributing factors to patient deaths, such as missed treatments, laboratory values, or ultrafiltration rates. The FA stated the only data being reviewed by the facility was the number of deaths, the cause of death, and the gross mortality rate. During an interview on 02/20/2025 at 3:45 PM, the FA stated there was no evidence of adverse event analysis conducted during the facility quality assurance performance improvement (QAPI) meetings. The FA reported multiple potential causes that might have contributed to the lack of tracking, trending, analysis (investigation) of adverse events in QAPI, such as she was recently reassigned to this clinic and during the second QAPI meeting she attended, she was able to catch the omission of adverse event reporting, and it was revealed the registered nurses (RNs) were not inputting adverse events into the system correctly. The FA stated she educated the RNs at the time but had no evidence of the education provided. During an interview on 02/21/2025 at 10:46 AM, the Medical Director stated the expectation was to review all required items during their QAPI meeting.”