Davita West Broadway Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44000 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a sanitary environment to decrease transmission of infectious agents within and between the unit and any nearby public areas. Observation of the facility’s 16 of 16 patient chairs revealed debris and other foreign substances located on the metal parts of the chairs’ sides and the bottom of the chairs. In addition, interview revealed the facility had experienced a problem with bed bugs and roaches. The findings include: 1. Record review of the facility’s policy titled, “DSD Infection Control for Dialysis Facilities,” revised, April 2024 revealed at the end of each treatment, the dialysis station was to be cleaned and disinfected, to include disinfection of the dialysis chairs. Observation on 03/25/2025 between 11:22 AM and 11:39 AM, revealed the dialysis chairs at stations 1, 2, 3, 6, 7, 8, 13, 14, 17, 18, 19, 20, 21, 22, 23, and 24 had debris on the metal parts of the sides and bottom of the chairs. Continued observation revealed the chair at station 2 had a piece of yellow plastic attached to the metal bar. Further observation revealed the chair at station 23 had a piece of popcorn lying on the bar. 2. Review of the facility’s pest control policy, “ECTOPARASITIC INFESTATIONS 9FLEAS, LICE, COMMON BED BUGS0 MANAGEMENT,” dated 05/06/2013, revealed bed bugs were becoming more prevalent and could be spread from infested used furniture, luggage, and bedding. Per policy review, bed bug bites typically occurred at night and intense itching might be present. Continued review revealed measures to prevent transmission were to be followed and included patients exhibiting possible signs and symptoms of bed bug infestation might require information about the need for home pest control services. Further review revealed the frequency of the dialysis facility’s pest control services/inspections might need to be temporarily increased until the situation was resolved. Review of the facility’s pest control documentation revealed pest control treatments were completed as follows: Terminix - 09/23/2024 Rentokil - 10/15/2024 Rentokil - 10/25/2024 Rentokil - 12/18/2024 Rentokil - 12/27/2024 Terminix - 01/15/2025 Terminix - 01/16/2025 Terminix - 02/18/2025 In interview on 03/25/2025 at 12:38 AM, the Social Worker (SW) stated there had been an outbreak of bed bugs and roaches in the facility. She reported “it started in the fall” and had gotten worse. The SW said they had talked with the local and state health departments, and were told the facility was responsible in controlling the pests. She stated she attempted to have patients who had been identified as having bed bugs store their belongings in the lobby. The SW said the facility provided the patients with paper blankets. She stated a Patient Care Technician (PCT) took a picture of roaches coming out of an electric outlet at the facility and sent it to her. The SW further stated a while back a nurse got bit by “a bug.” She additionally stated the facility had educated the patients known to have bed bugs, on how to remove them from their home. In interview on 03/25/2025 at 12:57 PM, the Administrative Assistant (AA) stated there had been patients who had bed bugs who came to the facility. She said “they” attempted to have those patients keep their belongings in the facility’s lobby, and gave the patients disposable blankets. The AA reported they had ordered “extra” Terminix treatment and the use of “Sterifab,” a bug and germ solution that killed bed bugs and roaches. She stated the bed bug and roach problem was currently under control. In interview on 03/25/2025 at 1:23 PM, PCT 1 stated there were some patients who came into the facility who had bed bugs. She said there was also a problem with roaches at the facility. PCT 1 reported she took a video of roaches coming out of an electric outlet at the facility. She stated “they” had been trying to control the “bugs” by having Terminix come in more often. PCT 1 further stated “they” had patients known to have bed bugs place their belongings in a plastic bag. She additionally stated she had not seen any bed bugs recently. In interview on 03/25/2025 at 1:30 PM, PCT 2 stated she knew there was a problem with bed bugs and roaches at the facility. PCT 2 further stated “they” were attempting to control “the bugs” by putting the patients’ belongings in plastic bags. She stated she had not seen any bed bugs recently. In interview on 03/25/2025 at 1:38 PM, PCT 3 stated bed bugs and roaches had been “a problem for a while” at the facility. PCT 3 stated they had not seen any bed bugs recently. In interview on 03/25/2025 at 2:01 PM, the Dietitian stated she started noticing bed bugs and roaches in the facility “around December.” She said she had noticed roaches crawling on the floor and at the nurse’s stations. The Dietician further stated she saw the bed bug PCT 1 brought to her. She additionally reported PCT 1 had taken a piece of tape and caught the bug which had been crawling on a patient. The Dietician also said she had not seen any bed bugs recently. In interview on 03/25/2025 at 2:19 PM, Registered Nurse (RN) 1 stated she was the Clinical Coordinator. She said she first noticed bed bugs and roaches in the facility “around December.” RN 1 reported she had seen the bed bugs and roaches on the facility floor and at the nurse’s station. She stated PCT 1 came to her with a bed bug on a piece of tape that she had removed from off a patient. The RN said PCT 2 had also brought her a bed bug on a piece of tape. She explained they talked to the patients in private (known to have bed bugs) and let them know they would have to leave their belongings in the lobby, where their belongings were placed in a plastic bag. RN 1 further stated they gave the patients paper blankets to use, and gave them two or three if needed. RN 1 additionally stated she had not seen any bed bugs recently. In interview on 03/25/2025 at 2:40 PM, the Advanced Practice Registered Nurse (APRN) stated the facility was using paper blankets; however, she did not think those were enough to keep the patients warm. She reported she wished the facility had “a dedicated area” for patients who had issues with pests. In interview on 03/25/2025 at 3:38 PM, the Medical Director stated the facility notified her of the issue with “bugs.” She said the facility had asked patients who had issues with pests to leave their belongings in the lobby. The Medical Director further stated the patients had not complained to her about pests or having to use the paper blankets. She stated she had not had any recent complaints about bed bugs. In interview on 03/26/2025 at 8:15 AM, the Complainant reported seeing a bed bug in the facility. She had not been at the facility in the last two months. In interview on 03/26/2025 at 8:33 AM, the Assistant Administrator stated she had never told a patient they could go to another facility; however, there were bed bugs everywhere in the facility. She stated the bed bug situation was under control. In interview on 03/26/2025 at 8:44 AM, the Administrator stated she could not recall ever telling a patient they could go to another facility, but there were bed bugs everywhere in the facility. The Administrator further stated the bed bug situation was under control. In interview on 03/26/2025 at 9:54 AM, RN 2 stated she “got bit by a bug,” while she had been sitting at the nurse’s station. She there had been a family who brought “in the bugs.” RN 2 reported the facility was attempting to prevent the pests by using a solution called Sterifab. She further stated “they” also had pest control companies coming in. She stated she had not seen any bed bugs recently. In interview on 03/26/2025 at 10:01 AM, RN 3 stated the bugs had been present in the facility since “about December.” She reported the Administrator, and the Assistant Administrator had been doing everything they could to solve the (bug) problem. She further said she had not seen any bed bugs recently. In interview on 03/26/2025 at 11:16 AM, during telephone interview, RN 4, the facility’s corporate Infection Preventionist (IP), stated she received an electronic mail (email) on 01/17/2025, from the Administrator about the pests. She said she recommended the patients’ physicians and Medical Director be notified of the pest problem. RN 4 additionally said she gave further recommendations as listed in the facility’s policy. She further stated the bed bug situation was under control. In interview on 03/26/2025 at 11:58 AM, during telephone interview, the Nephrologist stated she had been notified of the problem with “pests” at the facility. She further stated “maybe” the “hygiene” of the facility could be better.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 30271 Based on observation, interview, and facility policy review, the facility failed to protect patient medical records files from potential moisture damage for one of one medical record storage rooms. This deficient practice had the potential to affect all records stored in the storage room. The findings include: A review of the facility policy titled, “Medical Records Custodian and Maintenance,” with a revision date of 10/2019, revealed, “Verifies that all medical records are stored in a safe manner to protect against loss, destruction or unauthorized use.” During an observation on 05/28/2024 at 10:58 AM, the surveyor noted the facility was protected by a fire sprinkler system. The medical record storage room had two sprinkler heads located on the ceiling, one at each end of the room. Patients’ medical records were stored on two metal mobile open shelving carts. The room also contained multiple metal filing cabinets, but the records were not storing in the metal file cabinets. The Facility Administrator was responsible for the care and storage of the medical records were stored on an opened metal cart. The medical records were not protected if the sprinkler heads were activated by fire or any other disaster. During an interview on 05/28/2024 at 10:58 AM, the Facility Administrator confirmed the medical record room was not equipped to protect the medical records from moisture damage.”