Davita Slidell Kidney Care

“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: 14442 Based on policy review, observation, and interview, the dialysis facility failed to demonstrate that it followed standard infection control precautions for cleaning and disinfection of the dialysis station. This deficient practice was evidenced by failing to ensure 10 (a, b, c, d, e, f, g, h, i, j) of 10 (a, b, c, d, e, f, g, h, i, j) in-center hemodialysis station wall boxes inspected were free from a build-up of dried clear crusty substances and residue. The facility had a total of 25 in-center hemodialysis stations. Findings: Review of the dialysis facility “Policy: 1-05-01 Title: Infection Control for Dialysis Facilities” with a revision date April 2023 revealed, in part: “Disinfection. 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: i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. Teammates will monitor and address wall box residue/build up and patency issues.” Observation of the in-center hemodialysis treatment room on 02/19/2025 from 10:12 AM to 10:54 AM revealed wall boxes at dialysis stations a, b, c, d, e, f, g, h, i, and j had a build-up of dried clear crusty substances and residue. In interviews on 02/19/2025 at 10:17 AM and 10:39 AM, S2LPN and S6PCT confirmed in-center hemodialysis wall boxes had a build-up of dried acid concentrate, residue, and other debris. In an interview on 02/19/2025 at 11:46 AM, S1Facility Administrator confirmed in-center hemodialysis station wall boxes had a build-up of dried acid concentrate and other debris. S1Facility Administrator confirmed wall boxes should be cleaned and disinfected at the end of each patient treatment.”

“ENVIRONMENT-SCHEMATIC DIAGRAMS/LABELS CFR(s): 494.40(a) 8 Environment: schematic diagrams/labels Water systems should include schematic diagrams that identify components, valves, sample ports, and flow direction. Additionally, piping should be labeled to indicate the contents of the pipe and direction of flow. If water system manufacturers have not done so, users should label major water system components in a manner that not only identifies a device but also describes its function, how performance is verified, and what actions to take in the event performance is not within an acceptable range. This Standard is not met as evidenced by: 14442 Based on observation, policy review, and interview, the dialysis facility failed to ensure instructions for testing and measuring levels of total chlorine in water used to prepare dialysate were available for staff reference in the water treatment room. This deficient practice had the potential to impact the 96 in-center hemodialysis patients on census. Findings: On 02/19/2025 at 9:45 AM, an observation was made in the water treatment room of S2LPN performing total chlorine testing using the Sterichek Total Chlorine Test Kit. Further observation revealed instructions for the Sterichek Total Chlorine Test Kit test procedures not posted for staff reference in the water treatment room. Review of the dialysis facility “Policy: 2-03-01 Title: Water Treatment Systems Minimum Component Requirement” with a revision date October 2021 revealed, in part: “General. 7. All water system components will be identified with DaVita labeling, as well as manufacturer labels, to describe its function, performance and actions to be taken if not in acceptable ranges.” In an interview on 02/19/2025 at 9:51 AM, S4BMT confirmed instructions for total chlorine test using the Sterichek Total Chlorine Test Kit should be posted in the water treatment room for staff reference. S4BMT confirmed the instructions were not posted.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 14442 Based on policy review, observation, and interview, the dialysis facility failed to ensure accurate monitoring of the carbon adsorption system as evidenced by staff (S2LPN, S3RN) failing to follow total chlorine testing procedures. This deficient practice had the potential to impact the 96 in-center hemodialysis patients on census. Findings: Review of the dialysis facility “Policy: 1-18-03B Total Chlorine Test Using Sterichek Total Chlorine Test Kit” with a revision date March 2015 revealed, in part: “Notes: Total chlorine testing with the use of the SteriChek Chlorine Test Kit is used to measure low levels of total chlorine (i.e. total chloramines plus free chlorine) in feed water used to prepare dialysate. Procedure 1. Rinse the sample tubes thoroughly with the water to be tested. Fill each sample tube to the line marked on the tube with the sample. Cap both tubes. 3. Obtain one DPD Total Chlorine Powder Pillow and check the expiration date. Uncap one of the sample tubes. Open one 15 ml DPD Total Chlorine Powder Pillow and add the contents of the pillow to one of the sample tubes. Recap the sample tube and shake the tube gently for approximately 30 seconds. 4. Remove caps from both tubes. 5. Place the sample tube with the prepared sample into the chamber on the inside of the comparator. Place the sample tube without the powder pillow in the outside chamber. 6. Hold the comparator to let light fall on top of the tubes and rotate the color wheel inside the comparator to obtain a color match. 7. Read the Total Chlorine level as indicated on the comparator.” On 02/19/2025 at 9:45 AM, an observation was made of S2LPN performing total chlorine testing using Sterichek Total Chlorine Test Kit. S2LPN rinsed and filled sample tubes with water to be tested to the fill line marked on the tubes. S2LPN did not cap both tubes as stated in procedure step 1. S2LPN added the contents of a Sterichek DPD Total Chlorine Powder Pillow to one of the sample tubes. S2LPN did not cap and shake the sample tube gently as stated in procedure step 3. In an interview on 02/19/2025 at 9:54 AM, S2LPN confirmed that tubes were not capped as stated in facility “Total Chlorine Test Using Sterichek Total Chlorine Test Kit” policies and procedures. On 02/19/2025 at 10:54 AM, an observation was made of S3RN performing total chlorine testing using the Sterichek Total Chlorine Test Kit. S3RN rinsed and filled sample tubes with water to be tested to the fill line marked on the tubes. S3RN added the contents of a Sterichek DPD Total Chlorine Powder Pillow to one of the sample tubes. S3RN capped and shook the sample tube with the powder pillow gently for approximately 30 seconds. S3RN did not remove caps from both tubes as stated in procedure step 4 to let light fall on top of the tubes to obtain a color match. In an interview on 02/19/2025 at 10:56 AM, S3RN confirmed that caps were not removed from tubes to let light fall on top of the tubes as stated in facility “Total Chlorine Test Using Sterichek Total Chlorine Test Kit” policies and procedures.”

“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: 14442 Based on observation, record review, and interview, the dialysis facility failed to ensure the building floors were maintained. This deficient practice was evidenced by having floors with numerous scratches, brownish/grayish discoloration, and scuff marks. Findings: Observation of the dialysis facility floors with S1Facility Administrator on 02/20/2025 at 9:24 AM revealed floors in the lobby/waiting room, in-center hemodialysis treatment room, biomedical repair room, and hallways located on the in-center hemodialysis area had numerous scratches at varying depths, brownish/grayish discoloration, scuff marks, and dull in appearance. Review of dialysis facility “Grievance/Investigation Document Policy: 3-01-06D” records revealed, in part, patient complaints on 10/23/2024, 11/05/2024, and 12/26/2024 that floors were “dirty.” In an interview on 02/20/2025 at 9:37 AM, S1Facility Administrator confirmed floors had numerous scratches at varying depths, brownish/grayish discoloration, scuff marks, and dull in appearance. S1Facility Administrator confirmed patients have complained about the condition of floors.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 14442 Based on observation and interview, the dialysis facility failed to ensure all patient treatment equipment was maintained. This deficient practice was evidenced by failing to ensure in-center hemodialysis patient treatment chairs were maintained to allow effective cleaning/disinfection by having tears and cracks in the vinyl covering for 10 (a, b, c, d, e, f, g, h, i, j) of 10 (a, b, c, d, e, f, g, h, i, j) treatment chairs inspected. The dialysis facility had 25 in-center hemodialysis patient treatment stations. Findings: Observation of the in-center hemodialysis treatment room on 02/19/2025 from 10:12 AM to 10:54 AM revealed patient treatment chairs at dialysis stations a, b, c, d, e, f, g, h, i, and j had tears and cracks in the vinyl covering. In an interview on 02/19/2025 at 10:17 AM, S2LPN confirmed patient treatment chairs at dialysis stations a, b, c, d, e, f, g, h, i, and j were unable to be adequately cleaned and disinfected due to torn and cracked vinyl coverings. In an interview on 02/19/2025 at 11:51 AM, S1Facility Administrator confirmed the dialysis facility had patient treatment chairs with torn and cracked vinyl coverings. S1Facility Administrator confirmed patient treatment chairs with torn and cracked vinyl coverings created an issue with chairs being adequately cleaned and disinfected.”

“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: 14442 Based on record review and interview, the dialysis facility failed to ensure patients’ volume status was adequately monitored by patient care staff. This deficient practice was evidenced by patient care staff failing to report abnormal blood pressure and heart rate findings during treatment for 1 (#4) of 4 (#1-#4) sampled in-center hemodialysis patients. This deficient practice had the potential to impact the 96 in-center hemodialysis patients on census. Findings: Review of the dialysis facility “Policy: 1-03-08 Title: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” with a revision date April 2024 revealed, in part: “9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: b. At a minimum, obtain and document the following: i. Blood pressure. ii. Heart or pulse rate. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 13. All findings, interventions and patient response will be documented in the patient’s medical record. Abnormal Findings: 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. Blood Pressure-Intradialytic: Systolic less than 90 mm/Hg. Diastolic less than 50 mm/Hg. Heart or Pulse Rate Pre/Intra/Post: greater than 100 beats per minute and/or an irregular heart beat.” Review of Patient #4’s “Treatment Details Report” dated 11/20/2024 revealed S8PCT submitted the following: 1:13 PM, blood pressure 77/48 mm/Hg, heart rate 133 beats per minute. Further review revealed no evidence these findings were reported to the licensed nurse and a licensed nurse assessed the patient to determine if any clinical interventions were necessary. Review of Patient #4’s “Treatment Details Report” dated 12/02/2024 revealed S6PCT submitted the following: 12:32 PM, blood pressure 60/41 mm/Hg. 12:34 PM, blood pressure 86/36 mm/Hg. At 1:00 PM, S9PCT submitted the following: blood pressure 81/52, heart rate 113 beats per minute. Further review revealed no evidence these findings were reported to the licensed nurse and a licensed nurse assessed the patient to determine if any clinical interventions were necessary. In an interview on 02/24/2025 at 12:53 PM, S1Facility Administrator confirmed there was no evidence PCTs reported Patient #4’s blood pressure and heart rate findings to a licensed nurse.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 14442 Based on record review and interview, the dialysis facility failed to ensure the patient’s dialysis prescription for blood flow rate and dialysis flow rate were delivered as ordered by the physician for 3 (#2, #3, #4) of 4 (#1-#4) sampled in-center hemodialysis patients. This deficient practice had the potential to impact the 96 in-center hemodialysis patients on census. Findings: Review of the dialysis facility “Policy: 1-03-08 Title: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” with a revision date April 2024 revealed, in part: “3. 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 a licensed nurse within one hour of treatment initiation. Prescription components include but are not necessarily limited to: f. Blood flow rate g. Dialysate flow rate 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: b. At a minimum, obtain and document the following: iii. Blood and dialysate flows. 10. If the dialysis prescription is not being met (including dialysate flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and licensed nurse informed.” 1. Review of Patient #1’s “Dialysis Prescription” revealed, in part: “Blood Flow Rate 400 mL/min.” Review of Patient #1’s “Treatment Details Report” dated 12/19/2024, 12/23/2024, 12/26/2024, 12/28/2024, and 01/02/2025 revealed the patient’s BFR was not delivered as ordered by the physician. Further review revealed staff did not document a reason why the dialysis prescription was not met. In an interview on 02/20/2025 at 11:13 AM, S1Facility Administrator confirmed Patient #1’s dialysis prescription was not delivered as ordered by the physician. S1Facility Manager confirmed staff did not document a reason why the dialysis prescription was not met. 2. Review of Patient #4’s “Dialysis Prescription” revealed, in part: “Blood Flow Rate 400 mL/min Dialysate Flow Rate 800 mL/min.” Review of Patient #4’s “Treatment Details Report” dated 11/18/2024, 11/20/2024, and 11/29/2024 revealed the patient’s BFR and DFR were not delivered as ordered by the physician. Further review revealed staff did not document a reason why the dialysis prescription was not met. In an interview on 02/24/2025 at 12:53 PM, S1Facility Administrator confirmed Patient #4’s dialysis prescription was not delivered as ordered by the physician. S1Facility Manager confirmed staff did not document a reason why the dialysis prescription was not met. 3. Review of Patient #3’s “Dialysis Prescription” revealed, in part: “Dialysate Flow Rate 800 mL/min.” Review of Patient #3’s “Treatment Details Report” dated 02/18/2025 revealed the patient’s DFR was not delivered as ordered by the physician. Further review revealed staff did not document a reason why the dialysis prescription was not met. In an interview on 02/24/2025 at 12:55 PM, S1Facility Administrator confirmed Patient #3’s dialysis prescription was not delivered as ordered by the physician.”