Davita Easton Dialysis Center

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 36839 Based on observations and a review of the facility’s policies and procedures, the governing body failed to ensure that the clinical staff followed their policy on implementing proper utilization of personal protective equipment (PPE). This failure placed all the patients and staff at risk of exposure to infectious diseases and blood borne pathogens. Findings included: The facility’s policy and procedure 5-06-01, page 2 states that PPE is to be (5a) Removed prior to leaving the treatment/training area, (5c) PPE is not to be worn in non-treatment areas. According to the Centers for Disease Control and Prevention (CDC), used personal protective equipment (PPE) is considered “contaminated” from areas that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside. Therefore, when a gown or full PPE is worn, PPE should be removed prior to leaving the treatment area. During observations in the facility on 3/31/2025, the following were noted: 1. At 11:54 a.m., Staff #15, a patient care technician (PCT) was observed walking in the hallway wearing a PPE mask and gown seen in the hallway between the dialysis treatment room and the supply room on her phone wearing a PPE gown. 2. At 2:11 p.m., the nurse practitioner went from the clinical floor to the patients’ lobby wearing a PPE gown. These findings were discussed with the governing body during the exit conference on 4/1/2025.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 36839 Based on observations and a review of the facility’s policies and procedures, the governing body failed to ensure that the items taken to the dialysis stations were either disposed of, dedicated for use on a single patient, or cleaned and disinfected before being returned to a common clean area. This failure placed the patients at potential risk for exposure to blood-borne pathogens and other infectious diseases. Findings included: The facility’s Infection Control policy states (Policy#12-07-01, page 4, #34): “If electronic thermometers and/or blood glucose meters are used, measures will be taken to prevent cross contamination between patients... If the potential for contamination exists, the device outer casing is wiped with an appropriate disinfectant before being returned to a clean area or using on another patient.” During observations on the treatment floor on 3/31/2025, it was noted that Staff #6 obtained the patient’s temperature at station #14 post dialysis treatment where it was observed that the thermometer touched the patient’s forehead. The staff then returned the used thermometer to the designated area without disinfecting it. This finding was discussed with the governing body during the exit on 4/1/2025.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 36839 Based on infection control observations, the governing body failed to ensure that the clinical staff followed safe practices when handling infectious wastes. This failure created a potential risk of blood exposure and risk of harm to patients and staff in the unit. The findings include: The Occupational Health and Safety Administration (OSHA): 29CFR1910.1030(d)(2)(xi) states: “All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. Carrying contaminated blood tubing and dialyzer from the patient’s station across the treatment floor to a biohazard box could result in unknown spattering of blood. Therefore, if an employee carries contaminated dialysis tubing and dialyzer from a patient’s station, at the end of treatment, to the biohazard box that is located across the treatment floor, this could result in a blood splatter. During observations in the clinical treatment room on 3/31/2025, the following were noted: 1. At 1:35 p.m., the patient care technician (PCT) removed the used blood tubings and dialyzer from the dialysis machine at station #13 and carried them approximately 10 feet to the biohazard trash to discard them. 2. At 1:42 p.m., the PCT removed the used blood tubings and dialyzer from the dialysis machine at station #2 and walked 12 steps to the biohazard trash to discard them. These findings were discussed with the governing body during the exit conference on 4/1/2025.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36839 Based on observations, the facility’s governing body failed to ensure that every patient’s vascular access was visible during hemodialysis treatment. This failure placed the patients at potential risk of harm and possible death. Findings included: During observations on the clinical floor on 3/31/2025, the vascular access site of the patient at station #5 was covered with a blanket from 12:45-1:05 p.m. while the patient was having dialysis treatment. The access site was not easily or readily visible to the clinical staff. This finding was verified by the charge nurse upon observation on 3/31/2025.”

“PR-CAN HAVE ADVANCE DIR,TOLD FAC AD P&P CFR(s): 494.70(a)(6) The patient has the right to- (6) Be informed about his or her right to execute advance directives, and the facility ’ s policy regarding advance directives; This Standard is not met as evidenced by: 36839 Based on medical record review, the governing body failed to ensure that all of the facility’s patients had a completed Medical Orders for Life-Sustaining Treatment Form (MOLST) in their patient records. This failure denied the patient’s rights to formulate treatment decisions that served their end-of-life needs. Patients #6, #7 and #9 Maryland Code 10.01.21.04B(4)E(1)(2)(3) mandates that, starting July 1, 2013, kidney dialysis centers must accept, update, and complete the Medical Orders for Life-Sustaining Treatment (MOLST) form during the patient admission process. When completing or updating the MOLST form, health care facilities must offer patients or authorized decision makers the opportunity to participate. If declined, the facility must document the refusal in the medical record, including the date, time, participants, and a summary of the discussion. Patients are to be informed that the MOLST form becomes part of the medical record, accessible through standard record procedures. A MOLST form must be signed and dated by a licensed physician, nurse practitioner, or physician assistant to be valid. Each page with orders must be signed and dated. A review of the facility’s medical records on 4/1/2025 revealed 3 out of 10 sampled patients did not have their completed MOLST forms. 1. Patient #6 whose initial dialysis treatment at the facility was on 8/20/2024. 2. Patient #7 whose initial dialysis treatment at the facility was on 4/18/2023. 3. Patient #9 (peritoneal dialysis patient) whose initial dialysis treatment at the facility was on 12/2/2024”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 36839 Based on observations, the governing body failed to ensure that the contact information for the State Survey Agency and Renal Network were current and accurate. This failure denied the patients their rights. Findings Included: The Centers for Medicare and Medicaid Services (CMS) requires that all in-center dialysis facilities post the current contact information for the applicable End-Stage Renal Disease (ESRD) Network and State Survey Agency (SSA) and the current complaint telephone numbers for each. The purpose of this posting is to ensure that patients are aware of their rights and have access to important contact information should they need to file a complaint or report a concern. However, it is important to note that this posting is meant to supplement, not replace, individual communication with each patient about their rights in a way that they can understand. During a tour of the peritoneal dialysis (PD) unit which had a separate patient entrance and waiting room from the in-center dialysis unit, it was noted that the contact information of Quality Insights Renal Network 5, The Office of Health Care Quality and The Maryland Commission on Kidney Disease were not posted for the patients to see. This finding was confirmed by the facility administrator on 4/1/2025.”

“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: 36839 Based on review of the dialysis patients’ treatment flowsheets, the governing body failed to ensure that the patients received their treatment according to the dialysis prescriptions. The failure to ensure that the dialysis prescriptions were implemented according to the doctor’s orders placed the patients at potential risk of harm or injury and denied their patient rights.. Patients ##1 and #2 Findings included: A review of the sampled patients’ treatment flowsheets on 4/1/2025 revealed the following: 1. On treatment day 3/29/2025, Patient #1 dialyzed for 217 minutes which was 37 minutes longer than the prescribed treatment time of 180 minutes. No documentation found showing there was an order from the physician to extend the patient’s treatment time. 2. On treatment day 3/25/2025, Patient #2’s blood flow rate (BFR) was set at 350 mL/minute instead of 450 mL/minute during the entire dialysis treatment. No backup documentation was found explaining why the prescribed BFR was not followed. These findings were discussed with the governing body during the exit on 4/1/2025.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 36839 Based on the review of medical records and the facility’s policies and procedures, the governing body, and the interdisciplinary team (IDT) failed to ensure that a 30-day comprehensive assessment had been completed on all new patients within the latter of 30 calendar days, or 13 treatments beginning with the first outpatient dialysis session. This failure placed the affected patients at potential risk of harm and denied the patients their rights. Patients: #5 and #7 Findings included: According to the facility’s policies and procedures titled Interdisciplinary Team (IDT) Patient Assessment and Plan of Care (Policy #1-14-01, page 2, #4), “A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment.” A review of the sampled patients’ medical records with the peritoneal dialysis nurse on 4/1/2025 revealed the following: 1. Patient #5 was admitted to this facility on 10/21/2022. The patient’s initial comprehensive assessment was done on 12/26/2022 which was >30 days from the time of the patient’s initial dialysis treatment. 2. Patient #7 was admitted to the facility on 4/18/2023. The patient’s initial comprehensive assessment was done on 6/2/23 which was >30 days from the time of the patient’s initial dialysis treatment.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36839 Based on review of medical records and the facility’s policies and procedures, the governing body failed to ensure that the facility’s interdisciplinary team (IDT) completed the 90-day follow-up comprehensive assessment. This failure placed the affected patient at risk for receiving inadequate health care and denied the patient his or her rights. Patient #7 Findings included: According to the facility’s policy (1-14-01, page 2, #5), “A follow-up 90-day reassessment will be completed to evaluate the patient’s status and provide information to adjust the patient’s plan of care.” A review of the sampled patients’ medical records revealed the following: 1. Patient #7, who was admitted to the facility on 4/18/2023, had an initial comprehensive assessment completed on 6/2/2023, and a follow-up reassessment on 10/13/2023 which was more than 90 days from the time of the initial comprehensive assessment. 2. Patient #8, who was admitted to the facility on 10/24/2023, had an initial comprehensive assessment done on 11/30/2023. No follow-up (90-day) reassessment was found in the patient’s records. These findings were confirmed by the peritoneal dialysis nurse who reviewed the medical records with this surveyor on 4/1/2025.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 36839 Based on observations and a review of the facility’s policies and procedures, the facility’s administration failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access prior to cannulation, and practiced the correct infection control protocol. This failure placed the safety and well being of the patients at potential risk of harm in maintaining their vascular access. Findings included: The facility’s policy on Arteriovenous Fistula (AVF) or Graft (AVG) Cannulation (1-04-01E) states: “Do not palpate insertion site once the area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” During observations on the dialysis treatment floor on 3/31/2025 at 2:40 p.m., it was noted that Staff #7, the patient care technician assigned at station #12, touched the patient’s access site right before needle insertion after it had already been prepped.”