Davita Frederick Dialysis

“ENVIRONMENT-ACCESS TO PORTS/METERS CFR(s): 494.40(a) 8 Environment: access to ports/meters The layout of the water purification system should provide easy access to all components of the system, including all meters, gauges, and sampling ports used for monitoring system performance. This Standard is not met as evidenced by: 47759 Based on observations and staff interviews, the facility’s governing body failed to ensure easy access to all components of the system such as: (1) water pressure gauges and (2) water valves. This failure placed the water system at risk for possible damage that may affect patient care. Findings Included: According to the American National Standards Institute (ANSI/AAMI RD52:2004), the layout of the water purification system should provide easy access to all components of the system, including all meters, gauges, and sampling ports used for monitoring system performance. On 01/12/2024, at 02:42 p.m., during observations of the water room, the surveyor observed stacks of water softener pellets adjacent to the secondary carbon tank blocking the G1, H1, and H2 valve as well as the P4 pressure gauge. At 02:45 p.m., during interviews, the Facility Administrator corroborated that all components of the water system should be easily accessible and not blocked by any items.”

“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: 47759 Based on observations and staff interviews, the governing body failed to ensure an environment free from defects or hazards in order to maintain safety and functionality. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings included: On 01/19/2024 at 10:30 a.m., during review of the facility’s policies and procedures titled “Physical Environment” (Policy: 08-04-01) page 1 number 1 states “The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public safe, functional, and comfortable treatment environment.” Number 2 states “The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates, and the public.” On 01/12/2024, at 11:45 a.m.-12:00 p.m., during inspection of the treatment floor, the surveyor observed the following: 1.Blue, black, white residues surrounding the strainer assembly of the faucet as well as brown residues surrounding the basin of the sink located at the back portion of the treatment floor near stations #22 and #23. During interviews, the Facility Administrator (FA) corroborated that the sink does need to be replaced. 2. One part of the cabinet handle dangling and unattached located across station #16. During interviews, Staff #1 corroborated that the cabinet needs an upgrade. 3. Peeling laminate countertop across Station #3 as well as peeling laminate countertop near stations #22 and #23. During interviews, the Facility Administrator (FA) corroborated that the countertop needs to be fixed as it poses an infection control concern. On 01/12/2024, at 02:42 p.m., during inspection of the water room, the surveyor observed the following: 1. Brown and white crystallization surrounding the pipe on the wall connected to the storage tank. 2. Brown residue surrounding the floor near the water heater. 3. White crystallization surrounding the granuflo dissolution unit. 4. Gross amount of black and gray residue all throughout the floor of the water room 5. Gross amount of white crystallization underneath the sink located between the water room and the storage room.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the facility’s implemented infection control protocol. This failure placed the safety and wellbeing of the patients at potential risk of harm in maintaining their vascular access. Staff: # 5 Findings included: According to the facility’s policies and procedures titled “AV Fistula or Graft Cannulation with Nipro Or Medsystems Safety Fistula Needles (SFN) And Administration of Heparin Loading Dose” page 3 number 13 states “Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” On 01/12/2024, during observations of the treatment floor, the surveyor observed the following: 1. At 10:18 a.m., during observation of the clinical staffs’ practice, the surveyor observed Staff #5 cleansed the access site of patient at station #12 [Patient J], then touched the patient’s skin prior to cannulation without disinfecting the access site again. 2. At 10:43 a.m., during observation of the clinical staff’s practice, the surveyor observed Staff #5 cleansed the access site of patient at station #13 [Patient K], then touched the patient’s skin prior to cannulation without disinfecting the access site again.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 47759 Based on record review and staff interviews, the governing body failed to ensure an adequate number of qualified and trained staff to meet the needs of the patients. This failure placed the patients at potential risk and denied their rights to a minimum standard of medical care. Findings Include: The Code of Maryland Regulations 10.05.04.06C (Dialysis Monitoring for Freestanding Kidney Dialysis Centers) states: (a) In-Center Daytime Hemodialysis. When in-center daytime hemodialysis is performed, the monitoring individual-to-patient ratio at each center shall be: (i) A minimum of one staff member to three participants; and (ii) Sufficient to meet the needs of patients. ... (c) The center shall establish provisions for back-up staff coverage during unexpected illnesses, vacations, and holidays. (d) The charge nurse may not be included in the staffing ratio except: (i) When there are nine or fewer patients; or (ii) In the event of an emergency. 1.On 01/18/2023 at 09:45 a.m., a review of the facility’s staffing exception report from December through January 2024 revealed that staffing ratios did not meet the requirements on the following dates: a. December 2023: 11, 13, 16, 18, 19, 20, 21, 22, 23, 26, 27, 28 b. January 2024: 2, 8, 9, and 10 In all instances, the charge nurse was either included in the staffing ratio or had to monitor patients. 2. On 01/18/2023, interviews with the Facility Administrator revealed that despite the inadequate staffing for December, the facility recently accepted two additional patients for the month of January.”