Davita Middlebrook 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: 36839 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene requirements were complied with by all of the clinical staff. This failure placed all patients at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Findings included: As per the Centers for Disease Control and Prevention (CDC), even when using gloves, it is crucial to practice hand hygiene after glove removal due to potential contamination from glove defects and the outer surface during removal. During observations in the clinical treatment room on 8/19/2024 at 3:50 p.m., PCT #3 at station #7 did not perform any hand hygiene after glove removal. This finding was discussed with the administrative team during the exit on 8/20/2024.”

“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 (#12-07-01, page 4, #34) states: “If electronic thermometers and/or blood glucose meters are used, measures will be taken to prevent cross contamination between patients. For example, the thermometer should not be placed on a potentially contaminated equipment such as the dialysis delivery system. 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 observation on 8/19/2024 at 3:30 p.m., it was noted that PCT #1 took a digital thermometer from the nurse’s station and brought it to station #14 to obtain Patient #6’s temperature, then placed the thermometer on the computer workstation (potentially contaminated equipment). This finding was discussed with the administrative team during the exit on 8/20/2024.”

“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 8/19/2024 at 2:58 a.m., it was noted that PCT #1 removed the used blood tubings and dialyzer from the dialysis machine at station #1 and carried it approximately 10 feet to the biohazard trash near the nurses’ station. This finding was discussed with the administrative team during the exit on 8/20/2024.”

“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: 36839 Based on observations on the review of the dialysis machine disinfection logs and a review of the facility’s policies and procedures, the governing body failed to ensure that all clinical staff followed the standard protocol for cleaning and disinfection of equipment and supplies used in dialysis. This failure placed all patients and staff at potential risk for exposure to bloodborne pathogens and other infectious diseases. Findings included: According to the facility’s Dialysis Delivery System Cleaning and Disinfection policy (#2-02-01), “All dialysis delivery systems, including backup dialysis delivery systems intended for patient use, are routinely required to be disinfected at no more than 72 hour interval.” An interview with the biomedical technician on 8/19/2024 confirmed that there is a total of 23 dialysis machines being used in the facility. A review of the facility’s dialysis machine clean and disinfection logs from 5/27/2024 to 8/17/2024 revealed that dialysis machine #22 had no documentation that it was cleaned and disinfected routinely between 5/27/2024 and 8/17/2024 except on 6/28/2024, 7/5/2024, 7/8/2024, 7/10/2024, 7/12/2024, 7/13/2024, 7/24/2024, 8/5/2024, 8/10/2024, 8/12/2024, and 8/14/2024. These findings were discussed with the administrative team during the exit on 8/20/2024.”

“PR-INFORMED OF INTERNAL GRIEVANCE PROCESS CFR(s): 494.70(a)(14) The patient has the right to- (14) Be informed of the facility’s internal grievance process; This Standard is not met as evidenced by: 36839 Based on the review of the facility’s grievance log and documentation and interview with the assistant facility administrator (AFA), the governing body failed to ensure that all patient grievances were addressed and thoroughly investigated. This failure denied the patient’s rights. Patient #5 RN #5 Findings included: A review of the facility’s policy titled Addressing Patient Grievances states, “3. All details of patient grievances and discussions will be documented...5. Based on the nature of the complaint, the appropriate member of the interdisciplinary team (IDT) will discuss the grievances with the patient and take appropriate action towards a solution if possible.” On 8/19/2024, a review of the facility’s Grievance/Investigation Document revealed that a complaint was filed by Patient #5 on 5/9/2024 which included: (1) Patient missing her ride because she was put on late despite requesting to be taken off before 2:00 p.m., (2) RN #5 had been frequently “rude” to the patient, emphasizing that all the other RNs are very nice and kind to her, (3) RN #5, at one point, refused to send the patient for an infusion when her hemoglobin was low. Upon review of the documented investigation and plan of resolution, it appears that only 2 out of 3 complaints were addressed and resolved (complaints #1 and #3). During interview, the AFA stated the patient did not mention anything about the issue with RN #5. No further documentation was found showing that this complaint was resolved or not. This finding was discussed with the administrative team during the exit conference on 8/20/2024.”

“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 placed all patients at potential risk of being denied their rights. Findings Included: During observations at the patient’s waiting room, it was noted that the contact information of the Office of Health Care Quality (OHCQ) and Quality Insights Renal Network 5 were not up to date. This finding was discussed with the administrative team during the exit conference on 8/20/2024.”

“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 8/19/2024 between 3:50 p.m. to 4:00 p.m., the following were observed: 1. PCT #3 touched the vascular access of the patient at station #7 right before needle insertion after the patient’s skin had already been prepped. 2. Staff #5 (RN) touched the vascular access of the patient at station #14 right before needle insertion after the patient’s skin had already been prepped. These observations were discussed with the administrative team during the exit conference on 8/20/2024.”