Davita Ridge Road Dialysis

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 44367 Based on observation and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the facility provided and maintained a safe treatment environment for its patients by ensuring the facility conducted fire drills quarterly per the facility’s policy. This failure placed the patients and visitors at potential risk of harm in the event of a fire. Review on 04/12/2024 of the facility’s policy 4-07-01 entitled “Facility Emergency Management Plan” revealed, “Fire safety drills: Required on a Quarterly basis.” During review of the emergency preparedness binder on 04/12/2024, the surveyor noted that the facility conducted a fire drill in November 2023 and January 2024. There was only one fire drill documented before November 2023, which was November 2022. The Facility Administrator was given the opportunity to provide the three fire drills that were supposed to be conducted after November 2022 and before November 2023; However, no additional documentation was provided. The Facility Administrator corroborated that the facility did not conduct fire drills quarterly as required per policy.”

“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: 44367 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene and glove use requirements were followed by all staff who come in contact with the dialysis patients in the facility. This failure placed the patients and staff at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Staff: #4 Findings included: Review on 04/15/2024 of the facility’s policy 1-05-01 entitled, “Infection Control For Dialysis Facilities” states that, “Gloves shall be changed when: After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” During observation of the clinical treatment area on 04/15/2024 at 10:00 a.m., the surveyor observed that during treatment termination of a patient at Station 7, Staff #3 went from assisting the patients at station 7 and with the same gloves in place Staff #3 walked over to answer the machine’s alarm at occupied Station 3. Staff #3 did not remove gloves between patients. The Facility Administrator was informed of findings on 04/15/2024.”

“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: 44367 Based on observations of the clinical treatment area, the Facility Administrator and Medical Director 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. Staff: #3 Findings included: 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, used needles, syringes and dialyzer from the patient’s station across the treatment floor to a biohazard box, or sharps container could result in unknown spattering of blood. 1. During observations on the clinical treatment area on 04/10/2024 at 02:11 p.m., the surveyor observed that Staff #3 removed the dirty bloodlines and dialyzer (contaminated with blood and normal saline) from machine 12 at station 7 and walked across occupied station 4, to discard in the biohazardous waste bin in front of occupied station 3. The Facility Administrator was informed of the findings on 04/10/2024.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44367 Based on observations and review of the facility’s policies and procedures, the governing body and the medical director failed to ensure that the clinical staff complied with the appropriate catheter care techniques and procedures. This failure placed patients at potential risk of infection or harm in maintaining their central venous catheter. Staff: #1 Findings include: According to the National Institute of Health (NIH), “A central venous catheter (CVC) is an indwelling device inserted into a large, central vein (most commonly the internal jugular, subclavian, or femoral) and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava, or right atrium [parts of the heart].” Review of the facility’s policy 1-04-02B entitled “Central Venous Catheter (CVC) with clearguard HD antimicrobial end caps” states to “Teammate and patient will wear masks covering the nose and mouth during this procedure... Clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds , apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery ...Then wait 60 seconds for air dry time.” 1. During observation of the clinical treatment area on 04/15/2024 at 10:00 a.m., during initiation of treatment of a CVC patient at station 5, the surveyor observed that Staff #1 cleaned the exit site from dirty to clean rather than clean to dirty (insertion site to the periphery). The surveyor also observed that the face mask was not properly placed on the patient’s face, exposing the nose during the entire process. The Facility Administrator was informed of the findings on 04/15/2024”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 44367 Based on observations and interviews with the facility staff, the facility administrator and medical director failed to ensure the water purification and storage system was only accessed by authorized personnel. This failure had the potential to place all patients at potential risk of harm from unauthorized access to the water treatment system. Findings include: Review on 04/10/2024 of the facility’s policy 2-03-01 “Water Treatment Systems Minimum Component” revealed that, “Access to the water treatment system should be restricted to those personal/trained teammates responsible for monitoring, maintenance of the system and supply ordering.” During the flash tour of the water treatment area on 04/10/2024 at 09:45 a.m., the surveyor observed that the door to the water treatment room was propped open allowing free access.The door had an electronic key pad in place and was confirmed by the surveyor to be in working order. The Facility Administrator observed and corroborated the findings on 04/10/2024 at 09:45 a.m.”

“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: 44367 Based on observation and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that all of it’s ancillary equipment was maintenance per policy and manufacturer’s recommendations to ensure safety for patients. This failure placed the patients at potential risk of harm and or injury. Review on 04/10/2024 of the facility’s policy 4-08-18 entitled “Use of a Mechanical Device for Lifting Patients” revealed that “FA/manager or designee should conduct a safety check on all mechanical devices twice a year to assess that the device(s) are safe for use.” Review 04/10/2024 of the facility ancillary equipment maintenance report entitled, “Medical Equipment inspection report” revealed that the facility’s mechanical lift has not been maintained according to the facility’s policy. During the visual inspection of the mechanical lift on 04/10/2024, the surveyor noted there was not a proof of maintenance label attached to the lift. The Facility Administrator corroborated that the mechanical was not maintained per policy.”

“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: 44367 Based on observations, the facility’s administration failed to ensure that a copy of the address and contact numbers of the State Survey Agency (SSA), was prominently displayed where it can be easily seen and read by the patients, and/or patient advocates. This failure denied the patients their rights. Findings included: The Office of Health Care Quality (OHCQ) located at 7120 Samuel Morse Drive, Second Floor, Columbia, MD 21046, contact number is (410) 402-8015 and the Quality Insights Renal Network 5, which is P.O. Box 29274, Henrico, VA 23242 and contact number is (804) 320-0004. Both must be easily accessed by patients, caregivers, advocates and staff to make complaints and/or make inquiries regarding the services provided by dialysis facilities. During observation of the patient’s waiting room on 04/15/2024 at 12:45 p.m., it was noted that the complaint information of the SSA/Office of Health Care Quality (OHCQ) was not posted and easily seen by patients, visitors and staff. The Facility Administrator was informed of the findings on 04/15/2024.”

“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: 44367 Based on review of the dialysis patients’ treatment flowsheets, the facility’s administration and clinical staff failed to ensure that the dialysis prescriptions were followed as prescribed by the Nephrologist. This failure placed the patients at potential risk of harm and denied the patients their rights. Patients: #1 and #4 Findings included: Review on 04/12/2024 of the facility’s policy 1-03-08 “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” states, “If the dialysis prescription is not being met (including the inability to obtain prescribed blood flow rate or BFR) the reason will be documented, and the licensed nurse informed.” A review of the four (4) selected patients’ treatment flowsheets on 04/12/2024 revealed that two (2) or 50% of the selected patients did not receive the correct dialysis prescription as ordered by the Nephrologist. 1. On treatment date 04/10/2024, Patient #1’s BFR was prescribed for 400 ml/minute; However, the BFR was set at 300 ml/min from 10:31 a.m. to 01:27 p.m. There was no documentation found explaining why Patient #1’s BFR was not set on the dialysis machine as prescribed. 2. On treatment date 04/10/2024, Patient #4’s DFR was prescribed for 600 ml/minute; However, the DFR was set at 500 ml/min from 06:28 a.m. to 09:52 a.m. There was no documentation found explaining why Patient #4’s DFR was not set on the dialysis machine as prescribed. The Facility Administrator was informed of the findings on 04/12/2024.”

“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: 44367 Based on observations and review of the facility’s policies and procedures, the facility’s administration and the Medical Director failed to ensure that the clinical staff complied with the appropriate procedures when assessing the patients’ arterial vascular access (AVF/AVG) 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. Staff: #1 and #3 Findings included: Review on 04/10/2024 of the facility’s policy 01-04-01E entitled “Cannulation of Fistula or Graft” states “Do not palpate insertion site once are has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” Review on 04/10/2024 of the facility’s policy entitled “AV Fistula or Vein Graft - Initiating Dialysis for Mature Access” states that, “Before initiating dialysis the Dialysis Tech or nurse shall determine the integrity of the vascular access by palpating for a thrill and auscultating for a bruit...Aseptic technique shall be followed when initiating dialysis.” 1. During observation of the clinical treatment area on 04/10/2024 at 10:45 a.m., the surveyor noted that at station 1, Staff #1 palpated the insertion site of the access after being disinfected, prior to cannulation. Staff #1 did not re-clean the access. 2. Observation of the clinical treatment area on 04/10/2024 at 10:52 a.m. revealed that during treatment initiation of a AVF/AVG patient at station 7, Staff #3 did not listen for a bruit prior to cannulation. Staff #3 palpated the insertion site of the access after disinfection and prior to cannulation. Staff #3 did not re-clean the access. 3. Observation of the clinical treatment area on 04/10/2024 at 02:30 p.m. revealed that during treatment initiation of a AVF/AVG patient at station 9, Staff #3 did not listen to the patient’s access for a bruit prior to cannulation. The Facility Administrator was informed of the findings on 04/10/2024.”