Davita North Oakland 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: 15195 Based on observation, interview, and record review, the facility staff failed to perform hand hygiene after removing gloves in 1 (station #12) of 3 instances observed when preparing the hemodialysis machine and failed to perform hand hygiene in 1 (station #1) of 2 instances prior to preparing medications, resulting in the potential for cross contamination of infectious agents for the 21 patients present at the facility. Findings include: On 4/7/2025 at 1030, observation of Tech O, preparing the hemodialysis machine at station #12, revealed that s/he removed gloves and went to the keyboard without performing hand hygiene twice. On 4/7/25 at approximately 1100, interview with Tech O about this practice revealed that s/he normally would perform hand hygiene after removing gloves, but was unaware that s/he had not done so. 50585 On 4/7/2025 at 1120, Nurse Staff P was observed approaching station 1 to administer a medication. Staff P proceeded to glove their hands without applying hand sanitizer and administered an iron supplement. Immediately following the observation, Staff P was queried whether they should have used hand sanitizer, and they acknowledged that hand sanitizer should have been applied. According to the facility’s policy “Infection Control for Dialysis Facilities,” dated April 2023, “All teammates, Physicians, Non-Physician (NPP) will perform hand hygiene prior to gloving and immediately after removal of gloves.””

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure home peritoneal dialysis (PD) treatment sheets were consistently maintained for 1 (P-7) of 2 patients reviewed resulting in the potential for negative outcomes for the patient. Findings include: On 4/9/2025 at 0853, P-7’s Daily Home Peritoneal Dialysis Record treatment sheets were reviewed with PD Nurse Staff Q. P-7’s treatment sheets from 2/9/2025 to 2/10/2025 and from 2/13/2025 to 2/24/2025 revealed no documentation of the type of dextrose solutions used by P-7 when P-7 received PD at home. There was no documentation including blood pressure and weight of any PD performed on 2/11/2025 and 2/12/2025. PD Nurse Staff F signed and dated the treatment sheet as reviewed on 2/28/2025. Both the treatment sheet and Staff F’s Nurse Progress note for 2/28/2025 revealed no documentation of education for P-7 to document the type of PD solution used or the reason for missing documentation for 2/11/2025 and 2/12/2025. The treatment sheet for 2/25/2025 to 3/11/2025 revealed no documentation for the type of dextrose solutions used by P-7. PD Nurse Staff F signed and dated the treatment sheet as reviewed on 3/20/2025. Both the treatment sheet and the Staff F’s Nurse Progress note for 3/20/2025 revealed no documentation of education for P-7 to document the type of PD solution used. During the record review, Staff Q acknowledged the missing documentation and confirmed at the time of discovery that a note should have been documented that P-7 was educated about proper documentation either on the treatment sheet or in the nurse progress note. Staff F was off and was unable to be interviewed. According to the facility’s policy “Home Dialysis Monitoring and Ongoing Patient Education,” dated October 2023, “Document in the patient’s medical record that the patient, the caregiver, or both have received and demonstrated an adequate comprehension of the training by reviewing home patient clinical records for evident of compliant with their training.” The policy also revealed that “The Peritoneal Dialysis facility will retrieve home treatment records at least monthly, and review within seven (7) dates of receipt, if required has not been captured electronically.””

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 15195 Based on record review and interview, the medical director failed to ensure that staff followed orders and/or policies and procedures for 2 (#2, #3) of 7 patients reviewed, resulting in the potential for less than optimal outcomes. Findings include: Medical record review revealed that patient #2 was a 49-year-old male with end stage renal disease readmitted to the facility on 2/8/25. The patient dialyzed three times a week with orders effective on 2/8/25 to current for a blood flow rate (BFR) of 250 and a dialysate flow rate of 600. Review of the last nine dialysis treatment sheets revealed that two of nine dialysis treatments dated 3/18/25 and 3/20/25, documented blood flow rates of 400 for entire treatments. On 4/8/25 at approximately 1500, interview with the Facility Administrator (Staff A) verified that the patient should have been run at a BFR of 250. There was no physician order change or nurse note that documented a change in order. Medical record review revealed that patient #3 was a 34-year-old female with end stage renal disease admitted to the facility for incenter hemodialysis on 1/25/25. The patient lacked an initial nursing assessment prior to beginning hemodialysis. This was verified by the Interim Clinical Coordinator (Staff H). The facility policy titled “Initial Patient Nursing Assessment For New Patients, #1-03-07, dated April 2024” documented, “A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility.” Interview with the Medical Director (Staff C), on 4/8/25 at approximately 1415, verified that staff were expected to follow physician orders and the facility policies and procedures.”