Davita Pdi-Grand Rapids East

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 29955 Based on observation, interview, and record review, the facility failed to keep a sanitary environment in the dialysis treatment area resulting in the potential for the spread of infectious disease amongst all 126 patient receiving dialysis treatment at the facility. Findings include: On 7/9/2024 at 1030 during initial tour of the dialysis treatment area it was revealed the treatment floor was filthy, and causing footwear to stick to the floor. On 7/9/2024 at 1035 during initial tour of the dialysis treatment area observation of clean privacy screens and the clean emergency cart revealed they were adjacent to and touching the handwashing sink. On 7/9/2024 at 1037 during initial tour of the dialysis treatment area, the window in station 24 and station 25 were observed to be cloudy and smeared with unknown substance. On 7/9/2024 at 1039 during initial tour of the dialysis treatment area at station 24 and station 25 computers used for charting treatment were placed above the dirty sink area with no splash guards. On 7/9/2024 at 1040 during initial tour of the dialysis treatment area behind station 2 a white dried substance was observed across the window blind. On 7/9/2024 at 1045 during initial tour of the dialysis treatment area dead insects were observed in window sills along the back wall behind stations 2, 3, and 4. On 7/9/2024 at 1050 during the initial tour of the dialysis treatment area at the south nurse’s station an accumulation of a dry gray substance was noted around an electrical outlet area. On 7/9/2024 at 1052 during the initial tour of the dialysis treatment area handwashing sink area at the south and north nursing stations a water pitcher and small cups for providing water to patients was observed. On 7/9/2024 at 1100 an interview was conducted with the Regional Operations Director, staff M. Staff M was queried about the concerns of an unsanitary environment within the dialysis unit specifically the dialysis treatment area. Staff M stated that the company was in the process of replacing the current cleaning service due to failure to meet contractual agreement. Staff M stated termination of the company had been an ongoing process. Staff M also stated that dialysis employees were staying over to clean the facility as best they could. Staff M was queried how long the current cleaning company had been in place at the facility. Staff M stated since January of 2024. 28042 On 07/09/2024 at 1045 during observations on the treatment floor, the surveyor observed a sink in the south pod, marked “clean sink”. During the observation a black insect was seen crawling along the front edge of the sink. There was a black substance observed behind the faucet along the entire back splash of the sink. An approximately 5 centimeter (cm) circular black stain was observed on the bottom of the clean sink along with a wet paper towel in the drain. Also observed on the south pod: The splash guard between the dirty sink and the medication administration area was observed to have a white substance which had appeared to have dripped down and dried onto the splash guard. On 07/09/2024 at 1150 during observations of the north pod treatment area, the counter near the dirty sink was observed to have a gray electrical box without a cover and a gray dusty substance surrounding the box. Needle covers were observed in the bottom of the dirty sink. 38905 During a tour of the water room, with Bio-med “G”, on 7/11/24 at 0944, it was observed that about 20 linear feet of vinyl coving was missing from behind the acid tanks and perimeter portions of the water room, glue was visibly left behind where it used to be. Further evaluation found a small puddle and drip in the back right corner of the water room. When pointed out to Bio-med “G”, she was unaware of the drip and had not noticed the missing vinyl coving. Observation behind the middle acid bulk tank found a large brown splash on the wall. When asked if cleaners come back and clean the water or if staff are supposed to maintain its upkeep, Bio-med “G” stated staff should be helping with its upkeep. During a tour of the utility storage room, on 7/11/24 at 1004, it was observed that the two middle racks would move back and forth in the room, but the outside perimeter racks were stationary. Observation under the perimeter stationary racks found accumulation of dust and debris.”

“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: 28042 Based on observation, interview, and record review, the facility failed to ensure that items taken into the dialysis station were disinfected prior to being returned to a common clean area resulting in the potential to spread infectious agents to the 25 patients dialyzing on the treatment floor. Findings include: During an observation on 07/10/2024 at 0935, Staff J was observed bringing a large sharps container on wheels from the common area into patient station #10, using it while removing a patient from treatment, and returning it back to the common area without wiping it or cleaning it in any way. During an observation on 07/10/2024 at 0945, Staff L was observed bringing a large sharps container on wheels from the common area into patient station #12, using it while removing a patient from treatment, and returning it back to the common area without wiping it or cleaning it in any way. Staff Staff J (PCT) was queried on 07/10/2024 at 0950 as to the observations above. Staff J stated he should have cleaned the sharps container before taking it out of the station and that all items should be cleaned before being taken into the clean area. Review of facility, “Infection Control for Dialysis Facilities” policy dated April 2023, revealed #12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposures to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area.”

“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: 38905 Based on interview and record review, the facility failed to perform required preventative maintenance for the facilities 2008T premium hemodialysis machines for two out of the three machines sampled, resulting in an increased risk for machine pumps and motors to fall out of proper calibration. This deficient practice has the potential to affect all patients in the facility. Findings Include: During a review of the facility’s annual preventative maintenance (APM) logs, of their 2008T premium hemodialysis machines, with Biomed “G”, starting on 7/10/24 at 1045, the following was found: Machine number seven was logged at 41,342 hours during its APM on 2/13/23 and then 45,573 hours on its last performed APM. This puts machine number seven’s operating hours at 4,231 hours between APM. Further review of machine 17 found hours logged were 40,171 on its APM performed on 1/16/23 and 44,590 hours logged on its APM performed on 1/4/24. This puts machine number 17’s operating hours at 4,419 hours between APM. An interview with Biomed “G” found that with the clinic being nocturnal and operating late into the night with machines, they can get a lot of use and make it hard to get the APM in time. Biomed “G” further stated, some machines they have to end up doing the APM for the semi-annual because the parts don’t last the full year. A review of the facilities “Preventative Maintenance Schedules for Equipment” policy, dated 2/1/2009, found that “Preventative Maintenance schedules must be made in accordance with the manufactures recommendation used to perform a patient treatment”. A review of the manufacturer’s directions for use section 3.0 “Annual (4000 hour) Preventative Maintenance” states: Perform the following preventative maintenance procedures every 12 months or 4000 hours of machine operation, whichever comes first.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 28042 Based on record review and interview, the facility failed to have a registered nurse (RN) perform an assessment over an eight (8) month period for 1 (P-3) of 10 patients, out of a total sample of 10 patients reviewed, resulting in the potential for a poor patient outcome. Findings include: On 07/10/2024 at 1300, review of medical record for P-3 revealed she was a 78-year-old female admitted to the facility for in-center hemodialysis treatment on 09/08/2023 with a diagnosis of end stage renal disease. Review of monthly nursing progress notes for P-3 revealed monthly nursing progress notes dated 10/31/2023 and 11/25/2023 which documented a medication reconciliation, assessment of laboratory values, access, target weight, fluid, and modality. There were no monthly nursing progress notes after 11/25/2023 for P-3. In an interview on 07/10/2024 at 1345, Staff A stated he had reviewed the record for P-3 and did not locate any further monthly nursing progress notes or nursing assessments of P-3 that would count as the monthly progress note. Staff A stated it was the expectation that patients be assessed monthly by an RN and it be documented in their medical records. On 07/11/2024 at 1145, Review of the facility policy, “Progress Note Policy” dated October 2023 revealed, Nurse: Nurses are required to record patient progress notes at least monthly and for any clinical event, which must be recorded in a time frame that provides other disciplinary team members with an up-to-date picture of the status of the patient at all times.”