Davita Commerce Township 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, staff failed to perform hand hygiene after removing gloves in 1 (station #7) of 2 instances of performing catheter care and 2 (station #4, #5) of 2 instances of administering intravenous medications, resulting in the potential for cross contamination and infection for the eight patients receiving catheter care and the 55 patients receiving intravenous medications. Findings include: On 5/8/24 at 1050, Staff D was observed performing central venous catheter (CVC) care at station #7. Staff D wore double gloves (clear and blue) and after removing blue top gloves, she did not remove bottom clear gloves or perform hand hygiene during CVC care. Interview with Staff D on 5/8/24 at approximately 1100, revealed that she had an allergy to the blue gloves and did not know she was to remove both gloves and perform hand hygiene. On 5/8/24 at approximately 1105, interview with the Clinical Coordinator B, revealed that both gloves should be removed and hand hygiene should be performed to prevent cross contamination. On 5/9/24 at 1130, Staff J was observed giving Venofer 100 milligrams (mg) to the patient at station #4 without performing hand hygiene after completion of administration. Also on 5/9/24 at 1135, Staff J was observed giving Venofer 100 mg to the patient at station #5 without performing hand hygiene after completion of medication administration. Interview with Staff J, on 5/9/24 at approximately 1145, revealed that she was unaware that she had not performed hand hygiene after completion of medication administration. Review of the facility policy titled “Infection Control For Dialysis Facilities, #1-05-01, revised April 2023” documented, “All teammates, Physicians and Non-Physician (NPP) will perform hand...”prior to gloving and immediately after removal of gloves...””

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 15195 Based on observation, interview, and record review, the facility failed to ensure a clean area remained clean and dirty areas remained separate from the clean area, resulting in the potential for cross contamination and infections for all 55 patients served. Findings include: On 5/9/24 at 0915, Staff P was observed taking a machine fluid sample to the nurse station counter for pH (acid/base) testing without wiping the pH bottle or counter after use. A small spill was observed on the nurse counter next to clean intravenous fluids and clean dialyzers. On 5/9/24 at approximately 0910, interview with Staff P verified that she did not wipe the pH container or counter after spill. On 5/10/24 at approximately 1030, interview with the Facility Administrator and Manager Clinical Services R, revealed that there should be a separation of the pH testing area and the clean supplies. Review of the facility policy titled Infection Control For Dialysis Facilities, #1-05-01, revised April 2023” documented, “16. ... Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.””

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 15195 Based on document review and interview, the facility failed to ensure that 2 (J, Q) of 5 staff members reviewed had hepatitis B immunization or vaccination, resulting in the potential for spread of infection. Findings include: On 5/10/24 at approximately 0830, review of personnel files for Registered Nurse J and Biomed Staff Q revealed that there was no documentation of hepatitis B status or vaccination. Staff member J was hired on 6/6/22 and Staff Q was hired on 1/24/22. This was verified by the Facility Administrator on 5/10/24 at 0930. Review of the facility policy titled “Teammate Hepatitis B Monitoring and Follow Up Guidance, #4-06-03, revised April 2024” documented, “New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10 mlU/ml or greater from any time in the past, regardless of documentation indicating completion of the hepatitis B vaccine series, will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 days and offered the vaccination as indicated by their results...” This had not been done.”

“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 observation, interview, and record review, the medical director failed to ensure that staff followed policies/procedures in 1 (#1) of 5 patients reviewed for blood pressures and medication manufacturer’s direction for use in 2 (station 4, 5) of 2 patients given Venofer intravenous medication, resulting in the potential for unsatisfactory patient outcomes. Findings include: On 5/8/24 at approximately 1500, record review of patient #1’s six flow sheets (dated 4/26/24 - 5/7/24) revealed that on 5/2/24 the patient had elevated diastolic blood pressures of 161/133 at 1449 and 155/121 at 1450 . There was no documentation that the registered nurse or physician were notified. On 5/8/24 at approximately 1530, interview with Manager Clinical Services and the Facility Administrator revealed that this should have been reported and there was no documentation of staff reporting it to nurse or physician. On 5/9/24 at approximately 1030, interview with the Medical Director revealed that this was his patient and no one had notified him of the elevated blood pressure and there were no PRN (if needed) blood pressure medications ordered. Review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, #1-03-08, revised April 2024” documented, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time... Blood Pressure...Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” On 5/9/24 at 1130, Registered Nurse J was observed giving Venofer 100 mg (milligrams) IV push (intravenous) to the patient in station #4 in one minutes time. Also on 5/9/24 at 1130 Registered Nurse gave the patient in station #5 Venofer 100 mg in one minute’s time. Review of the Manufacturer’s Direction for Use dated 9/2020 documented to give “Venofer IV push 100 mg over 2 to 5 minutes.” Interview with Nurse J on 5/9/25 at approximately 1145 revealed that she had forgotten that Venofer needed to given over two to five minutes time.”