Davita Dearborn Home Dialysis Pd

“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: 47976 Based on observation, record review and interview, the facility failed to ensure staff performed hand hygiene per facility policy, resulting in the potential for the spread of infectious agents to all 16 patients receiving dialysis services at Skilled Nursing Facility A. Findings include: **Policy 1-12-17 titled “DSD Infection Control for Dialysis Facilities” (revised 4/2024) stated: “1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves ...d. after patient and dialysis system contact ...f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and computer keyboard/mouse.” ; “7 ...a. Gloves should be changed when: ...ii. When going from a “dirty” area or task to a “clean” area or task.”; and “15. The computer cart, terminals mounted on the counter, monitor and keyboard are considered clean areas.” During dialysis floor observation on 1/29/25 from 1200 to 1400, the following was noted: At 1223, Certified Clinical Hemodialysis Technician (Staff E) was observed working with a patient at station #2. Upon leaving station #2, Staff E removed her gloves and put on new gloves without performing hand hygiene first. At 1230, Registered Nurse (Staff D) was observed disinfecting station #6. During the process, Staff D was observed missing 2 opportunities for hand hygiene after removing her gloves. Staff D was also observed taking off her gloves, getting new/clean gloves from the box with dirty hands, then performing hand hygiene before putting on the new gloves, which were now contaminated. Also, during the disinfection process, Staff D was observed cleaning part of the machine, then wearing the same gloves to touch supplies from the clean cart across the room. At 1258, Staff E was observed working with a patient at station #4. Upon leaving station #4, Staff E was observed touching her computer cart and pencil with gloved hands before removing her gloves. Staff E then went to station #5 to assist a co-worker with new gloves without performing hand hygiene first. Findings were reviewed with and acknowledged by the Regional Operations Manager (Staff B) during an interview on 1/30/25 at 1300. 46476 On 1/29/25 at 1210 during hemodialysis floor observation of staff, Staff E, a Certified Clinical Hemodialysis Technician (CCHT), was observed while preparing the patient at Station #5 for disconnection of dialysis blood lines. During observation of the multi-step procedure, Staff E was observed removing a pair of dirty gloves and putting on a new pair of gloves two separate times without first performing hand hygiene. This finding was reviewed and acknowledged during interview by the Regional Operations Manager (Staff B) on 1/30/25 at 1310.”

“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: 46476 Based on observation, interview, and record review, the facility failed to ensure a wheelchair was disinfected before being taken into Station #5 resulting in the potential for cross contamination and a practice which could cause transmission of infectious disease to any of the 16 patients receiving dialysis at Skilled Nursing Facility A. Findings include: Facility policy titled “DSD Infection Control for Dialysis Facilities”, Policy: 1-12-17 was reviewed on 1/29/25. On page 3., it stated “12. Cleaning and/or disinfection of equipment ... will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area ... 47976 During dialysis floor observation on 1/29/25 from 1200 to 1400, the following was noted: At 1220, a wheelchair was observed in station #6 in contact with the sharps container and directly in front of the dialysis machine. Upon further observation, it was noted there was no longer a patient at station #6 as she had just left the treatment area in her wheelchair. The station was still noted to be “dirty” due to the bloodlines and trash still present at the station from the previous patient. Upon further investigation, it was determined the wheelchair belonged to the patient at station #5 who was still receiving treatment. At 1245, it was noted the wheelchair was moved back to station #5 by Registered Nurse (Staff E) without being disinfected first. Findings were reviewed with and acknowledged by the Regional Operations Manager (Staff B) during an interview on 1/30/25 at 1300.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 47976 Based on observation, record review, and interview, the facility failed to ensure clean supplies remained at a sufficient distance from patient stations to avoid contamination with blood, resulting in the potential for the spread of infectious agents to all 16 patients receiving dialysis services at Skilled Nursing Facility A. Findings include: **Policy 1-12-17 titled “DSD Infection Control for Dialysis Facilities” (revised 4/2024) stated under “Supplies” on page 2 that, “8. Supplies will be stored in a manner that maintains their integrity.” It also stated, “If a common supply cart is used to store clean supplies in the patient treatment den/beside area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood.” During dialysis floor observation on 1/29/25 from 1200 to 1400, the sharps container at station #5 was observed to be in direct contact with the cover of the clean supply cart that had been left open and clean supplies could be contaminated. Findings were reviewed with and acknowledged by the Regional Operations Manager (Staff B) during an interview on 1/30/25 at 1300.”

“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: 47976 Based on observation, record review, and interview, the facility failed to ensure all contaminated surfaces, medical devices, and equipment were cleaned after patient use, resulting in the potential for the spread of infections agents to all 16 patients receiving dialysis services at Skilled Nursing Facility A. Findings include: **Policy 1-12-17 titled “DSD Infection Control for Dialysis Facilities” (revised 4/2024) stated under “Disinfection” that, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected; a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings ...14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses.” At 1250, it was noted the sharps container and trash can located within station #6 were not disinfected during disinfection of the station. Findings were reviewed with and acknowledged by the Regional Operations Manager (Staff B) during an interview on 1/30/25 at 1300.”

“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: 38304 Based on observation, record review and interview, the Facility failed to maintain its emergency crash cart supplies, resulting in the potential for an inadequate response during an emergency event, endangering the health and safety of all 74 in-center patients currently receiving services. Findings include: On 1/29/2025 at 1024, inspection of the Facility’s crash cart AED (automated external defibrillator) equipment noted there was no replacement defibrillator pad. This finding was inspected/reviewed by the Regional Manager (Staff A) at 1128. Staff A was unable to determine the length of time the AED had been supplied with only one AED pad and no replacement pad was found on the treatment floor. Staff A noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Emergency Equipment Checks” No. 5-02-08 (revised October 2024) stated, “Verify that emergency equipment is maintained in a ready-to-use condition. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Weekly: AED (automated external defibrillator) is operational, and pads are compatible with AED device.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to ensure the dialysis prescription was delivered according to physician orders for 2 (P-1 and P-2) of 2 sample records reviewed for which the patient was receiving home hemodialysis resulting in the potential for not meeting the needed dialysis adequacy. Findings include: P-2: This 59-year-old was admitted to the facility on 3/26/24 with end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 1/30/25 and included 6 hemodialysis treatment flowsheet reports between the dates of 1/16/25 and 1/27/25. Active physician orders for the period reviewed included a blood flow rate (BFR) of 350 milliliters per min (mL/min), and a dialysate flow rate (DFR) of 500 mL/min for each treatment. During review, the following were noted: On the treatment report dated 1/16/25, the treatment began at 0831 and ended at 1210 (219 minutes). The DFR was set at 600 mL/min (100 mL/min more than prescribed) from 0831 until it was changed to the prescribed dose at 1130. There was no documentation for why the DFR was run above the prescribed dose for 179 mins of the treatment. On the treatment report dated 1/27/25, the treatment began at 0827 and ended at 1204 (217 minutes). The BFR was set at 300 mL/min (50 mL/min less than prescribed) from 0905 until the last recording at 1146. There was no documentation for why the BFR was run below the prescribed dose for 161 minutes of the treatment. These findings were reviewed and acknowledged during interview by the Regional Operations Manager (Staff B) on 1/30/25 at 1310. Staff B stated that the dose of dialysis should be run as prescribed by the physician and if a change was needed, it should always be documented. 47976 P-1: This 58-year-old patient was admitted to this dialysis facility on 12/28/24 with the diagnosis of end stage renal disease. During record review on 1/30/25, it was determined the dialysis prescription (dated 1/9/25) ordered the blood flow rate (BFR) at 400 milliliters per minute (mL/min) and the dialysate flow rate (DFR) at 600 mL/min. Upon review of the last 6 treatment sheets, it was determined the DFR was run at 500 mL/min from 1434 until the treatment ended at 1615 on 1/14/25 (101 minutes). There was no documentation regarding the reason for decreasing the DFR. Findings were reviewed with and acknowledged by the Regional Operations Manager (Staff B) during an interview on 1/30/25 at 1300.”

“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: 37411 Based on observation and interview, the Medical Director failed to ensure staff followed Facility policy regarding removing expired medications, resulting in the potential for less-than-optimal outcomes to all patients currently receiving services in the Facility’s home program and the potential for poor patient outcomes for all 74 patients currently receiving services at this Facility. Facility Policy: “Medication Policy” (revised November 2023) Procedure stated, “Policy: n. Disposal of expired medications, including all over the counter and nutritional product sample are removed from the treatment and inventory areas and disposed of per state/local regulations.” During a tour of the treatment floor on 1/29/25 at 1125, it was noted that the refrigerator contained the following expired medications: 1 box of Mircera 50 mcg/0.3mL Exp 04/2024 and 2 boxes of Pneumococcal 13-valent Conjugate Vaccine 0.5 mL Exp 2024 Dec. These expired medications were given to Regional Manager (Staff A) when observed. Staff A confirmed the medications were indeed expired during an interview on 1/29/25 at 1125.”