Davita Alger Heights Dialysis

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 38304 Based on observation, record review and interview, the Facility failed to maintain an updated patient census and patient emergency contacts in the emergency preparedness program, resulting in the potential for inadequate Facility response during an emergency event, and potentially endangering the safety of all in-center patients receiving treatment in the Facility during an emergent event. Findings include: During dialysis floor observation on 2/4/25 at 0938, the contents of the emergency binder located next to the emergency crash cart was inspected. The patient list used for contact information for the current census was reviewed and noted the last update occurred on “July 2024”. A list of patients admitted within the last 90 days of 2/4/25 was compared against the emergency patient contact list. All six newly admitted (less than 90 days) patient names were not included in the emergency patient contact list. This finding was reviewed and acknowledged by the Facility administrator (Staff A) later that day at 1135. The Facility failed to ensure an up to date and accurate patient list was available for use in the event of an emergency to account for the safety of all patients involved.”

“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: 37411 Based on observation, record review, and interview, the facility failed to ensure items taken into the dialysis station were cleaned or disinfected before being taken into a common area or used on another patient, resulting in the potential to spread infectious diseases to all 16 patients receiving in-center hemodialysis at this facility at the time of observation. Findings include: **Policy titled “Infection Control for Dialysis Facilities” (revised April 2023) stated under “Supplies: 9. If a common supply cart is used to store clean supplies in the patient treatment area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. The cart will not be moved between stations to distribute supplies ... Disinfections: Cleaning and/or disinfection of equipment and work surfaces will be perfomed 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 or removal from treatment area.” During dialysis floor observation on 2/4/25, the following was noted: At 1000, the staff were observed using the Hoyer lift (mechanical lift used for people who are unable to stand) on the patient at station 7. Afterwards, Staff H (Patient Care Technician) was observed rolling the Hoyer lift back to the corner for storage without disinfecting it first. At 1015, Staff G (Certified Clinical Hemodialysis Tech) was observed taking a rolling cart containing multiple boxes of exam gloves and a rolling red biohazard waste receptacle into the treatment bubble, and then removing them to a common area without sanitizing the cart and receptacle. These findings were reviewed with and acknowledged by the Facility Administrator (Staff A) during an interview on 2/5/25 at 1420. 38304 On 2/4/2025, treatment floor observations at 0920 through 1140 and 1325 through 1515, noted 8 of 8 computer workstations on wheels (CWOW) were located between dialysis machines concerning Stations #1-16. The CWOW’s which are used to document in the medical record, were located within 12-14 inches of the dialysis machines. Staff were observed grabbing the sides of CWOW with non-gloved hands which were not disinfected prior to touching/typing on the CWOW’s. During times of observation noted above, six of six instances of staff cleaning the dialysis station after treatment found none of the CWOW’s were wiped down and disinfected. Subsequently, the CWOW’s were deemed to be “dirty” equipment. Ten observations during the times noted above found the CWOWS were moved over to gain better access to the back chase or the other dialysis machine located on the other side of the CWOW. In doing so, there were four instances where the CWOW contacted the dialysis machine and two instances where the CWOW touched a protruding blood line. This finding was reviewed and acknowledged by the Facility administrator (Staff A) on 2/4/25 at 1205. The Facility failed to adhere to its policy referenced below in ensuring non-disposable items/equipment are to be disinfected after patient treatments. Facility Policy: “Infection Control for Dialysis Facilities” Policy No. 5-06-01 (revised April 2023) stated, “Non-disposable items are to be disinfected after each patient use... If item cannot be cleaned and disinfected, it will be dedicated for use on a single patient.” Note: Infection control policy language did not specifically address CWOW’s being disinfected or when a CWOW contacts the dialysis treatment station.”

“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: 38304 Based on observation, interview and record review, the Facility failed to ensure staff followed policy and procedure when providing care to patients with a central venous catheter (CVC) in 1 (P-9) of 2 observations for discontinuation of dialysis with a CVC, resulting in an increased risk for infection and potential for poor patient outcomes for all in-center patients with a CVC currently receiving services. Findings include: On 2/4/25 at 1407, Staff G (Certified Clinical Hemodialysis Technician) was observed disconnecting the patient’s CVC, a port that goes into a large vein in the chest at station #16. During the procedure, Staff G was observed using an alcohol pad to hold onto 1 of 2 catheter stems (arterial and venous) while disconnecting the blood line. Staff G then wiped the end of the catheter hub (open end) with an alcohol pad for 8 seconds before attaching the cap. Staff G then repeated the same procedure on the second catheter stem for 9 seconds without using a clock for time verification on either CVC catheter stem. During an interview at 1412, Staff G was queried what the Facility policy was regarding the time needed to scrub each of the CVC hubs. Staff G believed it was 20 seconds and that he probably shortened the times needed. The findings above were reviewed and acknowledged by the Facility Administrator on 2/6/25 at 1314. Staff A noted this did not meet Facility expectations.”

“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 and acid supply lines, resulting in the potential for an inadequate response during an emergency event and altered acid delivery to the dialysis machines, and potentially endangering the health and safety of all 77 in-center patients currently receiving services. Findings include: During dialysis floor observation on 2/4/25 at 0942, review of the Facility’s crash cart AED (automated external defibrillator) device noted there was no defibrillator pad. This finding was inspected/reviewed by the Facility Administrator (Staff A) at 1137. Staff A noted the AED replacement pad was in the front office. Staff A was then queried if it would be more appropriate to have the replacement pad stored in or next to the AED machine located on the crash cart in the event of a code blue. Staff A then agreed the replacement pad should be with the AED machine. Facility Policy: “Emergency Equipment Checks: Policy No. 5-02-08 (revised October 2024) stated, “The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Manufacturer’s AED pads are present on cart.” 43001 At 9:38am on 2/5/2025 during a tour of the treatment floor, a pile of material was observed on the floor next to treatment station 17. Staff N was asked what was on the floor and they did not know. Upon opening the chase, which was covering the piping coming from the ceiling, it was observed that an acid line had about 3 inches of build up on one of the 45 degree elbow connections causing the leak of acid on the floor. Staff N was asked if they knew about the leak and they did not. The preventative maintenance reporting system was checked as well and had no reporting of the leak.”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 37411 Based on observation and interview, the facility failed to maintain patient privacy and confidentiality for 2 of 16 patients observed receiving treatment. resulting in the potential for unauthorized access to patient information for 77 patients served by the facility. Findings include: On 2/4/25 at 1100 during the treatment floor flash tour, it was observed that a clear bag with a roll of tape in it was clipped to a glass divider across from station 13 with a patient’s first and last name written on a sticky note. Additionally, at 1110 it was observed that a sticky note was placed on a glass divider across from station 3 that contained a patient’s first and last name, wheelchair weight, leather coat weight and zip up gray hoody weight. These findings were reviewed with and acknowledged by the Facility Administrator (Staff A) during an interview on 2/5/25 at 1420. Facility Policy: “Non-disclosure and Confidential Information Policy” (revised 1/1/2020) Policy stated, “Policy: ... Confidential information pertaining to patients includes, but is not limited to, information such as: Name ... Teammates should be aware that all Confidential Information is considered secret and is made available to them in confidence. Except in the performance of duties, teammates shall not, directly or indirectly for any reason whatsoever, publish, summarize, disclose or use any such Confidential Information.””

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 38304 Based on record review and interview, the Facility failed to have Against Medical Advice (AMA) documentation per their policy concerning early termination of dialysis treatment for 1 (P-5) of 7 in-center records reviewed, out of a total sample of 7 records reviewed, resulting in the potential for the patient to not understand their right to refuse treatments and the possible consequences of early termination. Findings include: P-5: This 72-year-old male was admitted to the dialysis Facility on 8/22/23, with diagnoses which included end stage renal disease, hypertension, and anemia. P-5 was receiving treatments 3 times per week (Tues-Thurs-Sat) for an ordered duration of 240 minutes each treatment. On 2/5/25, record review of P-5’s six most recent in-center dialysis treatments (1/22/25 through 2/4/25) noted the following concerns: The treatment flow sheets dated 2/4/25, 2/1/25, and 1/30/25, had an ordered run time of 240 minutes. Treatment documentation on 2/4/25 noted the dialysis treatment was shortened by 62 minutes per patient choice; on 2/1/25 the dialysis treatment was documented being shortened by 72 minutes per patient choice, and the treatment on 1/30/25 was shortened by 62 minutes per patient choice. On 2/6/25 at 1304, a request was made to review the AMA (against medical advice) forms concerning the shortened treatment dates above. All three shortened treatments had no documented AMA forms found in the medical record. In addition, the three treatments above had no physician notification or education provided which explained the cumulative harm to the patient when dialysis treatments are shortened. The findings above were reviewed and acknowledged by the Facility Administrator on 2/6/25 at 1309. Staff A noted this did not meet Facility expectations or its policy referenced below. Facility Policy “Prescribed Treatment Time Not Met” Policy No. 1-01-09 (revised April 2024) stated, “The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment against Medical Advice form any time the patient request to terminate their treatment earlier than the prescribed run time.””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to ensure staff reported a change in weight for 1 (P-1) of 7 sample patient records reviewed resulting in the potential for unrecognized changes in volume status and poor patient outcomes. Findings include: Facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, Policy: 1-03-08, was reviewed on 2/5/25. On page 1., it stated “2. The Nursing assessment will be performed ... The assessment includes the following components ... v. Review of documentation for accuracy, completion, and patient data ...” On page 5., it stated “15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s record ... Fluid Status: Pre-treatment: Any weight loss from last post weight ... Post-treatment: if patient is above or below 1 kg from the target weight ...” P-1: This 81-year-old was admitted to facility on 11/9/23 with end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 2/5/25 and included 6 hemodialysis treatment reports dated 1/21/25 through 2/1/25. The patient’s target weight (weight without excess fluid) during the period of review was 67.8 kilograms (kg). During review of the treatment reports, the following were noted: On the treatment report dated 1/23/25, the patient’s post-dialysis weight was recorded as 67.8 kg. On the treatment report dated 1/25/25, the patient’s pre-treatment weight was recorded as 65.9 kg (1.9 kg less than last post-dialysis weight on 1/23/25), and post-dialysis weight was recorded as 64.9 (2.9 kg below target weight). On the treatment report dated 1/28/25, the patient’s pre-treatment weight was recorded as 64.8 kg (0.1 kg less than post weight on 1/25/25), and post-dialysis weight was recorded as 64.5 kg (3.3 kg below target weight). On the treatment report dated 1/30/25, the patient’s post-dialysis weight was 66.3 kg (1.5 kg below target weight). On the treatment report dated 2/1/25, the patient’s pre-dialysis weight was recorded as 68.4 kg, and the post-dialysis weight was recorded as 49.7 kg (a difference of 18.7 kg less than pre-weight and 18.1 kg less than target weight). There was no documentation on any of the above treatment sheets indicating nurse awareness of pre-treatment weight loss or post-dialysis weights which were 1 kg (or more) below target weight. These findings were reviewed and acknowledged during interview with the Facility Administrator (Staff A) and General Facility Administrator (Staff B) on 2/6/25 at 1400. Staff A stated that P-1 has been having weight issues recently due to decline and agreed that the weight changes noted (especially pre-treatment weights below target weight), should have been reviewed with the physician to determine a safe amount of fluid removal during dialysis treatments. Staff A also agreed that the large weight change of 18.7 kg that was recorded on 2/1/25 was most likely a data entry error that should have been recognized and followed up on by the nurse.”

“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: 37411 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-4) of 7 sample records reviewed resulting in the potential for not meeting dialysis adequacy. Findings include: Facility Policy: “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” (revised April 2024) states, “10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” P-4: This 56-year-old female was admitted to the Facility on 10/8/18, with diagnoses which included end stage renal disease, hypertension and congestive heart failure. On 2/6/25, record review of P-4’s six most recent in-center dialysis treatments (1/24/25 through 2/5/25) noted the following concerns: The treatment flow sheet dated 1/29/25 documented the physician ordered Dialysis Prescription as BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate) were to be delivered at 400 milliliters/minute (mL/min) and 600 mL/min respectively throughout treatment. However, the 1/29/25 treatment sheet documented that the BFR was ran at 375. Additionally, the 2/3/25 treatment sheet documented that the DFR was ran at 500. These findings were reviewed with and acknowledged by the Facility Administrator (Staff A) during an interview on 2/6/25 at 1240 and stated, “There is no documentation or order for running a lower BFR or DFR”. 46476 P-1: This 81-year-old was admitted to facility on 11/9/23 with end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 2/5/25 and included 6 hemodialysis treatment reports dated 1/21/25 through 2/1/25. The physician ordered blood flow rate (BFR) during the period of review was 400 milters/minute (mL/min). During review of the treatment reports, the following was noted: On the treatment report dated 2/1/25, the treatment began at 0553 and ended at 0943 (3 hours and 52 minutes). The BFR was running at 200 mL/min for the duration of the treatment. There was no documentation indicating that the nurse was aware of, had received new orders for, or had any explanation for the BFR being run 200 mL/min less than prescribed for this treatment. These findings were reviewed and acknowledged during interview with the Facility Administrator (Staff A) and General Facility Administrator (Staff B) on 2/6/25 at 1400. Staff A was not able to provide any further information regarding a reason for the low BFR on the treatment report above.”