Davita Fashion Square Dialysis

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 38304 Based on observation and interview, the facility failed to clean or replace used personal protective equipment (PPE) prior to use in another patient station(s) and failed to replace PPE during contact with dirty items, resulting in the potential for spread of infectious agents to the 11 patients that were currently dialyzing on the treatment floor. Findings include: On 11/7/2023 at 1052, Staff G was observed dropping her PPE (face shield) onto the treatment floor between Station #7 and Station #8. Staff G proceeded to pick up the face shield off the floor and place it back onto her head without aseptically cleaning all areas or replacing with a new face shield. Staff G was then observed providing care to patients at Station #5, #7 and #8. Staff G was interviewed at 1103 concerning the observation. Staff G acknowledged the risk of cross contamination and replaced the dirty face shield with a new one. On 11/7/2023 at 1115, Staff H was observed pushing down a filled trash container near Station #9 to make more room. Staff H’s gown made significant contact with multiple used items within the trash container. Staff H afterwards disposed of the used gloves and performed hand hygiene. However, Staff H failed to change out the protective gown before providing patient care afterwards at Station #9 and #10. Staff H was interviewed at 1125 concerning the observation. Staff H acknowledged the above finding and then proceeded to replace the dirty gown with a new one. During an interview on 11/7/23 at 1540, the above findings were discussed with the Facility Administrator (Staff A) at which time the Staff A acknowledged the practice presented a risk for cross contamination and noted this failed to meet facility expectations.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 38304 Based on record review and interview, the facility failed to ensure that 1 (P-4) of 5 patients received treatments and interventions as ordered in the patient’s Plan of Care (POC), out of a total sample of 5 records reviewed, resulting in the potential for unmet clinical needs and the potential for a poor outcome. Findings include: On 11/8/2023, review of P-4’s POC orders effective 7/7/2023, revealed the following medication order: “Oxygen-3 Liters/Minute per nasal cannula every dialysis treatment.” On dialysis treatment days (Monday-Wednesday-Friday with add on treatment as needed), P-4 was to receive the above order at the start of dialysis to help ensure oxygen demands concerning P-4 were safely met throughout the entire ordered treatment time (210 minutes). The 6 most recent dialysis treatment sheets (10/25/23 through 11/6/23) for P-4 were reviewed on 11/8/23, and found the following delayed administration of oxygen as ordered: 10/25/23, treatment started at 0650 with oxygen administered at 0713, delay of 23 minutes. 10/26/23 (add-on treatment), started at 0605 with oxygen administered at 0900, delay of 175 minutes. 10/27/23, treatment started at 0727 with oxygen administered at 0758, delay of 31 minutes. 10/30/23, treatment started at 0658 with oxygen administered at 0722, delay of 24 minutes. 11/01/23, treatment was missed. 11/03/23, treatment started at 0709 with oxygen administered at 0715, delay of 6 minutes. 11/6/23, treatment started at 0655 with oxygen administered at 0707, delay of 12 minutes. This finding was reviewed with and acknowledged by the Facility Administrator (Staff A) during an interview on 11/9/23 at 0950. Staff A stated all pertinent clinicians will be instructed to specifically document the entire time any patient is utilizing oxygen within the facility as ordered to ensure patient safety.”