Davita Harrisonville Renal Center

“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: 18018 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff provided and maintained a clean environment when staff failed to: - Maintain clean surfaces of various drains, equipment, and the floor free from a large crack and areas with the top surface of the floor worn off located in the Water Treatment Room. - Maintain the Bio-Med Room floor free of a dried white substance, a rust-like substance on the hot water heater, a large dry/wet area behind the water heater, maintain a clean sink, and dust build-up on the frame of the metal storage units and on oxygen tanks . - Maintain a clean floor in the Bio-Hazardous Room and the surfaces of the black pallets free from dust and dirt. These failed practices had the potential for increased risk of cross-contamination and transmission of pathogens to all patients and staff. The In-Center Hemodialysis (Hemodialysis - a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 32 and the Home Peritoneal Dialysis (HPD - a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body) census was five for total census of 37. Findings included: 1. Observations conducted during the Flash Tour on 02/10/25 from 2:27 PM to 2:49 PM showed: Water Treatment Room - The eye water station pipes contained a greenish blue colored substance on the pipe’s surface. - The 2K (K - potassium) - 2.5Ca (Ca - Calcium) tank contained a rust-like substance on the metal and metal frame, and a dried white substance was on top of the tank. - The floor drain located next to the 2K - 2.5Ca tank contained dark spots on the outside surface of the floor drain. - The floor between the 2K and 3K-2.5Ca tanks contained approximately 20 peeling and missing areas of the top surface of the floor and several additional areas throughout the room contained peeling and/or missing areas of the top surface of the floor that varied in size. - In front and between the 2nd Carbon Filter Tank and the Primary Carbon Filter Tank contained a large crack in the floor that ran from one end of the floor to the other end. - The black tank stand contained a dried white substance on the surface of the tank’s stand. - A water vacuum contained dust and dirt build-up on the outside surface. - The black spout on the 2K tank contained a dried white substance on the surface of the spout. - The floor drain behind the Reverse Osmosis (RO) System and next to the DI monitor contained an orange/blackish brown substance on the outside surface and a light-yellow colored substance was on the inside surface of the drain. - Four black pallets contained dust, dirt build-up, and a white dried substance on the surfaces of the pallets. - Two black portable carts contained a dried white substance on the surfaces of the carts. - A black plastic storage unit that contained the equipment to test the chlorine levels in water contained a dried white substance on the surface of the unit. - The white pipe under the CM130 contained approximately six areas of a light-tan/yellowish green colored areas and the wall above the CM130 contained streaks running down the wall. - The metal above the blue filter contained a dried white substance on the metal’s surface and the floor drain under the blue filter contained dark colored areas on the outside and inside surface of the drain. Bio-Med Room - The floor throughout the Bio-Hazardous Room contained areas of a white dried substance that varied in size and amount. - The metal wire storage unit contained areas with dust on the storage unit’s surface. - The metal box for the hot water heater contained a rust-like substance on the bottom edge of the metal box. - The floor behind the hot water heater contained a large oblong shaped area of water and a large dried spot. - Four oxygen tanks contained dust build-up on the outside surface of the tanks. - The sink’s outside and inside surface was dirty. Bio-Hazardous Room - The Bio-Hazardous Room contained dust, dirt, and pieces of brown paper on the floor throughout the room. - The black pallets contained dust and dirt build-up on the surfaces. 2. Review of the facility’s policy titled, “Physical Environment,” dated April 2018, showed staff directives: The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates, and the public. 3. During an interview on 02/10/25 2:30 PM, Staff A, Registered Nurse - Facility Administrator, stated a work order had been placed to replace/repair the Water Treatment Room floor related to the large crack, peeling and or the missing top layer surface of the floor. Staff A stated the expectation of staff was to maintain clean surfaces throughout the dialysis clinic.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 18018 Based on observation, interview, and policy review, the facility failed to ensure patients’ dialysis vascular (blood vessels) access sites/bloodline connections and face remained uncovered and in view during dialysis treatment for four patients (#1, #7, #13 and #16) observed for non-visible access/bloodline connections and/or face. A non-visible access/bloodline connection or patient’s face could result in staffs’ failure to quickly detect needle dislodgement or bloodline disconnection, which could result in significant bleeding episodes and affect the safety of all patients that received dialysis treatment at the facility. The In-Center Hemodialysis (Hemodialysis - a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 32 and the Home Peritoneal Dialysis (HPD - a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body) census was five for total census of 37. Findings included: 1. Observations made on 02/10/25 showed from 12:00 PM to 1:30 PM, Patient #7, Patient #13 and Patient #16 was receiving dialysis treatment, however, the patients’ access sites and bloodline connections was covered by a blanket and non-visible to staff. 2. Observation on 02/10/25 at 4:09 PM, showed Patient #1 was receiving dialysis treatment, however, the patient’s face was covered by a blanket and non-visible to staff. 3. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2024, showed directive for staff: The vascular access site, bloodline connections and the patient’s face should be visible throughout the dialysis treatment. 4. During an interview on 02/13/25 at 2:00 PM, Staff A, Registered Nurse - Facility Administrator, stated staff expectation was to follow the facility’s policy related patients’ access sites, bloodline connections and face to remain visible to staff throughout patients dialysis treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 18018 Based on review of patients’ Treatment Details Report, policy review, and interview the facility failed to ensure that staff followed physician orders for: - Hourly heparin (medication used to thin blood and/or prevent blood clot formation) infusion for two patients (#1,and #8) out of four patients’ Treatment Details Report reviewed for heparin infusion. The failure to follow the heparin order had the potential for dialysis complications including excessive bleeding or clotting for all patients that received heparin. - Blood flow rate (BFR - how fast blood is pumped through the dialyzer - artificial kidney and then pumped back into the patient during their hemodialysis treatment) for three patients (#3, #7 and #8) out of four patients’ Treatment Details Report reviewed for BFR. - Dialysate flow rate (DFR - how fast toxins are removed from blood into the dialysate) for three patients (#1, #7 and #8) out of four patients’ Treatment Details Report reviewed for DFR. The failure to follow the BFR and DFR order had the potential to affect the adequacy of patients’ dialysis treatments. - Perform and document a Pre-Treatment Nurse Assessment for three patients (#1, #3, and #7) out of four patients’ Treatment Details Report reviewed for Pre-Treatment Nurse Assessments. - Monitor patients’ blood pressure throughout the dialysis treatment for three patients (#1, #3, and #7) out of four patients’ Treatment Details Report reviewed for blood pressure monitoring during dialysis treatment. These failures had the potential to affect all In-Center Hemodialysis patients that received dialysis treatments at the facility. The In-Center Hemodialysis (Hemodialysis - a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 32 and the Home Peritoneal Dialysis (HPD - a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body) census was five for total census of 37. Findings included: 1. Review of Patient #1’s Treatment Details Report showed: Hourly Heparin Infusion - The hourly heparin infusion was ordered to be stopped 60 minutes before the end of the dialysis treatment. - On 02/7/25 the documented hourly heparin infusion was stopped at 4:44 PM and the patient’s dialysis treatment was terminated at 5:05 PM and not 60 minutes before the end of the treatment as ordered. - On 02/05/25 the documented hourly heparin infusion was stopped at 5:06 PM and the patient’s dialysis treatment was terminated at 5:22 PM and not 60 minutes before the end of the treatment as ordered. DFR - The ordered DFR was ordered to run at 500 milliliters (mL - unit of measurement) per minute (min). - The patient’s documented DFR was not ran at the ordered rate of 500 mL/min on 02/10/25, 02/07/25 and 02/03/25. Staff failed to document the reason the DFR was not ran at the ordered rate. Pre-Treatment Nurse Assessment - On 02/07/25 staff failed to document a Pre-Treatment Nurse Assessment of the patient within one hour of the start of the dialysis treatment. The patient’s treatment was initiated at 1:45 PM and the Pre-Treatment Nurse Assessment was documented at 3:40 PM. - On 02/05/25 staff failed to document a Pre-Treatment Nurse Assessment of the patient within one hour of the start of the dialysis treatment. The patient’s treatment was initiated at 2:41 PM and the Pre-Treatment Nurse Assessment was documented at 4:08 PM. Blood Pressure Monitored Every 30 Minutes During Dialysis Treatment - On 02/10/25 the patient’s blood pressure was not taken every 30 minutes throughout the dialysis treatment. 2. Review of Patient #3’s Treatment Details Report showed: BFR - The ordered BFR was ordered to run at 400 mL/min. - The patient’s documented BFR was not ran at the ordered rate of 400 mL/min on 02/07/25 and 01/31/25. Staff failed to document the reason the BFR was not ran at the ordered rate. Pre-Treatment Nurse Assessment - On 02/03/25 staff failed to document a Pre-Treatment Nurse Assessment of the patient within one hour of the start of the dialysis treatment. The patient’s treatment was initiated at 1:37 PM and the Pre-Treatment Nurse Assessment was documented at 3:07 PM. - On 01/27/25 staff failed to document a Pre-Treatment Nurse Assessment of the patient within one hour of the start of the dialysis treatment. The patient’s treatment was initiated at 1:40 PM and the Pre-Treatment Nurse Assessment was documented at 3:00 PM. Blood Pressure Monitored Every 30 Minutes During Dialysis Treatment - On 02/10/25 the patient’s blood pressure was not taken every 30 minutes throughout the dialysis treatment. 3. Review of Patient #7’s Treatment Details Report showed: BFR - The ordered BFR was ordered to run at 400 mL/min. - The patient’s documented BFR was not ran at the ordered rate of 400 mL/min on 01/10/25 and staff failed to document the reason the BFR was not ran at the ordered rate. DFR - The ordered DFR was ordered to run at 800 mL/min. - The patient’s documented DFR was not ran at the ordered rate of 800 mL/min on 02/03/25, 01/13/25, 01/10/25, and 01/08/25. Staff failed to document the reason the DFR was not ran at the ordered rate. Pre-Treatment Nurse Assessment - On 02/10/25 staff failed to document a Pre-Treatment Nurse Assessment of the patient within one hour of the start of the dialysis treatment. The patient’s treatment was initiated at 11:33 AM and the Pre-Treatment Nurse Assessment was documented at 1:28 PM. Blood Pressure Monitored Every 30 Minutes During Dialysis Treatment - On 01/13/25 and 01/10/25 the patient’s blood pressure was not taken every 30 minutes throughout the dialysis treatment. 4. Review of Patient #8’s Treatment Details Report showed: Hourly Heparin Infusion - The hourly heparin infusion was ordered not to be stopped before the end of the dialysis treatment. - On 02/10/25 the documented hourly heparin infusion was stopped at 8:48 AM and the patient’s dialysis treatment was terminated at 9:48 AM. - On 02/05/25 the documented hourly heparin infusion was stopped at 8:52 AM and the patient’s dialysis treatment was terminated at 9:52 AM. - On 02/03/25 the documented hourly heparin infusion was stopped at 8:43 AM and the patient’s dialysis treatment was terminated at 10:13 AM. - On 01/29/25 the documented hourly heparin infusion was stopped at 8:54 AM and the patient’s dialysis treatment was terminated at 9:55 AM. Staff failed to infuse the hourly heparin to the end of the patient’s dialysis treatment as ordered. BFR - The ordered BFR was ordered to run at 450 mL/min. - The patient’s documented BFR was not ran at the ordered rate of 450 mL/min on 02/10/25, 02/05/25, and 01/29/25. Staff failed to document the reason the BFR was not ran at the ordered rate. DFR - The ordered DFR was ordered to run at 500 mL/min. - The patient’s documented DFR was not ran at the ordered rate of 500 mL/min on 02/10/25, 02/07/25, 02/05/25, 02/03/25, 01/31/25, and 01/29/25. Staff failed to document the reason the DFR was not ran at the ordered rate. 5. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2024, showed staff directives: - The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation. - Intradialytic treatment monitoring and data collection which may be performed by the PCT (PCT - Patient Care Technician) or licensed nurse include: Non-nocturnal treatments are completed at least every thirty (30) minutes. At a minimum, obtain and document the following: Blood pressure. - Prescription components include but are not necessarily limited to: Blood Flow Rate, Dialysate Flow Rate, and Heparinization (intradialytic infusion setting). - 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. - All findings, interventions and patient response will be documented in the patient’s medical record. 6. During an interview on 02/13/25 at 8:40 AM, Staff A, Registered Nurse - Facility Administrator, stated staff was expected to follow physician’s orders for patients’ dialysis prescription and to follow the facility’s policy related to pre/post treatment data collection and nursing assessments conducted throughout patients’ dialysis treatments.”