Davita Hope Again Dialysis Center

“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: 36473 Based on interview, observations and policy review, the facility failed to ensure staff disinfected a patient lift device after patient use and prior to being used for a second patient for two patients (#7 and #8). These failures had the potential for cross-contamination and increased the risk for infections for all patients. The facility census was 67 in-center hemodialysis (the process of purifying the blood of persons whose kidneys were not working) and eight peritoneal dialysis (PD, a treatment of kidney failure using the lining of your abdomen to filter your blood) patients. Findings included: 1.During an interview on 1/16/25 at 1:30 PM, Staff A, Facility Administrator, stated they expected staff to disinfect the “hoyer lifts” (patient lift devices) between each patient use. 2.Observation on 1/15/25 at 1:30 PM, showed Staff B, Certified Clinical Hemodialysis Technician (CCHT), moved Patient #7 with a lift device from the common area without disinfecting and used it to transfer the patient to their wheelchair. Staff B also failed to disinfect the lift device prior to moving it back to the common area. 3.Observation on 1/15/25 at 1:42 PM, showed Staff C, Patient Care Technician (PCT), moved Patient #8 with a lift device from the common area without disinfecting and used it to transfer the patient to their wheelchair. Staff C also failed to disinfect the lift device prior to moving it back to the common area. 4.Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” last reviewed on 04/2023, showed the direction for staff to clean and/or disinfect equipment prior to returning to clean/designated area and after patient use.”

“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: 36473 Based on interview, observation and policy review, the facility failed to ensure the staff viewed seven patient vascular access sites and bloodline connections (#10, #11, #15, #18, #19, #20 and #27) of 10 reviewed, throughout the patient’s hemodialysis (the process of purifying the blood of persons whose kidneys were not working) treatment to ensure patient safety. These failures had the potential for negative outcomes of all patients that presented to the facility for hemodialysis. The facility census was 67 in-center hemodialysis and eight peritoneal dialysis (PD, a treatment of kidney failure using the lining of your abdomen to filter your blood) patients. Findings included: 1.During an interview on 1/16/25 at 1:30 PM, Staff A, Facility Administrator, stated they expected all patient sites to be uncovered per policy, procedure and safety reasons. 2.Observations on 1/15/25 between 1:00 PM and 2:00 PM, showed Patient #10, #11 and #27’s vascular access sites and bloodline connections were covered and not visible. 3. Observations on 1/16/25 between 9:30 AM and 10:00 AM, showed Patient #15, #18, #19 and #20’s vascular access sites and bloodline connections were covered and not visible. 4.Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last reviewed on 04/2024, showed he direction for the patient care technician or licensed nurse, to ensure the vascular access site, blood line connections and the patient’s face was visible throughout the dialysis treatment.”

“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: 36473 Based on interview, record review and policy review, the facility failed to inform and offer the option to participate in their Interdisciplinary Team (IDT, Nephrologist, Nurse, Social Worker and Dietician) Care Plan Meetings for six patients (#1, #2, #3, #4, #5 and #6) out of six reviewed. These failures had the potential to eliminate the patient’s right to know about their care and effect all patients that presented for treatment at the facility. The facility census was 67 in-center Hemodialysis (the process of purifying the blood of persons whose kidneys were not working) patients and eight Home Peritoneal Dialysis (PD, a treatment of kidney failure using the lining of your abdomen to filter your blood) patients. Findings included: 1.During an interview on 1/16/25 at 1:30 PM, Staff A, Facility Administrator, stated they expected the social worker to present the facility’s letter informing the patients of their care plan meetings. 2. Review of Patient #1’s stable Plan of Care, showed the IDT meeting was completed on 05/10/24 and the letter with the option to attend or not attend dated 05/02/24 showed no option marked with no patient signature. 3. Review of Patient #1’s stable Plan of Care, showed the IDT meeting was completed on 07/12/24 and the letter with the option to attend or not attend dated 06/27/24 showed no option marked with no patient signature. 4.Review of Patient #1’s stable Plan of Care, showed the IDT meeting was completed on 08/05/24 and the letter with the option to attend or not attend dated 07/25/24 showed option not marked with no patient signature. 5.Review of Patient #2’s stable Plan of Care, showed the IDT meeting was completed on 03/22/24 and the letter with the option to attend or not attend dated 08/26/24 showed no option marked with no patient signature. 6. Review of Patient #3’s stable Plan of Care, showed the IDT meeting was completed on 10/08/24 and the letter with the option to attend or not attend dated 08/26/24 showed option marked with no patient signature. 7. Review of Patient #4’s stable Plan of Care, showed the IDT meeting was completed on 10/11/24 and the letter with the option to attend or not attend dated 09/19/24 showed option not marked with no patient signature. 8. Review of Patient #5’s stable Plan of Care, showed the IDT meeting was completed on 12/03/24 and the letter with the option to attend or not attend dated 12/03/24 showed option marked with no patient signature. 9. Review of Patient #6’s unstable Plan of Care, showed the IDT meeting was completed on 09/06/24 and the letter with the option to attend or not attend dated 08/14/24 showed option marked with no patient signature. 10. Review of Patient #6’s unstable Plan of Care, showed the IDT meeting was completed on 10/11/24 and the letter with the option to attend or not attend dated 09/06/24 showed option marked with no patient signature. 11. Review of Patient #6’s unstable Plan of Care, showed the IDT meeting was completed on 12/06/24 and the letter with the option to attend or not attend dated 12/02/24 showed option marked with no patient signature. 12.Review of the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 10/2024, showed the patient’s plan of care should have been completed by the facility’s interdisciplinary team, to include the patient or personal representative and should have been signed by the team members including the patient or the patient’s personal representative. If the patient chose not to sign, the choice and reason should have been documented. 13.Review of the facility’s policy titled, “Patient Rights,” last reviewed on 10/2021, showed patients were to be informed about and participate, if desired, in all aspects of their individualized plan of care.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 36473 Based on interview and record review the facility failed to ensure medication errors were reviewed and identified in the Quality Assessment Performance Improvement (QAPI) data to evaluate errors and take corrective actions to prevent reoccurrence. These failures had the potential to affect all patients’ health, safety and prevention of negative outcomes.The facility census was 67 in-center Hemodialysis (the process of purifying the blood of persons whose kidneys were not working) patients and eight Home Peritoneal Dialysis (PD, a treatment of kidney failure using the lining of your abdomen to filter your blood) patients. Findings included: 1.During an interview on 1/16/25 at 1:30 PM, Staff A, Facility Administrator, stated they expected physician orders to be followed. 2.Review of Patient #22’s flowsheet dated 1/04/25, showed the patient had an arteriovenous AV fistula and the physician ordered a heparin infusion for 0.4 ml/hr ending 60 minutes prior to the end of treatment. The flowsheet showed staff failed to discontinue the heparin 60 minutes prior to the end of treatment. 3.Review of Patient #23’s flowsheet dated 12/28/24, 12/30/24, 1/04/25 and 1/07/25 showed the patient had an arteriovenous AV fistula and the physician ordered a heparin infusion for 0.6 ml/hr ending 60 minutes prior to the end of treatment. The flowsheet showed staff failed to discontinue the heparin 60 minutes prior to the end of treatment. 4.Review of Patient #24’s flowsheet dated 1/02/25, showed the patient had an arteriovenous AV fistula and the physician ordered a heparin infusion for 0.4 ml/hr ending 60 minutes prior to the end of treatment. The flowsheet showed staff failed to discontinue the heparin 60 minutes prior to the end of treatment. 5.Review of Patient #25’s flowsheet dated 12/31/24, 1/07/25 and 1/10/25 showed the patient had an arteriovenous AV fistula and the physician ordered a heparin infusion for 0.4 ml/hr ending 60 minutes prior to the end of treatment. The flowsheet showed staff failed to discontinue the heparin 60 minutes prior to the end of treatment. 6.Review of Patient #26’s flowsheet dated 1/02/25, showed the physician ordered a heparin infusion for 0.6 ml/hr. The flowsheet showed staff discontinued the heparin one hour after starting dialysis with no documented reason. 7.Although requested, the facility failed to provide any medication errors listed on their log. 8.Review of the facility’s policy titled, “Medication Policy,” last reviewed on 10/2023, showed no medications were to be administered and given without an order from the physician. The policy also showed examples of medication errors include: - Administration of a medication not prescribed for the patient. - Administration of an incorrect dosage of an ordered medication. - A prescribed medication not administered to the patient. - A prescribed medication administered by an incorrect route. - A prescribed medication administered by an incorrect infusion rate.”

“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: 17026 Based on observations and staff interview, the facility staff failed to sanitize their hands between changing gloves during two observations, and staff failed to wear gloves when they adjusted the dialysis machine during one (station # 5) observation. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 82. Findings included: 1. Observation on 11/27/23 at 4:08 PM showed Patient Care Technician (PCT) (H) adjusted the dialysis machine at station # 5 without gloves on her hands. 2. Observation on 11/27/23 at 3:53 PM showed PCT (H) adjusted the dialysis machine at station # 10 but did not sanitize her hands after removing the gloves and before applying new gloves. 3. Observation on 11/28/23 at 1:26 PM showed Certified Clinical Hemodialysis Technician (CCHT) (I) adjusted the dialysis machine at station # 4 but did not sanitize her hands after removing the gloves and before applying new gloves. 4. During an interview on 11/28/23 at 10:13 AM, the facility administrator said staff should wear gloves when they adjust the dialysis machines and staff should sanitize their hands in between changing gloves.”

“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: 17026 Based on observations and staff interview, the facility staff failed to wait until the patient left the dialysis station to start station disinfection during three observations (station # 5, # 7, and # 15), and staff failed to fully disinfect the dialysis station during one (station # 2) out of six station disinfection observations. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 82. Findings included: 1. Observation on 11/27/23 at 3:36 PM showed Certified Clinical Hemodialysis Technician (CCHT) (L) started disinfecting the dialysis machine at station # 15 with the patient still at the dialysis station. Staff did not wait for the patient to leave the station to start station disinfection. 2. Observation on 11/27/23 at 4:11 PM showed CCHT (L) started disinfecting the dialysis machine at station # 5 with the patient still at the dialysis station. Staff did not wait for the patient to leave the station to start station disinfection. 3. Observation on 11/28/23 at 1:23 PM showed CCHT (I) started disinfecting the dialysis machine at station # 7 with the patient still at the dialysis station. Staff did not wait for the patient to leave the station to start station disinfection. 4. Observation on 11/27/23 at 3:05 PM showed Patient Care Technician (PCT) disinfected station # 2 but did not disinfect the prime waste bucket or the chase wall (wall that houses the water distribution system) behind the station. 5. During an interview on 11/27/23 at 10:13 AM, the facility administrator said staff should wait for the patient to leave the dialysis station before starting station disinfection, and staff should disinfect the entire station including the prime waste bucket and the chase wall.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 17026 Based on observation and staff interview, the facility staff failed to ensure seven containers of potential hydrogen (pH) strips (used to determine how acidic or basic a solution is) were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 82. Findings included: 1. Observation on 11/27/23 at 2:21 PM of the dialysis treatment area showed seven containers of 100 pH test strips that expired 8/31/23. 2. During an interview on 11/27/23 at 2:22 PM, the facility administrator said staff need to ensure the pH test strips were not expired.”

“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: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for the blood flow rate during dialysis treatment for three patients (Patient # 2, # 6, and # 20) out of eight clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 82. Findings included: 1. Review of the treatment flow sheet dated 11/25/23 for Patient # 2 showed the physician directed staff to set the blood flow rate at 350, but staff set the blood flow rate at 300 during the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 11/27/23 for Patient # 6 showed the physician directed staff to set the blood flow rate at 350, but staff set the blood flow rate at 400 during the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 11/25/23 for Patient # 20 showed the physician directed staff to set the blood flow rate at 450, but staff set the blood flow rate at 200 during the patient’s dialysis treatment. 4. During an interview on 11/28/23 at 10:13 AM, the facility administrator said staff should follow the physician order for the blood flow rate or document the reason for not following the physician order.”

“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: 17026 Based on record review and staff interview, the facility staff failed to document the reason for stopping dialysis treatment early for three patients (Patient # 2, # 6, and # 11) out of eight clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 82. Findings included: 1. Review of the treatment flow sheet dated 11/27/23 for Patient # 2 showed the physician directed staff provide the patient with three hours of dialysis treatment. The treatment flow sheet showed staff stopped the dialysis treatment 30 minutes early but did not document the reason. 2. Review of the treatment flow sheet dated 11/27/23 for Patient # 6 showed the physician directed staff provide the patient with three and a half hours of dialysis treatment. The treatment flow sheet showed staff stopped the dialysis treatment 35 minutes early but did not document the reason. 3. Review of the treatment flow sheet dated 11/22/23 for Patient # 11 showed the physician directed staff provide the patient with three and a half hours of dialysis treatment. The treatment flow sheet showed staff stopped the dialysis treatment 16 minutes early but did not document the reason. 4. During an interview on 11/28/23 at 10:13 AM, the facility administrator said staff should document the reason for stopping dialysis treatment early.”