Davita Rolla Dialysis

“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 wear gloves when they touched the dialysis machines or change gloves when going from one dialysis machine to another during three observations (station # 3, # 5, and # 14). This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 68. Findings included: 1. Observation on 1/17/24 at 10:18 AM showed Certified Clinical Hemodialysis Technician (CCHT) (F) adjusted the dialysis machine at station # 3 without gloves on her hands. 2. Observation on 1/17/24 at 10:24 AM showed CCHT (J) adjusted the dialysis machine at station # 14 and then adjusted the dialysis machine at station # 10 with the same gloves. Staff did not change gloves or sanitize hands in between stations. 3. Observation on 1/17/24 at 10:47 AM showed CCHT (F) adjusted the dialysis machine at station # 5 without gloves on her hands. 4. During an interview on 1/17/24 at 9:45 AM, the facility administrator said staff should wear gloves when they adjust the dialysis machines.”

“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 fully disinfect the dialysis station during three (station # 9, # 10, and # 12) out of five 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 68. Findings included: 1. Observation on 1/16/24 at 10:56 AM showed Patient Care Technician (PCT) (D) disinfected station # 10 but did not disinfect the prime waste bucket or the chase wall (wall behind the station that houses the water distribution system). 2. Observation on 1/16/24 at 1:47 PM showed PCT (D) disinfected station # 12 but did not disinfect chase wall. 3. Observation on 1/16/24 at 1:52 showed Certified Clinical Hemodialysis Technician (CCHT) (J) disinfected station # 10 but did not disinfect the prime waste bucket or the chase wall. 4. During an interview on 1/17/24 at 9:45 AM, the facility administrator said staff should disinfect the entire dialysis station during station disinfection.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure the Gentamicin (antibiotic medication) (20 vials) and the residual test strips (three containers) were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 68. Findings included: 1. Observation on 1/16/24 at 10:38 AM of the medication area showed 20 vials of Gentamicin that expired 9/23/23. 2. Observation of the water room on 1/16/24 at 10:23 AM showed three containers of residual test strips that expired 4/20/23. 3. During an interview on 1/16/24 at 10:40 AM, staff (G) said staff need to ensure the medications and residual 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 heparin (medication used to prevent blood clots) administration for two patients (Patient # 2 and # 42) out of seven clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in bleeding or clotting complications. The facility census was 68. Findings included: 1. Review of the treatment flow sheets dated 1/12/24 and 1/15/24 for Patient # 2 showed the physician directed staff to stop the heparin infusion 60 minutes before the end of the patient’s dialysis treatment. The treatment flow sheets showed staff continued the heparin infusion until the end of the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 1/12/24 for Patient # 42 showed the physician directed staff to stop the heparin infusion 60 minutes before the end of the patient’s dialysis treatment. The treatment flow sheets showed staff continued the heparin infusion until the end of the patient’s dialysis treatment. 3. During an interview on 1/17/24 at 9:45 AM, the facility administrator said staff should follow the physician order for heparin administration.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 17026 Based on record review and interviews, the facility staff failed to complete the monthly dietary progress note and failed to ensure the dietician attended the care plan meeting for two patients (Patient # 15 and # 23) out of seven clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 68. Findings included: 1. During an interview on 1/16/24 at 2:04 PM, Patient # 23 said she had not seen the dietician at the facility for at least a couple months. Review of the dietary progress notes for the patient showed staff completed the most recent dietary progress note for the patient on 11/28/23. 2. During an interview on 1/16/24 at 2:04 PM, Patient # 15 said he had not seen the dietician at the facility for at least a couple months. Review of the dietary progress notes for the patient showed staff completed the most recent dietary progress note for the patient on 11/29/23. 3. During an interview on 1/17/24 at 9:10 AM, the dietician said she was the dietician at other facilities and not able to attend some of the care plan meetings or complete some of the monthly dietary progress notes for some of the patients.”

“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: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for the blood flow rate for four patients (Patient # 6, # 9, # 25, and # 27) out of seven clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 68. Findings included: 1. Review of treatment flow sheet dated 1/9/24 for Patient # 6 showed the physician directed staff to set the blood flow rate at 400, but staff set the blood flow rate at 350 during the patient’s dialysis treatment. 2. Review of treatment flow sheet dated 1/10/24 for Patient # 9 showed the physician directed staff to set the blood flow rate at 400, but staff set the blood flow rate at 350 during the patient’s dialysis treatment. 3. Review of treatment flow sheet dated 1/8/24 for Patient # 25 showed the physician directed staff to set the blood flow rate at 400, but staff set the blood flow rate at 350 during the patient’s dialysis treatment. 4. Review of treatment flow sheet dated 1/6/24 for Patient # 27 showed the physician directed staff to set the blood flow rate at 300, but staff set the blood flow rate at 350 during the patient’s dialysis treatment. 5. During an interview on 1/17/24 at 9:45 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.”