Davita Hospital Hill Dialysis

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. 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 two (Patient # 1 and # 2) patients out of three clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 108. Findings included: 1. Review of the treatment flow sheets dated 5/8/24 and 5/10/24 for Patient # 1 showed the patient’s physician directed staff to set the blood flow rate at 500 during the patient’s dialysis treatment. The treatment flow sheet showed staff set the blood flow rate at 450 instead of 500. 2. Review of the treatment flow sheets dated 5/6/24 and 5/8/24 for Patient # 2 showed the patient’s physician directed staff to set the blood flow rate at 500 during the patient’s dialysis treatment. The treatment flow sheet showed staff set the blood flow rate at 350 instead of 500. 3. During an interview on 5/13/24 at 1:01 PM, the facility administrator said staff should follow the physician order for the blood flow rate or update the physician order if the physician changed the order for the blood flow rate.”

“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: 36473 Based on policy review, observation, and interview, the facility failed to ensure staff provided and maintained a clean environment free from potential contaminants when staff failed to: - Maintain four pipes under the chase walls free from various amounts of either a dried white substance or a thick tan colored substance. - Maintain the supply/wall boxes located behind the dialysis machines at each patient Station on the treatment floor free from various amounts of either a build-up of a dried white substance or various amounts of a light yellowish tan/light yellowish green colored substance located on the inside surface of the supply/wall boxes. - Maintain the biohazard room ceiling free from dirt and rust. - Maintain the laboratory centrifuge (machine used to separate components of a blood sample) free from dirt. - Maintain one dirty sink drain free from rust. - Maintain four biohazard bins screws free from rust. - Maintain four stools worn with open particle areas. - Remove two unclean brooms and two unclean dust pans from the patient areas. 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 (the process of purifying the blood of persons whose kidneys were not working) census was 106 . Findings included: 1. Review of the facility’s policy titled, “Physical Environment,” last reviewed on 04/2018, showed the direction for staff to maintain the space for patient treatment to provide needed care and prevent cross contamination. Pipes under the Chase Walls 2. Observation on 03/26/24 at 9:36 AM showed the pipes located under the chase walls at patient Stations #7, #8, #10 and #11 contained various amounts of either a thick dried white substance or various amounts of a thick build up of a light tan colored substance on the outside surface the pipes. Supply/Wall Boxes 3. Observation on 03/27/24 at 8:18 AM showed 20 out of 20 supply/wall boxes on the treatment floor behind each dialysis machine located at each patient Station contained various amounts of either a thick white dried substance or various amounts of a light yellowish tan/yellowish green colored substance on the inside surfaces of the supply/wall boxes. Biohazard Room 4. Observation on 03/25/24 at 1:50 PM in the Biohazard room, showed an unclean and rusted ceiling vent. Laboratory Centrifuge 5. Observation on 03/25/24 at 2:05 PM in the Laboratory work area, showed an unclean centrifuge. Sink 6. Observation on 03/25/24 at 2:10 PM on the patient treatment floor, showed a rusted drain in the dirty sink. Biohazard Bin Screws 7. Observation on 03/25/24 at 2:15 PM on the patient treatment floor, showed four Biohazard bins with 16 rusted screws. Stools 8. Observation on 03/25/24 at 2:30 PM on the patient treatment floor, showed four stools worn with torn areas with exposed particles. Brooms and Dustpans 9. Observation on 03/25/24 at 2:35 PM on the patient treatment floor, showed two unclean brooms and two unclean dustpans. 10. During an interview on 03/26/24 at 1:43 PM, Staff A, Registered Nurse, Manager of Clinical Services, stated they expected staff to address environmental issues monthly in the environmental rounds. 18018”

“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: 18018 Based on policy review, observation, and interview, the facility failed to ensure staff: - Performed hand hygiene (washing hands with soap and water or use of appropriate hand sanitizer) when indicated when staff provided care and treatments to patients. - Wore gloves when indicated and performed hand hygiene after glove removal and before re-gloving. - Performed hand hygiene before retrieval of supplies from the supply drawer/supply shelf. These failures to ensure staff practiced appropriate infection control prevention had the potential for cross contamination and the spread of infections to both patients and staff. The In-Center Hemodialysis census was 106. Findings included: Hand Hygiene - Gloves 1. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed staff directives in part: - All Teammates, Physicians and Non-Physician (NP) will perform hand hygiene: - Prior to gloving and immediately after removal of gloves; - After contamination with blood or other infectious material; - After patient and dialysis delivery system contact; and - Before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. - Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. 2. Observation on 03/25/24 at 2:22 PM, showed Staff H, Certified Clinical Hemodialysis Technician (CCHT), placed a glove on the right hand, however, Staff H failed to perform hand hygiene before gloving. At 2:46 PM, Staff H removed gloves, however, Staff H failed to perform hand hygiene after glove removal or before re-gloving to retrieve additional supplies from the supply drawer. Observation on 03/25/24 at 3:20 PM, showed Staff K, Patient Care Technician (PCT), removed gloves, however, Staff K failed to perform hand hygiene after glove removal and before re-gloving before typing on the computer keyboard. Observation on 03/25/24 at 3:29 PM, showed Staff K, PCT, was providing care for a patient in the isolation room and at the completion of providing care, Staff K removed gloves, however, staff failed to perform hand hygiene after glove removal or before exiting the Isolation room. Observation on 03/25/24 at 3:31 PM, showed Staff D, Registered Nurse (RN), disinfected/cleansed the dialysis chair in the isolation room. Staff D gloved, however, Staff D failed to perform hand hygiene before gloving. Wearing the same gloves worn to disinfect/cleanse the dialysis chair, Staff D retrieved additional wiping clothes from the bleach container. Observation on 03/26/24 at 9:34 AM, showed Staff Q, RN, placed a glove against the dialysis machine’s screen at patient Station #3 to turn off an alarm. Staff Q failed to place the glove on the hand to turn off the alarm. Observation on 03/26/24 at 9:56 AM, showed Staff P, CCHT, placed a glove against the dialysis machine’s screen at patient Station #9 to turn off an alarm. Staff P failed to place the glove on the hand to turn off the alarm. Observation on 03/26/24 at 9:54 AM, showed Staff G, CCHT, placed a glove against the dialysis machine’s screen at patient Station #1 to turn off an alarm. Staff G failed to place the glove on the hand to turn off the alarm. At 9:59 AM, Staff G wearing the same gloves to disconnect Patient #21 from dialysis, reached into staff’s scrub pants pocket and retrieved a pen. Observation on 03/26/24 at 10:17 AM, showed Staff P, CCHT, programmed the dialysis machine at patient Station #12 by placing a glove against the dialysis machine’s screen. Staff P failed to place a glove on the hand to program the dialysis machine. Observation on 03/26/24 at 10:30 AM, showed Staff O, CCHT, gloved, however, Staff O failed to perform hand hygiene before gloving. Observation on 03/26/24 at 11:37 AM, showed Staff Q, RN, placed a glove against the dialysis machine’s screen at patient Station #4 to turn off an alarm. Staff Q failed to place the glove on the hand to turn off the alarm. Observation on 03/26/24 at 11:45 AM, showed Staff P, CCHT, placed a glove against the dialysis machine’s screen at patient Station #18 to turn off an alarm. Staff P failed to place the glove on the hand to turn off the alarm. Observation on 03/26/24 at 1:46 PM, showed Staff Q, RN, removed gloves, however, Staff Q failed to perform hand hygiene after glove removal and before typing on the computer keyboard. Observation on 03/26/24 at 1:54 PM, showed Staff O, CCHT, placed a glove against the dialysis machine’s screen at patient Station #12 to turn off an alarm. Staff O failed to place the glove on the hand to turn off the alarm. Staff O gloved without hand hygiene to program the dialysis machine and wearing the same gloves retrieved additional gauze pads from the supply drawer. Observation on 03/26/24 at 2:00 PM, showed Staff P, CCHT, turned off the alarm on the dialysis machine at patient Station #12 without gloves on. Observation on 03/26/24 at 2:08 PM, showed Staff O, CCHT, placed a glove against the dialysis machine’s screen at patient Station #8 to turn off an alarm. Staff O failed to place the glove on the hand to turn off the alarm. Observation on 03/26/24 at 2:39 PM, showed Staff O, CCHT, removed gloves, however, Staff O failed to perform hand hygiene after glove removal and before retrieving tape from the supply box located on the supply shelf. Observation on 03/26/24 at 2:50 PM, showed Staff G, CCHT, removed gloves, however, Staff G failed to perform hand hygiene after glove removal and before re-gloving. Observation on 03/26/24 at 3:14 PM, showed Staff O, CCHT, removed gloves, however, Staff O failed to perform hand hygiene after glove removal or before re-gloving. Observations made on 03/26/24 at 3:13 PM and 3:18 PM, showed Staff Q, RN, placed a glove against the dialysis machine’s screens at patient Station #8 and #1 to turn off alarms. Staff Q failed to place the glove on the hand to turn off the alarms. Observation on 03/27/24 at 8:42 AM, showed Staff Q, RN, gloved twice without performing hand hygiene before, after or before re-gloving. Staff Q placed a glove against the dialysis machine’s screen to turn off an alarm. Staff Q failed to place the glove on the hand to turn off the alarm. Observation on 03/27/24 at 10:24 AM, showed Staff H, CCHT, removed gloves, however, Staff H failed to perform hand hygiene after glove removal and before re-gloving. Staffs’ Failure to: -Perform hand hygiene after glove removal and before re-gloving increased the risk of staff contaminating the gloves during re-gloving. - Remove gloves, perform hand hygiene, and re-glove before retrieving additional wiping cloths from the bleach container increased the risk of contamination of the remaining wiping cloths touched by the contaminated gloves. -Perform hand hygiene after glove removal and before retrieval of supplies from the supply drawer/supply shelf increased the risk of contamination of the remaining supplies. 3. During an interview on 03/27/24 at 1:43 PM, Staff A, RN, Manager of Clinical Services stated staff was expected to: - Perform hand hygiene before gloving, after removal of gloves and before re-gloving. - Perform hand hygiene after glove removal and before re-gloving to retrieve addition wiping clothes from the bleach container or additional supplies from the supply drawer/supply shelf. - Wear gloves when touching the dialysis machine and not just placing a glove against the dialysis machine’s screen. Staff A stated staff was expected to follow the facility’s policy related to hand hygiene and gloves.”

“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: 18018 Based on policy review, observation, and interview, the facility failed to ensure: - Staff wore Personal Protective Equipment (PPE, gown/coat, face mask, face shield/goggles and gloves) when staff provided care, treatment and services for patients identified as being positive for Hepatitis B (HBV, a severe virus of the liver that is spread through a person’s blood and body fluids) virus. - Staff removed their face mask after being in the isolation room caring for a patient with known positive Hepatitis B virus before returning to the treatment floor to provide care, treatment, and services to other patients. Wearing the same face mask worn in the isolation room increased the risk of spreading the virus to patients and staff on the treatment floor. These failed infection control practices increased the potential to spread the Hepatitis B virus to patients and staff throughout the facility. The In-Center Hemodialysis census was 106. Findings included: 1. Review of the facility’s policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” dated 10/2023 in part showed staff directives: -When entering the isolation room/area or station for any reason, physicians, NPPs, social workers, dieticians, and all other teammates will wear long-sleeved fluid resistant/fluid impervious gowns in addition to gloves, face shield, or mask and eye protection. -The long-sleeved gown will be tied in the back and gloves will be pulled over the cuffs of the sleeves. -PPE will be removed, gloves discarded, and hand hygiene performed immediately when leaving the room or area. 2. During the entrance conference on 03/25/24 with administrative staff, Staff T, Group Regional Operations Director, confirmed the facility provided dialysis treatments to two current patients with known positive HBV status. Staff T stated the positive HBV patients received their dialysis treatments in the isolation room located on the treatment floor and the isolation room was utilized only for patients with a positive HBV result. 3. Observation on 03/25/24 at 3:29 PM, showed Staff K, Patient Care Technician (PCT) provided care and treatment for Patient #6 located in the isolation room. At the completion of providing care and treatment, Staff K removed staff’s coat and gloves, however, Staff K failed to perform hand hygiene after removal of gloves. Staff K also failed to remove the face mask worn in the isolation room before staff returned to the treatment floor. Observation on 03/25/24 at 3:39 PM, showed Staff D, Registered Nurse (RN), exited the isolation room wearing the same face mask worn to provide care and treatments to Patient #6. Staff D failed to remove the face mask worn in the isolation room before staff returned to the treatment floor to provide care and service for patients. Observation on 03/27/24 at 8:36 AM, showed Staff H, CCHT, exited the isolation room wearing the same face mask worn to provide care and treatments to Patient #32. Staff H failed to remove the face mask worn in the isolation room before staff returned to the treatment floor to provide care and services for patients. Observation on 03/27/24 at 9:02 AM, showed Staff S, RN, Advanced Practice Registered Nurse (APRN), was in the isolation room without proper PPE. Staff failed to have a gown, gloves, or face mask on while in the isolation room with Patient #32. At 9:05 AM, Staff S exited the isolation room wearing the same white lab coat worn in the isolation room and Staff S failed to perform hand hygiene when staff exited the isolation room and before returning to the treatment floor. Staff S was observed visiting with patients in PODs A, B, C, D and E wearing the same lab coat as worn in the isolation room. 4. During an interview on 03/27/24 at 9:12, Staff S, RN, APRN, stated staff was expected to perform hand hygiene: - Before and after contact/touching a patient. - After touching the dialysis machine. - Before leaving the treatment floor. Staff S stated staff was expected to follow the following infection control practices when providing care and treatments for known HBV+ patients: - Wear a gown; - Wear gloves; and - Perform hand hygiene after providing cares and treatments. Staff S stated to her knowledge, staff did not need to wear a face mask in the Isolation Room when interacting with patients with HBV+ status. Staff S acknowledged she did not wear a gown, face mask or gloves when in the isolation room and she did not change her lab coat when she exited the isolation room and returned to the treatment floor and interacted with patients throughout the treatment floor. During an interview on 03/27/24 at 1:43 PM, Staff A, RN, Manager of Clinical Services, stated: - Only patients with a known HBV+ status received treatment in the isolation room. - The expectation of staff was to remove the face mask worn in the isolation room before staff returned to the treatment floor. - The expectation of staff was to remove PPE worn in the isolation room upon exiting and before staff returned to the treatment floor. Staff A stated staff was expected to follow the facility’s policy and procedure when providing care and treatment for HBV+ patients.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 18018 Based on policy review, observation, and interview, the facility failed to ensure staff appropriately disposed of bio-hazardous waste (bio-hazardous waste, blood and/or body fluids) for five out of five observations made of staff disposing bio-hazardous waste materials/items (used bloodlines and dialyzer) after patients’ dialysis treatments. This failed practice had the potential to cause an increase in cross-contamination and potentially increased infection risks to both patients and staff. The facility census was 106. Findings included: 1. Review of the facility’s policy titled, “Infection Control For Dialysis Facilities,” dated 04/2023, in part showed directives for staff: Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Review of the facility’s policy titled, “Termination of Dialysis Utilizing B Braun Dialog + Dialysis Delivery Systems With All Single Use Dialyzer Types and Streamline Blood Lines,” dated 10/2023, in part showed staff directives: Remove blood lines and dialyzer per manufacturer’s recommendation and discard in biohazardous container. 2. Observations made on 03/25/24 from 2:00 PM to 3:39 PM and on 03/26/24 from 8:32 AM to 3:18 PM showed a large red bio-hazard cart in POD A that was located next to a sink labeled “CLEAN”. Staff was observed carrying uncontained used bloodlines and dialyzers to the large red bio-hazard cart and disposed the used bio-hazardous materials/items into the cart. The used bloodlines and dialyzers were not contained in fluid resistant red bio-hazard waste bag, which increased the risk of splashing, spraying, splattering or generation of droplets onto the surface of the sink designated as “clean.” Observation on 03/25/24 at 2:20 PM, showed Staff B, Registered Nurse (RN), removed the used bloodlines and dialyzer from patient Station #2 and carried the uncontained bio-hazardous items to the large red bio-hazard cart across from patient Station #4 and located next to the “clean” sink. Observation on 03/25/24 at 2:22 PM, showed Staff H, Certified Clinical Hemodialysis Technician (CCHT), carried uncontained used bloodlines and dialyzer from patient Station #4 to the large red bio-hazard cart across from patient Station #4 and located next to the “clean” sink. Observation on 03/25/24 at approximately 3:20 PM, showed Staff D, RN, carried uncontained used bloodlines and dialyzer from patient Station #5 to the large red bio-hazard cart located across from patient Station #12. Observation on 03/26/24 at 2:13 PM, showed Staff P, CCHT, carried uncontained used bloodlines and dialyzer from patient Station #12 to the large red bio-hazard cart located across from patient Station #11. Observation on 03/26/24 at 2:51 PM, showed Staff G, CCHT, removed the used bloodlines and dialyzer from patient Station #1 and carried the uncontained bio-hazard materials/items in front of a patient while the patient received their dialysis treatment at patient Station #2. Staff G carried the uncontained bloodlines and dialyzer to the large red bio-hazard cart across from patient Station #4 located next to the “clean” sink. 3. During an interview on 03/27/26 at 1:43 PM, Staff A, RN, Manager of Clinical Services, stated staff are expected to retrieve the large red bio-hazard cart from its location on the POD and bring it to the patient Station when removing and disposing of the used bloodlines and dialyzer after a patient’s dialysis treatment. Staff A stated staff are not to carry used bio-hazard materials/items without being contained a fluid resistant bio-hazard bag. Staff A stated the large red bio-hazard cart should not be located next to the “clean” sink in POD A and there should be a separation between “clean” and “dirty” items.”

“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: 18018 Based on policy review, observation, and interview, the facility failed to ensure staff consistently, thoroughly, and properly disinfected and cleansed patients’ dialysis stations at the end of a patient’s dialysis treatment and prior to the initiation of the next patient’s dialysis treatment for four out of four station disinfection observations conducted. The failure to properly clean external surfaces that are frequently touched by patients and staff had the potential for increased cross-contamination that could cause infection risks to all patients and staff. The In-Center Hemodialysis census was 106. Findings included: 1. Review of the facility’s policy titled, “Infection Control For Dialysis Facilities,” dated April 2023, showed staff directives: - At the end of each treatment, the dialysis station will be cleaned and disinfected. - Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). - The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. Teammates will monitor and address wall box residue/build up and patency issues. - Priming containers are to be emptied prior to disinfection. - Dialysis delivery systems with computers/keyboards mounted on top, the computer and keyboard are considered “dirty” equipment. 2. Observation on 03/26/24 at 9:17 AM, showed Staff C, Certified Clinical Hemodialysis Technician (CCHT), failed to disinfect/cleanse the following items at patient Station #13: - The dialysis machine’s front, sides and back. - The dialysis machine’s supply lines and cords. - The prime bucket’s interior and exterior. - The chase wall. - Failed to place the dialysis chair in the reclined position prior to the disinfection/cleansing process. - Failed to disinfect/cleanse the footrest. - The intravenous (IV) pole an hooks. - The outside surface of the red sharps container. Observation on 03/26/24 showed Staff J, CCHT, failed to disinfect/cleanse the following items at patient Station #19: - The dialysis machine’s top and back. - The IV pole and hooks. - The outside surface of the red sharps container and garbage can. Observation on 03/26/24 at 2:24 PM, showed Staff P, CCHT, failed to disinfect and cleanse the following items at patient Station #12: - The dialysis machine’s supply lines and cords. - The supply/wall box. - The emergency kit attached to the television arm. Observation on 03/27/24 at 10:16 AM, showed Staff H, CCHT, failed to disinfect and cleanse the following items at patient Station #8: - The chase wall. - The emergency kit attached to the television arm. - The oxygen concentrator used by the patient during delivery of the dialysis treatment. - The IV pole hooks. 3. During an interview on 03/27/24 at 1:43 PM, Staff A, Registered Nurse, Manager of Clinical Services, stated the expectation for staff was to follow the facility’s policy “Infection Control for Dialysis Facilities” when disinfecting/cleansing patient Stations at the completion of a patient’s dialysis treatment and wall boxes are to be included in the patient Station disinfection/cleansing.”

“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 policy review, observation, and interview, 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 24 patients (#3, #4, #13, #14, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #36, #39, and #40) observed for non-visible access sites/bloodline connections and/or face. A non-visible access sites/bloodline connections 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 census was 106. Findings included: 1. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 10/2023 in part showed directives for staff: The vascular access site, bloodline connections and the patient’s face should be visible throughout the dialysis treatment. 2. Observations made on 03/25/24 at 2:15 PM, 2:17 PM, 2:18 PM and 2:19 PM showed Patient #3, #18, #19, and #39 received dialysis treatment, however, the patients’ access sites was covered by a blanket and non-visible to staff. Observation on 03/25/24 at 3:10 PM, showed Patient #20 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 at 8:32 AM, 9:15 AM and 9:35 AM, showed Patient #21 and #22 received dialysis treatment, however, the patients’ access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 from 8:51 AM to 10:15 AM, showed Patient #4 received dialysis treatment, however, the patients’ access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 at 9:15 AM, showed Patient #23 received dialysis treatment, however, the patient’s access sites and bloodline connections was covered by a jacket. Observations made on 03/26/24 from 11:25 AM to 11:55 AM, showed Patient #24 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 from 11:27 AM to 12:00 PM, showed Patient #36 received dialysis treatment, however, the patient’s face and access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 from 11:57 AM to 2:56 PM, showed Patient #25 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations made on 03/26/24 from 1:28 PM to 1:56 PM, showed Patient #26 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observation on 03/26/24 at 2:10 PM, showed Patients #13 and #14 received dialysis treatment, however, the patients’ access sites was covered by a blanket and non-visible to staff. Observations made on 03/27/24 at 8:09 AM, 9:09 AM, 9:30 AM, and 10:00 AM, showed Patients #27, #28, #29, #30, #31 and #40 received dialysis treatments, however, Patients #27’s, #29’s, and #40’s access sites was covered by a blanket, Patient #28’s face and access sites was covered by a blanket, and Patients #30’s and #31’s access sites and bloodline connections was covered by a blanket. The patients’ face, access sites and bloodline connections was non-visible to staff during the patients’ dialysis treatments. Observation on 03/27/24 at 9:34 AM, showed Patient #17 received dialysis treatment, however, the patient’s face, access sites and bloodline connections was covered by a blanket and non-visible to staff. Observation on 03/27/24 at 10:04 AM, showed Patient #32 received dialysis treatment in the Isolation Room, however, the patient’s access sites and bloodline connections was not visible to staff. Observation on 03/27/24 at 12:25 PM, showed Patient #33 received dialysis treatment, however, the patient’s access sites and bloodline connections was covered by a blanket and non-visible to staff. 3. During an interview on 03/27/24 at 1:43 PM, Staff A, Registered Nurse, Manager of Clinical Services, stated a patient’s face, access sites and bloodline connections are to always remain visible to staff when the patient received dialysis treatment. Staff A stated staff are expected to address with the patient the risks a of non-visible face, access sites, and bloodline connections during dialysis treatment and document the patient education in the patient’s medical record. Staff A stated staff was expected to follow the facility’s policy and procedures.”

“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: 36473 Based on policy review, review of patient treatment flowsheets, and interview, the facility failed to ensure staff followed the physician orders for Post Treatment Assessments for 29 patient treatments performed for nine (#1, #2, #3, #4, #5, #6, #8, #9 and #10) out of 10 reviewed. The facility also failed to complete the patient’s treatment times for 11 treatments for eight patients (#2, #3, #5, #7, #8, #9 & #10) for the last two weeks of flowsheets reviewed. These failures had the potential to miss patient complications and to affect adequacy of all dialysis treatments. The in-center hemodialysis (The process of purifying the blood of persons whose kidneys were not working) census was 106. Findings included: Post Treatment Assessments 1. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, last reviewed on 10/2023, showed the direction for the licensed nurses to assess the patient prior to discharge. 2. Review of Patient #1’s treatment flowsheets showed delayed post treatment assessments dated: - 03/13/24 - performed one hour and four minutes after the patient’s discharge; - 03/15/24 - performed two hours and 22 minutes after the patient’s discharge; - 03/18/24 - performed one hour and three minutes after the patient’s discharge; and - 03/25/24 - performed fifty-nine minutes after the patient’s discharge. 3. Review of Patient #2’s treatment flowsheet dated 03/12/24 showed delayed post treatment assessment performed two hours after the patient’s discharge. 4. Review of Patient #3’s treatment flowsheets showed delayed post treatment assessments dated: - 03/15/24 - performed four hours and one minute after the patient’s discharge; - 03/18/24 - performed one hour and 13 minutes after the patient’s discharge; - 03/20/24 - performed one hour and 58 minutes after the patient’s discharge 5. Review of Patient #4’s treatment flowsheets showed delayed post treatment assessments dated: - 03/02/24 - performed five hours and 35 minutes after the patient’s discharge; - 03/05/24 - performed four hours and 35 minutes after the patient’s discharge; - 03/12/24 - performed two hours and six minutes after the patient’s discharge; and - 03/20/24 - performed one hour and eight minutes after the patient’s discharge. 6. Review of Patient #5’s treatment flowsheets showed delayed post treatment assessments dated: - 03/13/24 - performed one hour and 42 minutes after the patient’s discharge; - 03/15/24 - performed five hours and 41 minutes after the patient’s discharge; - 03/18/24 - performed one hour and 15 minutes after the patient’s discharge; and - 03/20/24 - performed five hours and 46 minutes after the patient’s discharge. 7. Review of Patient #6’s treatment flowsheets showed delayed post treatment assessments dated: - 03/13/24 - performed two hours and 47 minutes after the patient’s discharge; - 03/15/24 - performed two hours and 13 minutes after the patient’s discharge; - 03/18/24 - performed one hour and 55 minutes after the patient’s discharge; and - 03/22/24 - performed two hours and 15 minutes after the patient’s discharge. 8. Review of Patient #8’s treatment flowsheet dated 03/08/24, showed delayed post treatment assessment performed two hours and 32 minutes after the patient was discharged. 9. Review of Patient #9’s treatment flowsheets showed delayed post treatment assessments dated: - 03/14/24 - performed one hour and seven minutes after the patient’s discharge; - 03/15/24 - performed six hour and 28 minutes after the patient’s discharge; and - 03/16/24 - performed 29 minutes after the patient’s discharge. 10. During an interview on 03/26/24 at 1:43 PM, Staff A, Manager of Clinical Services, stated that they expected the staff to document in the patient’s medical record when they were unable to document post treatment assessments. Against Medical Advice 11. Review of the facility’s policy titled, “Prescribed Treatment Time Not Met,” last review on 10/2023, showed that when patient requests early termination the direction for staff was to obtain the patient’s signature on an Against Medical Advice (AMA) form. Also, if the patient refuses to sign the AMA form, the staff was to document the response in the patient’s medical record. 12. Review of Patient #2’s treatment flowsheets dated 03/16/24 and 03/21/24, showed the patient’s treatments were terminated early, no AMA forms completed and no reasons documented. 13. Review of Patient #3’s treatment flowsheets dated 03/15/24, showed the patient’s treatment was terminated early, no AMA form completed and no reason documented. 14. Review of Patient #5’s treatment flowsheet dated 03/13/24, showed the patient’s treatment was terminated early, no AMA form completed and no reason documented. 15. Review of Patient #7’s treatment flowsheet dated 03/15/24, showed the patient’s treatment was terminated early, no AMA form completed and no reason documented. 16. Review of Patient #8’s treatment flowsheets dated 03/13/24 and 03/25/24, showed the patient’s treatments were terminated early, no AMA forms completed and no reasons documented. 17. Review of Patient #9’s treatment flowsheets dated 03/14/24, 03/16/24 and 03/19/24, showed the patient’s treatments were terminated early, no AMA forms completed and no reasons documented. 18. Review of Patient #10’s treatment flowsheets dated 03/12/24 and 03/16/24, showed the patient’s treatments were terminated early, no AMA forms completed and no reasons documented. 19. During an interview on 03/26/24, Staff A, Manager of Clinical Services, stated they expected staff to follow policy and complete the AMA forms.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 36473 Based on policy review, record review,and interview, the facility failed to ensure the patient was made aware of and authenticated their plan of care for two patients (#1 & #6) out of four reviewed at the time of review. These failures had the potential to affect all patients that received treatment at the facility. The in-center hemodialysis (The process of purifying the blood of persons whose kidneys were not working) census was 106. Findings included: 1. Review of the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” last review on 07/2023, showed the patient’s plan of care should be completed by the facility’s IDT team and the patient with signatures and date reviewed. 2. Review of Patient #1’s plan of care showed the last care plan reviewed was on 08/08/23 and the patient hadn’t signed until 10/02/23. 3. Review of Patient #6’s plan of care showed the last care plan reviewed was on 06/20/23 and the patient hadn’t signed until 10/02/23. 4. During an interview on 03/26/24 at 1:43 PM, Staff A, Manager of Clinical Services, stated care plans should be reviewed and signed by patients within 30 days of completion.”