Davita Kansas City 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: 17026 Based on observations and staff interview, the facility staff failed to maintain the area under the clean sink and dirty sink, and failed to maintain a sanitary sink at the facility dialysis den (dialysis service within a dedicated room of a nursing home) located at 904 East 68th Street, Kansas City MO 64131. This had the potential to effect all patients on dialysis and cause an increase in cross-contamination and infection risk. Findings included: 1. Observation on 3/10/25 at 11:21 AM showed the area under the clean sink had brown and yellow spills and stained areas throughout the cabinet area under the sink. 2. Observation on 3/10/25 at 11:24 AM showed the area under the dirty sink had brown and yellow spills and stained areas throughout the cabinet area under the sink. 3. Observation on 3/10/25 at 11:25 AM showed the dirty sink had yellow residue and stains around the sink area. 4. During an interview on 3/10/25 at 11:26 AM, the regional operations manager said staff need to ensure they maintain the sink and the areas under the clean sink and dirty sink.”

“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 adjusted the dialysis machine at three dialysis stations (station # 4, # 19, and # 17) and failed to sanitize their hands in between changing gloves during two 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 93. Findings included: 1. Observation on 3/3/25 at 12;14 PM showed staff (D) adjusted the dialysis machine at station # 19 without gloves on her hands. 2. Observation on 3/3/25 at 12:21 PM showed staff (J) adjusted the dialysis machine at station # 17 without gloves on her hands. 3. Observation on 3/3/25 at 12:32 PM showed staff (P) adjusted the dialysis machine at station # 16. Staff (P) then changed gloves but did not sanitize her hands in between changing gloves, and adjusted the dialysis machine at station # 22. 4. Observation on 3/3/25 at 1:26 PM showed staff (J) adjusted the dialysis machine at station # 17. Staff (J) then changed gloves but did not sanitize her hands in between changing gloves, and adjusted the dialysis machine at station # 8. 5. Observation on 3/4/25 at 8:02 AM showed staff (G) adjusted the dialysis machine at station # 4 without gloves on his hands. 6. During an interview on 3/4/25 at 1:42 PM, the manager of clinical services said staff should wear gloves when they adjust the dialysis machines and they should sanitize their hands in between changing gloves.”

“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: 17026 Based on observations and staff interview, the facility staff failed to ensure the dialysis access remained visible to staff during dialysis treatments for the patients at seven stations (station # 2, # 3, # 12, # 14, # 20, # 22, and # 23) out of 24 dialysis stations. This had the potential to effect all patients on dialysis and could result in unnoticed bleeding or unnoticed needle dislodgement during dialysis treatment. The facility census was 93. Findings included: 1. Observation on 3/3/25 at 12:12 PM, 1:16 PM, and 1:43 PM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 2, # 3, # 22, and # 23. 2. Observation on 3/3/25 at 1:49 PM and 3:18 PM showed the patient at dialysis station # 20 had a blanket that covered his dialysis access and a his head during dialysis treatment. 3. Observation on 3/3/25 at 3:20 PM and 3:43 PM showed the patient at station # 12 had his dialysis access covered with a blanket and not visible to staff. 4. Observation on 3/3/25 at 3:21 PM and 3:42 PM showed the patient at station # 14 had a blanket that covered her dialysis access and her head during dialysis treatment. 5. Observation on 3/4/25 at 10:01 AM showed the patient at dialysis station # 3 had his dialysis access covered with a blanket and not visible to staff. 6. During an interview on 3/4/25 at 1:42 PM, the manager of clinical services said staff need to try to ensure the dialysis access remains visible to staff during dialysis treatments.”

“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 or the dialysate flow rate for three patients (Patient # 25, # 59, and # 63), and failed to conduct the pre-Registered Nurse (RN) assessment within one hour of starting a patient on dialysis treatment for three patients (Patient # 1, # 7, and # 16) out of 12 clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 93. Findings included: 1. Review of the treatment flow sheet dated 2/25/25 for Patient # 25 showed the physician directed staff to set the blood flow rate at 350 and the dialysate flow rate at 500 during the patient’s dialysis treatment. Further review of the treatment flow sheet showed staff set the blood flow rate at 400 and the dialysate flow rate at 800. 2. Review of the treatment flow sheet dated 2/28/25 for Patient # 63 showed the physician directed staff to set the blood flow rate at 450 and the dialysate flow rate at 800 during the patient’s dialysis treatment. Further review of the treatment flow sheet showed staff set the blood flow rate at 370 and the dialysate flow rate at 500. 3. Review of the treatment flow sheet dated 2/26/25 for Patient # 59 showed the physician directed staff to set the blood flow rate at 450 during the patient’s dialysis treatment. Further review of the treatment flow sheet showed staff set the blood flow rate at 400. 4. Review of the treatment flow sheet dated 2/24/25 for Patient # 7 showed staff started the patient on dialysis treatment at 2:52 PM but did not conduct the pre-RN assessment until 4:31 PM. 5. Review of the treatment flow sheet dated 2/24/25 for Patient # 1 showed staff started the patient on dialysis treatment at 10:03 AM but did not conduct the pre-RN assessment until 11:29 AM. 6. Review of the treatment flow sheet dated 2/28/25 for Patient # 16 showed staff started the patient on dialysis treatment at 10:09 AM but did not conduct the pre-RN assessment until 11:34 AM 7. During an interview on 3/4/25 at 1:42 PM, the manager of clinical services said staff should conduct the pre-RN assessment within one hour of starting a patient on dialysis treatment, and staff should follow the physician order for the blood flow rate and dialysate flow rate.”

“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 interviews, the facility staff failed to fully disinfect the dialysis station during three(station 9, # 12, and #15) 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 87. Findings included: 1. Observation on 1/29/24 at 1:41 PM showed staff (C) disinfected station # 15 but did not lower the dialysis chair side trays to fully disinfect the area and did not disinfect the chase wall (wall behind the station that houses the water distribution system). 2. Observation 1/29/24 at 2:04 PM showed Certified Clinical Hemodialysis Technician (CCHT) (H) disinfected station # 12 but did not disinfect the chase wall behind the station where patients put their personal belongings. 3. Observation 1/29/24 at 2:29 PM showed Certified Clinical Hemodialysis Technician (CCHT) (H) disinfected station # 9 but did not disinfect the chase wall behind the station where patients put their personal belongings. 4. During an interview on 1/30/24 at 1:40 PM, the Manager of Clinical Services 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 three vials of medications were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 87. Findings included: 1. Observation on 1/29/24 at 12:24 PM of the laboratory room adjacent to the dialysis treatment area showed a vial of Cefepime (antibiotic medication) that expired 10/31/23. 2. Observation on 1/29/24 at 11:58 AM of the home dialysis laboratory room showed two vials of Vancomycin (antibiotic medication) that expired 1/1/24. 3. During an interview on 1/30/24 at 1:40 PM, the Manager of Clinical Services said staff need to ensure the medications were not expired.”

“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 dialysate flow rate for three (Patient # 25, # 37, and # 43) patients 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 87. Findings included; 1. Review of the treatment flow sheet dated 1/26/24 for Patient # 25 showed the physician directed staff to set the dialysate flow rate at 800 during the patient’s dialysis treatment. The treatment flow sheet showed staff set the dialysate flow rate at 500. 2. Review of the treatment flow sheet dated 1/29/24 for Patient # 37 showed the physician directed staff to set the dialysate flow rate at 500 during the patient’s dialysis treatment. The treatment flow sheet showed staff set the dialysate flow rate at 800. 3. Review of the treatment flow sheet dated 1/26/24 for Patient # 43 showed the physician directed staff to set the dialysate flow rate at 500 during the patient’s dialysis treatment. The treatment flow sheet showed staff set the dialysate flow rate at 600. 4. During an interview on 1/30/24 at 1:40 PM, the Manager of Clinical Services said staff should follow the physician order for the dialysate flow rate.”

“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 conduct the initial nursing assessment within one hour of a patient starting dialysis treatment for three (Patient # 33, # 37, and # 82) 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 87. Findings included: 1. Review of the treatment flow sheet dated 1/24/24 for Patient # 33 showed staff started the patient on dialysis treatment at 12:54 PM but did not conduct the initial nursing assessment until 2:50 PM. 2. Review of the treatment flow sheet dated 1/29/24 for Patient # 37 showed staff started the patient on dialysis treatment at 10:04 AM but did not conduct the initial nursing assessment until 11:33 AM. 3. Review of the treatment flow sheet dated 1/24/24 for Patient # 82 showed staff started the patient on dialysis treatment at 7:03 AM but did not conduct the initial nursing assessment until 8:29 AM. 4. During an interview on 1/30/24 at 1:40 PM, the Manager of Clinical Services said staff should conduct the initial nursing assessment within one hour of starting a patient on dialysis treatment.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This Standard is not met as evidenced by: 16639 Based on observation and interview the facility failed to ensure one of two exits on the ground floor remained free of obstructions. The facility census was 87. Findings included: 1. Observation on 01/30/24 at approximately 1:00 PM the rear exit of the building was observed to have a large plywood box and cardboard box stored under the stairs. The door which was the exit for this area was observed to have two empty wood pallets leaning against a wall directly outside the door. 2, During an interview upon the observation Staff N, Facility Administrator, stated a company picked up the wood pallets when empty and they are always placed outside the exit door. Staff N was unsure of why the plywood box was stored under the stairs and the cardboard box contained extra parts for a treatment chair.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 16639 Based on observation and interview the facility failed to ensure the sprinkler system had been repaired and restored to full function after a repair. The facility census was 87. Findings included: 1. Observation on 01/30/24 at approximately 1:15 PM the alarm panel for the fire protection system was observed to be flashing a trouble signal with an error message. 2. During an interview upon the observation Staff N, Facility Administrator, stated a week ago Sunday they did have repairs done to the sprinkler system. After contact with the building owner it was learned the repairs should have been completed a week ago Tuesday. Staff N stated they would contact their facility maintenance and ensure the system was in working order. 3. Staff N sent via email on 01/31/24 documents from two entities who had checked the alarm panel on 01/30/24. The documents showed in part sprinkler waterflow alarms in portions of the building had been disabled due to sprinkler system issues. The modules were enabled and the system was noted to then be in working order.”