Davita St.louis West Dialysis

“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 two water drains in the water room, failed to ensure the area under an exit door was sealed, and failed to ensure the laboratory area refrigerator remained clean. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 86. Findings included: 1. Observation on 8/11/25 at 11:15 AM of the water room showed an approximately one foot by one foot water drain near the water softener tanks that had rusted areas around the inside of the floor drain. 2. Observation on 8/11/25 at 11:17 AM of the water room showed an approximately one foot by one foot water drain in the back corner of the room that had black and yellow areas around the floor drain. 3. Observation on 8/11/25 at 11:19 AM of the storage room adjacent to the water room showed the exit door to the outside had an approximately one-fourth inch gap at the bottom of the door. 4. Observation on 8/11/25 at 11:22 AM of the laboratory area showed the refrigerator with laboratory supplies had black particles on the bottom shelf of the refrigerator. 5. During an interview on 8/12/25 at 12:40 PM, the biomedical operations manager said staff need to clean or replace the water drains in the water room and staff need to seal the area under the exit door in the storage room adjacent to the water room.”

“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 machines during four (station # 8, # 10 twice, and # 18) 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 86. Findings included: 1. Observation on 8/11/25 at 11:28 AM showed staff (K) adjusted the dialysis machine at station # 10 without gloves on his hands. 2. Observation on 8/11/25 at 11:37 AM showed staff (G) adjusted the dialysis machine at station # 18 without gloves on his hands. 3. Observation on 8/11/25 at 12:45 PM showed staff (A) adjusted the dialysis machine at station # 8 without gloves on her hands. 4. Observation on 8/11/25 at 1:35 PM showed staff (F) adjusted the dialysis machine at station # 10 without gloves on her hands. 5. During an interview on 8/12/25 at 12:55 PM, 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 # 7, # 8, and # 18) out of four 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 86. Findings included: 1. Observation on 8/11/25 at 2:59 PM showed staff (B) disinfected station # 8 but did not lower the dialysis chair side trays to fully clean the area between the trays and the chair. Staff also did not recline the dialysis chair to fully disinfect, and did not disinfect the chase wall (wall that houses the water distribution system) behind the station. 2. Observation on 8/11/25 at 1:31 PM showed staff (G) disinfected station # 18 but did not disinfect the intravenous pole/hooks and did not disinfect the chase wall behind the station. 3. Observation on 8/11/25 at 3;10 PM showed staff (B) disinfected station # 7 but did not lower the dialysis chair side trays to fully clean the area between the trays and the chair. Staff also did not recline the dialysis chair to fully disinfect, and did not disinfect the chase wall behind the station. 4. During an interview on 8/12/25 at 12:55 PM, the facility administrator said staff should disinfect the entire dialysis station during station disinfection.”

“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 was visible to staff for the patients at 11 (station # 1, # 2, # 4 # 5, # 6, # 7, # 8, # 9, # 15, # 17, and # 21) out of 21 dialysis stations. This had the potential to effect all patients on dialysis and cause an increase in complications if accidental needle dislodgment or bleeding around the dialysis access. The facility census was 86. Findings included: 1. Observations on 8/11/25 at 11:39 AM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 1, # 2, and # 5. Further observations on 8/11/25 at 1:06 PM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 1, # 2, and # 8. 2. Observations on 8/12/25 at 8:05 AM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 2, # 6, # 7, # 9, and # 21. 3. Observations on 8/12/25 at 9:31 AM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 3, # 17, and # 21. 4. Observations on 8/12/25 at 11:55 AM showed the patients had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 2, # 4, # 6, # 7, # 8, # 15, and # 21. 5. During an interview on 8/12/25 at 12:55 PM, the facility administrator agreed that staff need to ensure the patients keep their dialysis access visible to staff or document if the patient refuses to keep the dialysis access visible.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete the care plan within 30 days of a patient starting on dialysis treatment for two (Patient # 8 and # 44) patients out of nine clinical records reviewed, This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 86. Findings included: 1. Review on 8/12/25 at 8:50 AM of the clinical record for Patient # 8 showed the patient started dialysis treatment on 6/24/25 but staff did not fully complete the care plan since it had not been reviewed by the patient’s physician or reviewed with the patient yet. 2. Review on 8/12/25 at 9:08 AM of the clinical record for Patient # 44 showed the patient started dialysis treatment on 6/27/25 but staff did not fully complete the care plan since it had not been reviewed by the patient’s physician or reviewed with the patient yet. 3. During an interview on 8/12/25 at 9:20 AM, the facility administrator said staff need to ensure the care plans are completed within 30 days of a patient starting dialysis treatment. She said the physician still needed to review the care plan for these two patients and then staff needed to review the care plan with the patients.”