Davita Hazelwood Dialysis

“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 # 6, # 14, and # 20) out of four station disinfection observations. Additionally, staff failed to clean dried blood off the armrest of one (station # 1) dialysis chair, and failed to wait until the patient left the dialysis station to start station disinfection for one (Patient # 75) patient. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 76. Findings included: 1. Observation on 7/7/25 at 12:18 PM showed the dialysis chair at station # 1 had an approximately one inch by six inch area of dried blood on the armrest. 2. Observation on 7/7/25 at 1:56 PM showed staff (G) disinfected station # 14 but did not disinfect the chase wall (wall that houses the water distribution system) behind the station, or the intravenous pole or hooks. 3. Observation on 7/7/25 at 2:26 PM showed staff (A) disinfected station # 20 but did not disinfect the chase wall behind the station. 4. Observation on 7/7/25 at 2:44 PM showed staff (A) disinfected station # 6 but did not disinfect the chase wall behind the station. 5. During an interview on 7/8/25 at 8:28 AM, Patient # 75 said staff sometimes start disinfecting the dialysis machine while she is still in the dialysis chair and it splashes bleach on her personal belongings at times. 6. During an interview on 7/8/25 at 10:16 AM, the facility administrator said staff should wait until the patient leaves the dialysis station to start station disinfection and staff should disinfect the entire 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 initial and date when they opened medication vials and failed to ensure hemoccult slides (used to detect blood in stool samples) were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 76. Findings included: 1. Observation on 7/7/25 at 11:27 AM of the medication area showed two opened approximately half full vials of heparin (medication used to prevent blood clots) not initialed or dated when staff opened the vials to know when to discard them. 2. Observation on 7/8/25 at 9:26 AM of the medication area showed an approximately half full vial of doxercalciferol (medication that is a synthetic form of Vitamin D) not initialed or dated when staff opened the vial to know when to discard it. 3. Observation on 7/7/25 at 11:16 AM of the laboratory area showed approximately 100 hemoccult slides that expired 8/31/24. 4. During an interview on 7/8/25 at 10:16 AM, the facility administrator said staff need to ensure the supplies were not expired and staff need to initial and date medication vials when opened.”

“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 (Patient # 24 and # 46) 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 76. Findings included: 1. Review of the treatment flow sheet dated 7/7/25 for Patient # 24 showed the physician directed staff to stop the heparin administration 60 minutes before the end of dialysis treatment, but staff continued the heparin administration until the end of dialysis treatment for the patient. 2. Review of the treatment flow sheet dated 7/1/25 for Patient # 46 showed the physician directed staff to stop the heparin administration 90 minutes before the end of dialysis treatment, but staff did not stop the heparin until 28 minutes before the end of dialysis treatment for the patient. 3. During an interview on 7/8/25 at 2:25 PM, the facility administrator said staff should follow the physician orders for heparin administration.”

“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 dialysate flow rate for two (Patient # 51 and # 58) 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 76. Findings included: 1. Review of the treatment flow sheet dated 7/3/25 for Patient # 51 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. 2. Review of the treatment flow sheet dated 7/3/25 for Patient # 51 showed the physician directed staff to set the dialysate flow rate at 700 but staff set the dialysate flow rate at 500 during the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 7/1/25 for Patient # 58 showed the physician directed staff to set the dialysate flow rate at 500 but staff set the dialysate flow rate at 600 during the patient’s dialysis treatment. 4. During an interview on 7/8/25 at 2:25 PM, the facility administrator said staff should follow the physician orders for the blood flow rate and dialysate flow rate.”