Davita Rtc-Columbia Dialysis

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 36473 Based on interview, record review and policy review the facility failed to: - Protect one (#1) of one patient on the dialysis treatment unit from physical abuse that resulted with the potential for physical harm. (refer to V452). - Provide an assessment of harm for one (#1) of one patient post incident during dialysis treatment (refer to V452). - Complete a thorough investigation for physical abuse for one (#1) of one patient (refer to V452). - Protect all patients on the dialysis treatment unit from the potential for further assaults by allowing the alleged perpetrator (Staff A, Patient Care Technician [PCT]) to remain on the treatment unit and continue to work for four days after the incident without a complete investigation (refer to V452). These deficient practices resulted in the facility’s non-compliance with specific requirements found under the Condition of Participation: Patient Rights. The facility census was 58 in-center patients. The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 07/23/25, after the surveyor informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients. As of 07/23/25, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 36473 Based on interview, record review and policy review the facility failed to: - Protect one (#1) of one patient on the dialysis treatment unit from physical abuse that resulted with the potential for physical harm. - Provide a physical assessment of harm for one (#1) of one patient post incident during dialysis treatment. - Complete a thorough investigation for physical abuse for one (#1) of one patient. - Protect all patients on the dialysis treatment unit from the potential for further assaults by allowing the alleged perpetrator (AP, Staff A, Patient Care Technician [PCT]) to remain on the treatment unit and continue to work for four days after the incident without a complete investigation. These failures placed all patients that receive treatment at the facility at risk for emotional distress and physical harm. The facility census was 58 in-center patients. Findings included: 1.During a telephone interview on 07/21/25 at 8:00 AM, Staff B, Case Manager with Facility B, stated Patient #1 was her patient and reported to them they were assaulted by Staff A, PCT. Patient #1 told Staff B on 06/07/25 during a dialysis treatment, Patient #1 asked for a cup of ice and Staff A slammed a rolling cart into her abdomen. 2.During an interview on 07/22/25 at 8:40 AM, Patient #1, stated: - Staff A, PCT was her technician on 06/07/25 and when they asked for ice Staff A became irritated. - Staff A, PCT started the patient’s dialysis treatment. - Staff A, PCT brought Patient #1 a cup of ice and placed it on the patient’s side table. - They pulled herself forward and Staff A, PCT slammed Patient #1’s computer bag on the side table into their abdomen. - They felt threatened and felt it was intentional. - Staff A, PCT walked away and didn’t come back to check on them. - Their abdomen was sore and they had reported it to Staff C, Charge Nurse. - Staff C, Charge Nurse did not assess their abdomen after the incident. - They spoke with Staff D, former Facility Administrator about the incident. - Staff D and Staff A apologized three days after the incident. 3.During a telephone interview on 07/21/25 at 2:50 PM, Staff D, former Facility Administrator, stated Staff C, Charge Nurse emailed them a message regarding the incident and three days later Staff D met with the patient. Patient #1 identified Staff A, PCT as the alleged perpetrator. Staff D then met with Staff A, PCT and expected Staff A to apologize to Patient #1. Staff D stated they never sent an official complaint to Staff E, Regional Office Director, but spoke to Staff E at their weekly meeting about the incident. 4.During a telephone interview on 07/21/25 at 3:35 PM, Staff E, former Regional Office Director, stated they were not made aware of the complaint but were aware of Staff A’s unprofessional behavior and nothing physical. 5.During an interview on 07/21/25 at 2:30 PM, Staff C, Charge Nurse, stated Patient #1 stated they were scared of Staff A, PCT. Staff C passed this on to Staff D, former Facility Administrator and approximately 4-5 days later Staff D spoke with Staff A. Staff C stated Staff A had lashed out at several staff members and one patient. At the time of the incident, Staff C was preoccupied treating another patient for a cardiac code so visually they did not witness the incident and did not realize the need for an assessment. 6.During an interview on 07/22/25 at 9:20 AM, Staff H, PCT, stated they didn’t witness the incident on 06/07/25 between Staff A and Patient #1 but had witnessed Staff A on another day kick a trash can across the unit. 7.During an interview on 07/22/25 at 9:30 AM, Staff I, PCT, stated Staff A, PCT, raised their voice and screamed at staff in front of the patients. Staff A had a bad attitude toward patients and Staff I witnessed Staff A lash out at a family member. Staff I reported it to Staff D, former Facility Administrator. 8.During an interview on 07/22/25 at 9:10 AM, Staff G, Master of Social Work (MSW), stated Staff A was reckless. Staff G had overheard Staff A storm off and roll eyes at the charge nurse in front of the patients and reported it to Staff D, former Facility Administrator. They felt that Staff D and Staff A were friends outside of work, so Staff A’s behavior was tolerated. 9.During an interview on 07/22/25 at 8:00 AM, Patient #2, stated they remembered the day of the incident between Patient #1 and Staff A but couldn’t recall the details due to they were sleeping. Patient #2 did recall them yelling. 10.During an interview on 07/22/25 at 8:25 AM, Patient #3, stated they didn’t witness details, due to they were sleeping, but woke up to Patient #1 and Staff A yelling at each other. 11.Review of the following staffing sheets showed Staff A continued to work after the incident on 06/07/25 without a thorough investigation: - 06/07/25 showed Staff A worked from 4:45 AM - 11:30 AM. - 06/09/25 showed Staff A worked from 5:00 AM - 5:00 PM. - 06/10/25 showed Staff A worked from 4:45 AM - 11:30 AM. - 06/13/25 showed Staff A worked from 5:00 AM - 5:00 PM. - 06/14/25 showed Staff A worked from 5:00 AM - 1:00 PM. 12.Review of Staff A, PCT’s personnel file showed no training or education since 03/03/25 and their last day of employment was 06/14/25. Staff A started at the facility on 12/09/24 through 06/14/25 with no negative written documentation. 13.Review of Patient #1’s medical record showed a History and Physical (H&P) dated 10/25/24 from Facility C. The patient was a 51 year old female with a history of acid reflux, anxiety, osteoarthritis, depression, Type 1 diabetes mellitus, hypertension, sleep apnea, anemia, asthma, irregular heart rate and chronic bronchitis. Patient #1’s surgical history included a cardiac ablation, hysterectomy, C-section and incision and drainage of a shingles ulcer. 14.Although requested the facility failed to provide the last six months of complaint/grievance logs. 15.Although requested the facility failed to provide the last six months of adverse events logs. 16.Although requested the facility failed to provide any investigation or documentation of the incident that occurred between Patient #1 and Staff A, PCT on 06/07/25. 17.Review of the facility’s policy titled, “Addressing Patient Grievances: Davita Teammates,” last reviewed on 10/2024, showed the direction for staff to document all complaints/grievances on the facility’s Patient Grievance Log and all details of patient grievances and discussions should be documented. The Investigation Document should be maintained in a separate file and kept in a secure locked location. The Davita teammate that received the grievance, should report the grievance to the Charge Nurse, Facility Administrator (FA), or the Social Worker. 18.Review of the facility’s policy titled, “Patient Rights,” last reviewed on 04/2025, showed the patients should receive adequate, safe, sanitary and efficient dialysis treatment and respectful care by competent personnel in a comfortable environment.”

“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 hot water heater room and water room floor drain, failed to maintain a cabinet in the storage room, and failed to maintain the cabinet area below the dirty sink in the laboratory area. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 61. Findings included: 1. Observation on 3/17/25 at 9:41 AM of the hot water heater room showed approximately four inch by eight inch areas on both sides of the doorway with rust and missing door frame. Further observation of the hot water heater room showed brown spills and debris on the floor. 2. Observation on 3/17/25 at 9:44 AM of the water room showed the approximately one foot diameter floor drain had rust areas around the drain cover. 3. Observation on 3/17/25 at 9:28 AM of the storage room adjacent to the treatment area showed a cabinet with rusted hinges and rusted areas on the shelf. 4. Observation on 3/17/25 at 9:24 AM of the cabinet area below the dirty sink in the laboratory area showed spills and stains. 5. During an interview on 3/17/25 at 9:42 AM, the facility administrator said staff need to maintain the facility.”

“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 observations (station #5, # 7, and # 9 twice) out of 12 dialysis stations. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 61. Findings included: 1. Observation on 3/17/25 at 2:59 PM showed staff (B) adjusted the dialysis machine at station # 7 without gloves on her hands. 2. Observation on 3/17/25 at 3:28 PM showed staff (F) adjusted the dialysis machine at station # 5 without gloves on her hands. 3. Observation on 3/18/25 at 8:21 AM and 8:24 AM showed staff (C) adjusted the dialysis machine at station # 9 without gloves on her hands. 4. During an interview on 3/18/25 at 8:53 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 four (station # 8 twice, # 9, and # 10) 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 61. Findings included: 1. Observation on 3/17/25 at 11:19 AM showed staff (G) disinfected station # 9 but did not disinfect the chase wall (wall that houses the water distribution system) behind the station, the prime waste bucket on the dialysis machine, or the intravenous pole/hooks. 2. Observation on 3/17/25 at 11:28 AM showed staff (G) disinfected station # 10 but did not disinfect the chase wall, prime waste bucket, or intravenous pole/hooks. 3. Observation on 3/17/25 at 10:56 AM showed staff (F) disinfected station # 8 but did not disinfect the chase wall or lower the dialysis chair side trays to disinfect the area between the side trays and the dialysis chair. 4. Observation on 3/17/25 at 3:07 PM showed staff (F) disinfected station # 8, but did not disinfect the chase wall or prime waste bucket, and did not lower the dialysis chair side trays to disinfect the area between the side trays and the dialysis chair. 5. During an interview on 3/18/25 at 8:53 AM, the facility administrator said 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 heparin (medication used to prevent blood clots) when opened, and failed to ensure medications and supplies were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 61. Findings included: 1. Observation on 3/17/25 at 9:56 AM of the medication area showed an approximately half full vial and two full 50 milliliter vials of Lidocaine (medication used to prevent pain) that expired 2/1/25. 2. Observation on 3/17/25 at 9:57 AM of the medication area showed an approximately half full 30 milliliter vial of heparin not initialed or dated when staff opened it. 3. Observation on 3/17/25 at 9:33 AM of the storage area adjacent to the treatment area showed a container of residual test strips that expired 2/19/25. 4. During an interview on 3/17/25 at 9:59 AM, the facility administrator said staff need to ensure the medications and supplies 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 blood flow rate or the dialysate flow rate during dialysis treatment for three patients (Patient # 47, # 50, and # 61) out of six clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 61. Findings included: 1. Review of the treatment flow sheet dated 3/13/25 for Patient # 47 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 the treatment flow sheet dated 3/14/25 for Patient # 50 showed the physician directed staff to set the dialysate flow rate 800 but staff set the dialysate flow rate at 600 during the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 2/18/25 for Patient # 61 showed the physician directed staff to set the dialysate flow rate at 700 but staff set the dialysate flow rate at 600 during the patient’s dialysis treatment. 4. Review of the treatment flow sheet dated 2/15/25 for Patient # 61 showed the physician directed staff to set the blood flow rate at 400, but staff set the blood flow rate at 320 during the patient’s dialysis treatment. 5. During an interview on 3/18/25 at 8:53 AM, the facility administrator said staff should follow the physician orders for the blood flow rate and dialysate flow rate, or document why they didn’t follow the physician order.”

“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 observations and staff interview, the facility staff failed to ensure the dialysis machine showed the name of the patient on the dialysis machine for three (Patient # 7, # 38, and # 43) patients on dialysis treatment. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 61. Findings included: 1. Observation on 3/17/25 at 1:36 PM showed Patient # 7 on dialysis treatment at dialysis station # 8. Further observation showed the dialysis machine displayed the patient’s dialysis prescription but did not show the patient’s name. 2. Observation on 3/17/25 at 1:43 PM showed Patient # 38 on dialysis treatment at dialysis station # 7. Further observation showed the dialysis machine displayed the patient’s dialysis prescription but did not show the patient’s name. 3. Observation on 3/17/25 at 3:07 PM showed Patient # 43 on dialysis treatment at dialysis station # 11. Further observation showed the dialysis machine displayed the patient’s dialysis prescription but did not show the patient’s name. 4. During an interview on 3/17/25 at 1:39 PM, the regional operations director said staff need to ensure the dialysis machines showed the patient name and they were in the process of working with Information Technology (IT) to resolve.”