Davita Eastland Dialysis

“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 # 16 twice, # 18, and # 20) 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 85. Findings included: 1. Observation on 7/8/24 at 2:19 PM showed staff (M) adjusted dialysis machine at station # 16 without gloves on her hands. 2. Observation on 7/8/24 at 2:21 PM showed staff (M) adjusted dialysis machine at station # 16 without gloves on her hands again. 3. Observation on 7/8/24 at 2:30 PM showed staff (M) adjusted the dialysis machine at station # 20 without gloves on her hands. 4. Observation on 7/8/24 at 2:38 PM showed staff (B) adjusted the dialysis machine at station # 18 without gloves on her hands. 5. During an interview on 7/9/24 at 1:47 PM, the facility administrator said staff should wear gloves when they adjust the dialysis machines.”

“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 six vials of Vancomycin (antibiotic medication) were not expired and failed to ensure one vial of Lidocaine (medication used to reduce pain) was initialed and dated when staff opened the vial. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 85. Findings included: 1. Observation on 7/8/24 at 11:50 AM of the medication area showed six 500 milligram vials of Vancomycin that expired 7/1/24. 2. Observation on 7/8/24 at 11:52 AM of the medication area showed an approximately half full 10 milliliter vial of Lidocaine that staff did not initial or date when they opened it. 3. During an interview on 7/8/24 at 11:59 AM, the facility administrator said staff should initial and date all vials when opened and staff need to ensure medications were not expired.”

“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 patients’ dialysis access remained visible to staff during the patient’s dialysis treatment at eight (station # 5, # 6, # 7, # 8, # 9, # 11, # 16, and # 18) out of 20 dialysis stations. This had the potential to effect all patients on dialysis and cause an increase in complications in the event of a needle dislodgment or tubing disconnection. The facility census was 85. Findings included: 1. Observation on 7/8/24 at 11:45 AM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 5, # 6, and # 8. 2. Observation on 7/8/24 at 12:32 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 5 and # 18. 3. Observation on 7/8/24 at 1:01 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 6 and # 18. 4. Observation on 7/8/24 at 1:54 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 9 and # 18. 5. Observation on 7/9/24 at 8:31 AM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 7 and # 16. 6. Observation on 7/9/24 at 1:03 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 11 and # 16. 7. During an interview on 7/9/24 at 1:47 PM, the facility administrator said staff need to ensure the dialysis access is visible or document if the patient refuses to keep the dialysis access visible.”

“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 provide dialysis treatment for the physician prescribed time for two (Patient # 6 and # 10) 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 85. Findings included: 1. Review of the treatment flow sheet dated 7/3/24 for Patient # 6 showed the patient’s physician directed staff to provide the patient with three hours of dialysis treatment. The treatment flow sheet showed staff stopped the patient’s dialysis treatment 29 minutes early and did not document the reason for stopping dialysis treatment early. 2. Review of the treatment flow sheet dated 7/3/24 for Patient # 10 showed the patient’s physician directed staff to provide the patient with four hours of dialysis treatment. The treatment flow sheet showed staff stopped the patient’s dialysis treatment 30 minutes early and did not document the reason for stopping dialysis treatment early. 3. During an interview on 7/9/24 at 1:47 PM, the facility administrator said staff should follow the physician order for the dialysis treatment time or document a reason for stopping dialysis treatment early.”

“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 an initial nursing assessment within one hour of a patient starting on dialysis treatment for four (Patient # 18, # 35, # 46, and # 74) patients out of nine clinical records reviewed. This had the potential to effect all patients on dialysis treatment and cause an increase in complications. The facility census was 85. Findings included: 1. Review of the treatment flow sheet dated 7/1/24 for Patient # 74 showed staff started the patient on dialysis treatment at 11:36 AM but did not conduct the initial nursing assessment for the patient until 1:10 PM. 2. Review of the treatment flow sheet dated 7/6/24 for Patient # 46 showed staff started the patient on dialysis treatment at 6:29 AM but did not conduct the initial nursing assessment for the patient until 7:59 AM. 3. Review of the treatment flow sheet dated 7/5/24 for Patient # 35 showed staff started the patient on dialysis treatment at 12:02 PM but did not conduct the initial nursing assessment for the patient until 1:19 PM. 4. Review of the treatment flow sheet dated 7/3/24 for Patient # 18 showed staff started the patient on dialysis treatment at 11:15 AM but did not conduct the initial nursing assessment for the patient until 12:23 PM. 5. During an interview on 7/9/24 at 1:47 PM, the facility administrator said staff should conduct the initial nursing assessment within one hour of a patient starting on dialysis treatment or document a late entry note if they document late.”