Davita Swope 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: 36473 Based on observation, interview and policy review, the facility failed to ensure staff provided and maintained a clean environment free from potential contaminants when the staff failed to maintain: - The four sharps container roller carts of four observed located on the treatment floor, free of rust (a reddish or yellowish-brown flaky coating formed on iron or steel that had the potential to harbor dangerous bacteria). - The floors around and behind the patient stations free of dirt. - Two wall boxes of 19 observed free of discoloration and dirt. - One patient chair of 19 observed free of approximately a one foot rip with exposed foam (a porous material that had the potential to attract bacteria). - The treatment floor free of one capped needle. - The patient restroom (located off the treatment floor) free of dirt around the base of toilet. - The chlorine testing cart in the water room free of dirt. - The eye wash emergency station and sink in the water room free of rust and dirt. These failed practices had the potential for increased risk of cross-contamination and transmission of pathogens to all patients and staff. The in-center hemodialysis (the process of purifying the blood of persons whose kidneys were not working) patient census was 103. Findings included: TREATMENT FLOOR 1.Observations on 5/12/25 between 3:00 PM - 5:00 PM and on 5/13/25 between 8:30 AM - 1:00 PM showed four sharps container roller carts rusted at Station #6, Station #9, Station #12 and Station #15. 2.Observation on 5/12/25 between 3:00 PM - 5:00 PM, showed the patient treatment floors around and behind the patient hemodialysis machines were unclean. 3. Observation on 5/12/25 at 4:15 PM, showed at Station #15 and Station #19 discolored wall boxes. 4. Observation on 5/12/25 at 4:20 PM, showed at Station #14 one patient chair ripped in the center of the seat exposing foam material and approximately one foot long in length. 5. Observation on 5/12/25 at 4:00 PM, in front of Station #14 on the floor, one capped needle. 6. Observation on 5/12/25 at 4:30 PM, off the patient treatment floor, an unclean floor around the toilet in the patient’s restroom. 7. During an interview on 5/13/25 at 11:00 AM, Staff A, Facility Administrator, stated the facility’s cleaning company failed to clean on the weekends. 8. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” last reviewed on 4/2023, showed the direction for staff to minimize the spread of infections or bloodborne pathogens in the facility environment. WATER ROOM 9. Observation on 5/12/25 at 3:20 PM, in the water treatment room, showed: - The chlorine testing cart unclean. - One sink next to the emergency eyewash station with two large rusted screws and two rusted spacers. - The holder for the emergency eyewash station was unclean and rusted. 10. During an interview on 5/13/25 at 11:00 AM, Staff A, Facility Administrator, stated the biomed technician cleans the water room and the facility staff should have kept the chlorine testing cart clean.”

“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: 36473 Based on observation, interview and policy review, the facility failed to ensure that staff used proper aseptic (method that targets practices and procedures to reduce contamination) technique when performing Central Venous Catheter (CVC, a line placed in a large vein for hemodialysis [the process of purifying the blood of persons whose kidneys were not working] dressing changes performed for one patient (#2) of two observed. These failures had the potential for cross-contamination and the spread of infections to patients and staff. The in-center hemodialysis census was 103. Findings included: 1.Observation on 1/13/25 at 11:40 AM, Staff C, Certified Clinical Hemodialysis Technician (CCHT), during a CVC dressing change, showed Staff C failed to adhere to aseptic technique during the CVC site cleaning with a Chloraprep (a swabstick used to disinfect the skin and prevent infections) by touching the patient’s contaminated shirt and necklace. 2.During an interview with Staff A, Facility Administrator, stated staff should follow the facility’s policy and adhere to aseptic technique. 3. Review of the facility’s policy titled, “Central Venous Catheter with Clearguard Antimicrobial End Caps Procedure,” last reviewed on 4/2025, showed the direction for staff to perform a CVC dressing change using the aseptic technique.”

“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 # 12, # 17, and # 19) observations and failed to wait until the patient left the dialysis station to start station disinfection during one (station # 18) observation. This had the potential to effect all patients on dialysis and cause an increase in cross contamination risk. The facility had 19 dialysis stations and the census was 100. Findings included: 1. Observation on 1/14/25 at 10:27 AM showed Patient Care Technician (PCT) (R) disinfected the dialysis machine at station # 18 while the patient remained in the dialysis chair. Staff did not wait until the patient left the station to start station disinfection. 2. Observation on 1/13/25 at 12:24 PM showed PCT (D) disinfected station # 17 but did not disinfect the chase wall (wall that houses the water distribution system) behind the station. 3. Observation on 1/13/25 at 1:06 PM showed PCT (A) disinfected station # 19 but did not disinfect the chase wall behind the station. 4. Observation on 1/13/25 at 1:18 PM showed PCT (C) disinfected station # 12 but did not disinfect the intravenous fluid hooks or the chase wall behind the station. 5. During an interview on 1/14/25 at 10:55 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.”

“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 the blood flow rate during dialysis treatment for three (Patient # 14, # 74, and # 76) out of 10 clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 100. Findings included: 1. Review of the treatment flow sheet dated 1/3/25 for Patient # 14 showed the physician directed staff to set the blood flow rate at 400 during the patient’s dialysis treatment. Further review of the treatment flow sheet showed staff set the blood flow rate at 300 during the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 1/9/25 for Patient # 74 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 during the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 1/11/25 for Patient # 76 showed the physician directed staff to set the blood flow rate at 300 during the patient’s dialysis treatment. Further review of the treatment flow sheet showed staff set the blood flow rate at 350 during the patient’s dialysis treatment. 4. During an interview on 1/14/25 at 10:55 AM, the facility administrator said staff should follow the physician order for the blood flow rate, or document the reason for not following the order and document physician notification.”

“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 document a reason for stopping dialysis treatment early for two patients (Patient # 88 and # 91) out of 10 clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 100. Findings included: 1. Review of the treatment flow sheet 1/10/25 for Patient # 91 showed the physician directed staff to provide the patient with four hours of dialysis treatment. Further review of the treatment flow sheet sheet showed staff stopped dialysis treatment 40 minutes early without documenting a reason why. 2. Review of the treatment flow sheet dated 1/8/25 for Patient # 91 showed the physician directed staff to provide the patient with four hours of dialysis treatment. Further review of the treatment flow sheet sheet showed staff stopped dialysis treatment 30 minutes early without documenting a reason why. 3. Review of the treatment flow sheet dated 1/3/25 for Patient # 88 showed the physician directed staff to provide the patient with three hours of dialysis treatment. Further review of the treatment flow sheet sheet showed staff stopped dialysis treatment 19 minutes early without documenting a reason why. 4. During an interview on 1/14/25 at 10:55 AM, the facility administrator said staff should document a reason for stopping dialysis treatment early or have the patient sign an against medical advice form.”