Davita Sedc Burgaw Dialysis Center

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 26622 Based on facility policy review, observations, and staff interviews, the facility staff failed to prevent potential cross contamination by failing to place a clean field under the CVC (Central Venous Catheter) limbs and disinfect the CVC hubs per facility policy in one of two observation during a hemodialysis treatment discontinuation using a CVC (PCT #4, Station #8). Findings include: Review on 07/09/2025 of the facility policy titled “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” revised April 2025 revealed “... 16. Verify both catheter clamps are closed. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried. Upon Completion of Dialysis ... 28. Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination. ...” Observation on 07/09/2025 at 1145 in the patient treatment area revealed PCT #4 entered Station #8 and initiated termination of a Central Venous Catheter (CVC). Observation revealed PCT #4 performed hand hygiene and applied clean gloves. The PCT disconnected the extracorporeal lines from the CVC without placing a new clean moisture barrier pad under the CVC limbs. Observation revealed PCT #4 cleansed the arterial catheter hub and the venous catheter hubs for 5 seconds each. The observation revealed that PCT #4 failed to cleanse each catheter hub for 15 seconds per facility policy. Observation revealed the facility policy was not followed. Interview on 07/09/2025 at 1200 with PCT #4 revealed the PCT did not place a clean field under the catheter limbs prior to removing the dialysis lines. The PCT stated “was not aware that a clean field had to be placed.” The PCT stated that the hubs were disinfected for 15 seconds. Interview revealed that PCT #4 did not watch the clock above the station while disinfecting the catheter hubs. Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed that the staff should place a clean moisture barrier pad underneath the catheter limbs to prevent contamination and anytime a barrier pad became soiled. Interview revealed that the staff were expected to scrub each catheter hub with an alcohol pad for fifteen (15) seconds per facility policy. Interview revealed the staff failed to follow the facility policy.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 26622 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to ensure machine prescription verifications were performed by a nurse within one hour of initiation of hemodialysis treatment in 2 of 5 (Patients #2 and #4, ) sampled in-center hemodialysis records reviewed and failed to monitor a patient at a minimum of every 30 minutes during hemodialysis treatments for 4 of 5 sampled in-center hemodialysis records reviewed (Pt. #1, #2, #3 and #5) Findings include: Review on 07/09/2025 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed “Policy .... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation ...” 1. Review of the medical record for Patient #2 revealed a 70-year-old male admitted for In-Center Hemodialysis treatments on 05/06/2025. Review of the Treatment Flowsheet dated 06/24/2025 revealed Patient #2’s treatment was initiated at 1119. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1302 (1 hour and 43 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 06/26/2025 revealed Patient #2’s treatment was initiated at 1046. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1322 (2 hours and 36 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 07/05/2025 revealed Patient #2’s treatment was initiated at 1119. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1234 (75 minutes after initiation of treatment). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 2. Review of the medical record for Patient #4 revealed a 56-year-old male admitted for In-Center Hemodialysis treatments on 01/14/2025. Review of the Treatment Flowsheet dated 06/26/2025 revealed Patient #4’s treatment was initiated at 0606. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0716 (70 minutes after initiation of treatment). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. Review on 07/09/2025 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed “INTRADIALYTIC DATA COLLECTION/ASSESSMENT ...9. Intradialytic treatment monitoring and data collection ...includes: a. Vital signs and treatment monitoring iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. ...b. At a minimum, obtain and document the following: i. Blood pressure. ii. Heart or pulse rate. iii. Blood and dialysate flows, arterial and venous pressures. iv. Fluid removal and/or replacement. v. Vascular access visible and line connections intact. vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints.” 1. Review of the medical record for Patient #1 revealed a 61-year-old female admitted for In-Center Hemodialysis treatments on 01/24/2025. Review of the Treatment Flowsheet for 07/03/2025 revealed the staff documented monitoring at 1400 and the next monitoring documentation was at 1500 (60 minutes later). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the staff were expected to monitor the patients every 30 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites and checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to document the patient monitoring per policy. 2. Review of the medical record for Patient #2 revealed a 70-year-old male admitted for In-Center Hemodialysis treatments on 05/06/2025. Review of the Treatment Flowsheet for 06/24/2025 revealed the staff documented monitoring at 1119 and the next monitoring documentation was at 1201 (42 minutes later). Review revealed the staff documented monitoring at 1431 and the next monitoring documentation was at 1511 (40 minutes later). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the staff were expected to monitor the patients every 30 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites and checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to document the patient monitoring per policy. 3. Review of the medical record for Patient #3 revealed a 76-year-old male admitted for In-Center Hemodialysis treatments on 08/15/2024. Review of the Treatment Flowsheet for 07/01/2025 revealed the staff documented monitoring at 1105 and the next monitoring documentation was at 1204 (59 minutes later). Review revealed the staff documented monitoring at 1042 and the next monitoring documentation was at 1155 (73 minutes later). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the staff were expected to monitor the patients every 30 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites and checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to document the patient monitoring per policy. 4. Review of the medical record for Patient #5 revealed a 36-year-old female admitted for In-Center Hemodialysis treatments on 07/01/2025. Review of the Treatment Flowsheet for 07/03/2025 revealed the staff documented monitoring at 1442 and the next monitoring documentation was at 1526 (44 minutes later). Review revealed the staff documented monitoring at 1518 and the next monitoring documentation was at 1607 (51 minutes later). Interview on 07/09/2025 at 1615 with the Manager of Clinical Services revealed the staff were expected to monitor the patients every 30 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites and checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to document the patient monitoring per policy.”