Davita Dialysis Care of Martin County

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 26622 Based on policy review, observations, and staff interviews, the facility staff failed to prevent cross-contamination by failing to disinfect a dialysis station chair prior to setting up the dialysis machine for a new patient for 1 of 2 cleaning of dialysis station observed (Station #12). Findings Included: Review on 02/14/2025 of current facility policy “Infection Control For Dialysis Facilities”, Policy: 1-05-01, revised 4/2023, revealed “PURPOSE: To minimize the spread of infections or blood borne pathogens in the dialysis facility environment. ... Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to be disinfected include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair...) ...” Observation on 02/12/2025 at 1030 in the patient treatment area revealed Hemodialysis Machine (HDM) #38 located at Station #12 was set up with new dialysis tubing, dialyzer and fluids and ready for patient use. The observation revealed that PCT #2 was disinfecting the dialysis chair in Station #12. The observation revealed that PCT #2 failed to clean the dialysis chair prior to setting up the dialysis machine for the next patient. Interview on 02/12/2025 at 1030 during the observation with PCT #2 revealed the dialysis station chair should have been cleaned/disinfected prior to setting up the hemodialysis machchine for the next patient. Interview revealed the staff failed to follow the facility policy. Interview on 02/12/2025 at 1230 with the Manager of Clinical Services revealed that the dialysis chair should have been cleaned/disinfected prior to setting up the dialysis machine for another patient. Interview revealed the dialysis station that included the chair and the dialysis machine should be cleaned at the same time.”

“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 #3 and #4) sampled in-center hemodialysis records reviewed. Findings include: Review on 02/14/2025 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 #3 revealed a 68-year-old male admitted for In-Center Hemodialysis treatments on 11/10/2020. Review of the Treatment Flowsheet dated 01/29/2025 revealed Patient #3’s treatment was initiated at 0550. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0706 (1 hour and 16 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 02/07/2025 revealed Patient #3’s treatment was initiated at 0551. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0653 (1 hour and 2 minutes after initiation of treatment). Interview on 02/14/2025 at 1030 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 74-year-old female admitted for In-Center Hemodialysis treatments on 01//23/2024. Review of the Treatment Flowsheet dated 01/28/2025 revealed Patient #4’s treatment was initiated at 0852. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1049 (1 hour and 57 minutes after initiation of treatment). Interview on 02/14/2025 at 1030 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.”

“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: 26622 Based on policy review, medical record review, and staff interview the facility staff failed to follow the adequacy plan of care by failing to dialyze 4 of 5 (Patient #1, #3, #4 and #5) in-center hemodialysis patients at the prescribed BFR/DFR and/or treatment duration. Findings included: Review on 02/14/2025 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed “INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 9. ... b. At a minimum, obtain and document the following: ... iii. Blood and dialysate flows, arterial and venous pressures ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” 1. Review of the medical record for Patient #1 revealed a 73-year-old female admitted for In-Center Hemodialysis treatments on 01/06/2025. Review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 01/29/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0814 and ended at 1235 (231 of 240 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 325, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/05/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0926 and ended at 1327 (226 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 287 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/07/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0915 and ended at 1325 (241 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 375 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #1’s blood flow rate was decreased in 3 of 6 treatments with no notification of the registered nurse. Interview on 02/14/2025 at 1030 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 2. Review of the medical record for Patient #3 revealed a 68-year-old male admitted for In-Center Hemodialysis treatments on 11/10/2020. Review of the Physician orders revealed Patient #3’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 01/31/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0550 and ended at 0934 (193 of 225 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 406 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Flowsheet revealed Patient #3’s hemodialysis treatment was shortened by 32 minutes, with no documentation for the shortened treatment or leaving against medical advice form. Review of the Treatment Flowsheet dated 02/07/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0559 and ended at 0916 (196 of 225 minutes). Review of the Flowsheet revealed Patient #3’s hemodialysis treatment was shortened by 29 minutes, with no documentation for the shortened treatment or leaving against medical advice form. Review of the treatment sheets revealed that Patient #3’s blood flow rate and/or treatment duration was decreased in 2 of 6 treatments with no notification of the registered nurse. Interview on 02/14/2025 at 1030 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments. Interview revealed the facility staff were expected to run patients for the prescribed treatment duration and to have the patient sign an against medical advice form if treatment was shortened. The interview confirmed the medical record findings that patient #3 had a decreased BFR/treatment duration in 2 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 3. Review of the medical record for Patient #4 revealed a 74-year-old female admitted for In-Center Hemodialysis treatments on 01/23/2024. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 01/30/2025 revealed Patient #4’s hemodialysis treatment was initiated at 1014 and ended at 1419 (240 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 308 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/04/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0809 and ended at 1304 (283 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 368 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #4’s blood flow rate was decreased in 2 of 6 treatments with no notification of the registered nurse. Interview on 02/14/2025 at 1030 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments. The interview confirmed the medical record findings that patient #4 had a decreased BFR in 2 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 4. Review of the medical record for Patient #5 revealed a 42-year-old male admitted for In-Center Hemodialysis treatments on 02/11/2009. Review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 02/08/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0757 and ended at 1242 (264 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 417, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #5’s blood flow rate was decreased in 1 of 6 treatment with no notification of the registered nurse. Interview on 02/14/2025 at 1030 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments. The interview confirmed the medical record findings that patient #5 had a decreased BFR in 1 of 6 treatment with no documentation for the decreased BFR and Registered Nurse notification.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 26622 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis after touching the access sites per policy before cannulation of 2 of 2 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #17, PCT #3 and Station #9, PCT #2). Findings included: Review on 02/11/2025 of the facility policy titled “AV (Arterio-venous) Fistula or Graft Cannulation ...” revised October 2022 revealed “ ... Skin Antiseptic ... Procedure ... 8. Locate and palpate the needle cannulation sites prior to skin preparation. ... 13. Do not palpate insertion site once area has been prepped.” 1. Observation on 02/12/2025 at 1005 in the patient treatment area revealed PCT #3 entered Station #17 and initiated access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #3 performed hand hygiene and applied clean gloves. PCT #3 cleansed the arterial and venous access sites with Povidone Iodine pads for 30 seconds. PCT #3 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #3 touched the arterial and venous access sites with a gloved finger after initial disinfection and failed to re-disinfect each access site prior to cannulation with a needle. Interview on 02/12/2025 at 1015 with PCT #3 revealed that each site should be disinfected for 30 seconds and should not be touched after disinfection. PCT #3 revealed that if the access sites were touched after disinfection, that the sites should be disinfected again prior to needle cannulation. Interview revealed PCT #3 failed to re-disinfect the access sites per facility policy. Interview on 02/12/2025 at 1230 with the Manager of Clinical Services revealed the staff were expected to re-disinfect each access site after contamination and prior to cannulation. Interview revealed the staff failed to follow the facility policy. 2. Observation on 02/12/2025 at 1120 in the patient treatment area revealed PCT #2 entered Station #9 and initiated access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #2 performed hand hygiene and applied clean gloves. PCT #2 cleansed the arterial and venous access sites with Povidone Iodine pads for 30 seconds. PCT #2 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #2 touched the arterial and venous access sites with a gloved finger after initial disinfection and failed to re-disinfect each access site prior to cannulation with a needle. Interview on 02/12/2025 at 1130 with PCT #2 revealed that each site should be disinfected for 30 seconds and should not be touched after disinfection. PCT #2 indicated that if the access sites were touched after disinfection, that the sites should be disinfected again prior to needle cannulation. Interview revealed PCT #2 failed to re-disinfect the access sites per facility policy. Interview on 02/12/2025 at 1230 with the Manager of Clinical Services revealed the staff were expected to re-disinfect each access site after contamination and prior to cannulation. Interview revealed the staff failed to follow the facility policy.”