Davita Reidsville 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: 38766 Based on facility policy and procedure reviews, observations, and staff interviews, the facility staff failed to prevent cross-contamination by not performing hand hygiene after removing dirty gloves and before obtaining medication from the medication cabinet for 1 of 2 observations (Sta. 31, PCT #2). Findings included: Review on 08/22/2023 of the facility’s policy titled, “Infection Control for Dialysis Facilities” revised 04/2023 revealed, “...Hand Hygiene 1. All teammates, physicians, and Non-Physician (NPPs) will perform hand hygiene ...g. before touching clean areas such as supplies, supply cart, and chairside... Observation on 02/05/2025 at 1120 on the treatment floor revealed PCT #2 walked into Station 31, donned clean gloves, and cannulated the patient’s AVF/G. The observation revealed after cannulating the patient, PCT #2 walked to the medication preparation area at the nurses’ station without removing the dirty gloves or performing hand hygiene. The observation revealed the RN handed PCT #2 four syringes of Heparin (an anticoagulant medication). The observation revealed that PCT #2 walked back to Station 31, placed two of the four syringes on the chairside table, and handed the other two syringes to the PCT in the next Station (Station 30). The observation revealed PCT #2 failed to remove gloves and perform hand hygiene between dirty and clean tasks per facility policy. An interview on 02/05/2025 at 1125 with PCT #4 revealed PCT #2 should have removed her gloves and performed hand hygiene before leaving the dialysis station. The interview revealed, “this was not normal practice. I was just a bit stressed”. The interview revealed that PCT #2 should have only picked up heparin for one patient at a time. The interview revealed PCT #2 failed to follow the facility policy.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to maintain oxygen (O2) cylinders per facility policy for nine (9) of 30 O2 cylinders observed. Findings included: A review on 02/04/2025 of the “Material Safety Data Sheet” issued 07/1994 revealed “...Special Storage Recommendations ...Cylinders should be stored upright and firmly secured to prevent falling or being knocked over...” An observation on 02/04/2025 between 1225 and 1345 during a tour of the treatment floor revealed that 30 oxygen cylinders were stored in an area near the nursing station. Nine of the 30 cylinders were sitting on the floor unsecured, and they were not kept secured from falling. An interview on 02/04/2025 at 1415 with the covering FA revealed that the staff needed to call the company that provided the oxygen cylinders to come and pick some cylinders up. An interview on 02/05/2025 at 1400 with the CSM revealed “they are not supposed to be left unsecured on the floor. The interview revealed, “we (the clinic) will make sure we have all cylinders secured in an oxygen cart.” The interview confirmed the findings.”

“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: 38766 Based on observations and staff interviews, the facility staff failed to promote patient safety by not ensuring patients’ access sites were visible during treatment for 1 of 7 in-center patients observed (Patients #12). Findings included: A 02/04/2025 of the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” revised in 04/2024 revealed, “...Intradialytic Data Collection/Assessment... b. At a minimum, obtain and document the following: v. Vascular access visible and line connection intact... c. The vascular access site, bloodline connections, and the patient’s face should be visible throughout the dialysis treatment...” An observation on 02/04/2025 between 1225 and 1345 revealed a patient was in Station 30, HDM 3, and had the access site covered with a blanket. Observation revealed that at 1335, RN #1 entered the station for medication administration and left the station without visualizing the access site and the connections. Between 1225 and 1327, the observation revealed RN #1 and the two PCTs on staff were in the bay checking on the patients and attending to machine alarms. The observation revealed the access site remained covered until 1337 after being prompted by the surveyor. The observation revealed that the patient had a right central venous catheter. The observation revealed the access site remained covered for 62 minutes during treatment. An interview on 02/04/2025 at 1337 with RN #1 revealed that the patient’s access site should remain visible for safety reasons. The interview revealed that the staff, including the nurse, should pull down the patient’s blanket so the access could be visible at all times. The interview confirmed that the policy was not followed.”

“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: 38766 Based on facility policy and procedure review, medical record reviews, and staff interviews, the facility staff failed to complete a post-treatment assessment for 2 of 4 patients’ discharge observations (Pt. #4 and #11). Findings included: A review on 02/04/2025 of the facility’s policy and procedure, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” revised in 04/2024 revealed, “...Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and reviewing the patient’s response to the treatment and status prior to discharge. 1. An observation on 02/04/2025 between 1225 and 1345 revealed Patient #11 was being dialyzed in Station 2, HDM 13. The observation noted that at 1314, the patient completed his treatment and was decannulated by the PCT staff. After the decannulation, the PCT walked the patient to the scale and obtained the patient’s post-treatment weight. The observation failed to reveal a post-treatment assessment completed by the RN on staff. A medical record review on 02/05/2025 of Patient #11 revealed the patient was admitted to the facility on 10/08/2024 for in-center hemodialysis treatment. A review of a Treatment Flowsheet dated 02/04/2025 revealed RN #1 documented a post-treatment nursing assessment at 1355 with the comment of “Orientation To: place; time... Cardiovascular & Fluid: regular rate & rhythm...” An interview on 02/04/2025 at 1327 with RN #1 revealed that patients should be assessed by the nurse at the end of their treatments before leaving the treatment floor. The interview revealed that RN #1 was busy and did not get to assess the patient. The interview revealed RN #1 admitted to noticing the patient leaving the treatment floor and had said goodbye to the patient. The interview confirmed that the policy was not followed. 2. An observation on 02/04/2025 between 1225 and 1345 revealed Patient #4 was being dialyzed in Station 8, HDM 22. The observation noted that at 1320, the patient completed his treatment and was decannulated by the PCT staff. After the decannulation, the PCT wheeled the patient to the scale and obtained the patient’s post-treatment weight. The observation failed to reveal a post-treatment assessment completed by the RN on staff. A medical record review on 02/05/2025 of Patient #4 revealed the patient was admitted to the facility on 02/22/2019 for in-center hemodialysis treatment. A review of a Treatment Flowsheet dated 02/04/2025 revealed RN #1 documented a post-treatment nursing assessment at 1354 with the comment, “Orientation To: person; place; time... Cardiovascular & Fluid: regular rate & rhythm...” An interview on 02/04/2025 at 1327 with RN #1 revealed that patients should be assessed by the nurse at the end of their treatments before leaving the treatment floor. The interview revealed that RN #1 was busy and did not get to assess the patient. The interview revealed RN #1 admitted to noticing the patient leaving the treatment floor and had said goodbye to the patient. The interview confirmed that the policy was not followed.”

“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: 38766 Based on policy and procedure reviews, emergency drill reviews, and staff interviews, the facility administration failed to follow the policy in ensuring fire drills were conducted quarterly per facility policy. Findings included: A review of the “Facility Emergency Management Plan (ICHD, Home)” revised 10/ 2024 revealed “...Fire Safety Preparedness 1. FA, or designee, is responsible to: ...b. Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional trading and education needs...” A review of emergency fire drills on 02/06/2025 revealed that the fire drill was documented on 01/12/2024, and another drill was done on 02/06/2025 during the survey. The review revealed no fire drill was conducted in almost 13 months. An interview on 02/06/2025 at 1545 with the Manager of Clinical Services (MCS) revealed that they could not locate other documentation regarding fire drills. The interview revealed the MCS had conducted a fire drill this morning (02/06/2025). The interview confirmed that a fire drill should be done every quarterly, and that the policy was not followed.”