Davita Maxton Dialysis

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 26622 Based on observations, policy review and interview the facility failed to ensure that staff wore appropriate footwear to prevent potential blood exposure/needle stick for 1 of 3 staff members observed in the treatment area (PCT #3). The findings include: Review on 09/17/2025 of the facility teammate policies revealed Section 5: Work Environment (not dated) “Teammates who work in a facility, including facility administrators and support teammates, must wear slip-resistant, closed-toe shoes at all times.” Observations during tour of the treatment area on 09/16/2025 revealed that PCT #3 was initiating and discontinuing patients hemodialysis treatments. The observation revealed that PCT #3 was wearing “crocs” type shoes with holes across the top front half of the shoes. Observation revealed that PCT #3 failed to follow the facility teammate policy. Interview on 09/16/2025 at 1530 with the Facility Administrator and the Manager of Clinical Services revealed that the staff teammates should not wear shoes with holes across the top or open-toed shoes while caring for patients on the treatment floor. Interview revealed that PCT failed to follow the facility teammate policy.”

“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: 26622 Based on policy and procedure review, observation and staff interview, the facility staff failed to use aseptic technique when preparing medication syringes for 1 of 2 facility staff observed preparing the medication syringes (RN #1). Findings included: Review on 09/16/2025 of the facility policy titled “Medication Policy” revised October 2023, revealed “... Policy ... 8. All teammates administering medications must utilize aseptic technique. ...” Review on 09/16/2025 of the facility’s procedure “Preparation and Administration of Parenteral Medications...,” revised April 2024, revealed “... Procedure ... 7. If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol prep pad. A new alcohol prep pad is used prior to each time a vial is entered. ...” Observation on 09/16/2025 at 1003 revealed Registered Nurse (RN) #1 prepared the intra-dialysis medication “Venofer (used to treat anemia in chronic dialysis patients) from a single-dose vial at a medication preparation area. The observation revealed RN #1 removed the plastic cap and proceeded to insert the syringe/needle through the rubber stopper without cleaning the rubber stopper with alcohol. The observation revealed RN #1 failed to utilize aseptic technic, prior to inserting the syringe/needle per facility policy. Interview on 09/16/2025 at 1003 with RN #1 revealed the nurse indicated that newly opened single-dose vial did not require cleaning the rubber stopper after removing the plastic cap on the vial. Interview revealed RN #1 should have wiped the rubber stopper on the vial prior to the insertion of the syringe/needle. The interview revealed RN #1 failed to follow the facility’s medication policies. Interview on 09/16/2025 at 1530 with the Facility Administrator and Manager of Clinical Services revealed that the rubber stopper on the medication vial should should have been cleaned with an alcohol pad prior to inserting the syringe/needle. Interview revealed that RN #1 failed to follow the facility policies.”

“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 policy review, observation and interview, the patient care staff failed to prevent cross contamination by failing to disinfect the CVC (Central Venous Catheter) exit site with 2 % Chlorhexidine Gluconate/70 % Isopropyl alcohol for 30 seconds per facility policy for 1 of 2 observed CVC exit sites disinfected with Chlorhexidine (PCT #2, Station #12), 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 #3, Station #5). Findings include: 1. Review on 09/17/2025 of the facility policy/procedure titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” effective April 2025 revealed “... 8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for minimum of 30 seconds...” Observation on 09/16/2025 at 1045 in the patient treatment area revealed PCT #2 entered Station #12 and initiated CVC exit site care for dialysis treatment with a CVC. PCT #2 cleansed the CVC exit site and area around site with 2% Chlorhexidine for less than 30 seconds. Observation revealed that the PCT failed to disinfect the CVC exit site for thirty (30) seconds per facility policy. Interview on 09/16/2025 at 1100 with PCT #2 revealed that the CVC exit site should be disinfected for 30 seconds. The interview confirmed that PCT #2 did not follow the facility policy. Interview on 09/16/2025 at 1530 with the Manager of Clinical Services and the Facility Administrator revealed the staff were expected to disinfect the CVC catheter exit site with Chlorhexidine swabs for 30 seconds and allow the site to dry for 60 seconds prior to applying new dressing per facility policy. Interview revealed the staff failed to follow the facility policy. 2. Review on 09/17/2025 of the facility policy titled “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” revised April 2025 revealed “... 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. ... 34. Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds. Remove any residue, for example blood. Hold the catheter until the antiseptic has dried. ...” Observation on 09/16/2025 at 1005 in the patient treatment area revealed PCT #3 entered Station #5 and initiated termination of a Central Venous Catheter (CVC). Observation revealed PCT #3 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 #3 cleansed the arterial catheter hub and the venous catheter hubs for for less than 15 seconds each. The observation revealed that PCT #3 failed to cleanse each catheter hub for 15 seconds per facility policy. Observation revealed the facility policy was not followed. Interview on 09/16/2025 at 1100 with PCT #3 revealed the PCT did not place a clean field under the catheter limbs prior to removing the dialysis lines. The PCT stated “I forgot to place the clean field.” The PCT stated that the hubs were disinfected for 15 seconds. Interview revealed that PCT #3 did not watch the clock or watch while disinfecting the catheter hubs. Interview on 09/16/2025 at 1530 with the Manager of Clinical Services and Facility Administrator 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.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 26622 Based on review of facility policy/procedure, manufacturer’s instructions for use, observation and interview, the facility staff failed to perform a chlorine test per the facility policy for 1 of 1 chlorine check observed (RN #5). Findings include: Review on 09/17/1025 of the facility policy titled “E-Z CHEK SENSITIVE TOTAL CHLORINE TESTING” revision date June 1016 revealed “... Procedure 1. Fill sample cup with 20 ml (milliliters) of water. Discard sample and refill to 20 ml mark with water to be tested. Rational 1. Rinsing the sample cup with a water sample will remove any residual from previous sample testing. ...” Review on 09/17/2025 of the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips Instructions for Use (not dated) revealed “Test Procedure Semi-Quantitative Procedure for Feed Water and Rinse Water Total Chlorine Testing ... 2. Rinse standard sample cup ... with water to be tested. Re-fill with approximately 20 ml of test water. ...” Observation of RN #5 on 09/17/2025 at 1050 revealed RN #5 entered the water room and performed a chlorine test. RN #5 turned the water valve on and removed a cup from the shelf above the water valve. RN #5 then obtained a sample of water and tested the sample with the E-Z Chek Chlorine test strip. The observation failed to reveal that RN #5 rinsed the cup and obtained a 2nd sample of water prior to performing the chlorine test. Observation revealed that RN #5 failed to follow the facility policy and manufacturer’s directions for use. Interview on 09/17/2025 at 1315 with the Facility Administrator and Manager of Clinical Services revealed the staff were expected to rinse the cup with water, then obtain the 20 milliliters of water required for the chlorine test prior to the insertion of test strip into the sampled water. Interview revealed the facility staff failed to follow the facility policy and manufacturer’s directions for use.”

“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 3 of 5 (Patients #1, #3 and #2) sampled in-center hemodialysis records reviewed. Findings include: Review on 09/17/2025 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 #1 revealed a 74-year-old male admitted for In-Center Hemodialysis treatments on 08/23/2025. Review of the Treatment Flowsheet dated 09/06/2025 revealed Patient #1’s treatment was initiated at 0554. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0719 (1 hour and 25 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 09/09/2025 revealed Patient #1’s treatment was initiated at 0557. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0825 (2 hours and 28 minutes after initiation of treatment). Review of the Treatment Flowsheet dated 09/11/2025 revealed Patient #1’s treatment was initiated at 0548. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0653 (65 minutes after initiation of treatment). Interview on 09/16/2025 at 1530 with the Facility Administrator and 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 #3 revealed a 58-year-old female admitted for In-Center Hemodialysis treatments on 08/19/2025. Review of the Treatment Flowsheet dated 09/05/2025 revealed Patient #3’s treatment was initiated at 0625. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 0730 (1 hour and 5 minutes after initiation of treatment). Interview on 09/16/2025 at 1530 with the Facility Administrator and 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. 3. Review of the medical record for Patient #2 revealed a 40-year-old female admitted for In-Center Hemodialysis treatments on 12/24/2022. Review of the Treatment Flowsheet dated 09/05/2025 revealed Patient #2’s treatment was initiated at 1001. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1104 (1 hour and 3 minutes after initiation of treatment). Interview on 09/16/2025 at 1530 with the Facility Administrator and 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 3 of 5 (Patient #3, #4 and #5) in-center hemodialysis patients at the prescribed BFR/DFR and/or treatment duration. Findings included: Review on 09/17/2025 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 #3 revealed a 58-year-old female admitted for In-Center Hemodialysis treatments on 08/19/2025. Review of the Physician orders revealed Patient #3’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 09/01/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0629 and ended at 1038 (232 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 295, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 09/03/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0624 and ended at 1035 (243 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 310, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 09/09/2025 revealed Patient #3’s hemodialysis treatment was initiated at 1020 and ended at 1319 (170 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 313, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 09/13/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0916 and ended at 1258 (204 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 288, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #3’s blood flow rate was decreased in 4 of 6 treatments, with no notification of the registered nurse. Interview on 09/16/2025 at 1530 with the Facility Administrator and 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/DFR during the patient treatments. The interview confirmed the medical record findings that patient #3 had a decreased BFR in 4 of 6 treatments, with no documentation for the decreased BFR and Registered Nurse notification. 2. Review of the medical record for Patient #4 revealed a 58-year-old male admitted for In-Center Hemodialysis treatments on 12/05/2024. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 09/04/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0711 and ended at 1120 (239 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 394, with no documentation for the increased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 09/13/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0942 and ended at 1320 (216 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 400, with no documentation for the increased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #4’s blood flow rate was increased in 2 of 4 treatments, with no notification of the registered nurse. Interview on 09/16/2025 at 1530 with the Facility Administrator and 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 increased BFR during the patient treatments. The interview confirmed the medical record findings that patient #4 had an increased BFR in 2 of 4 treatments, with no documentation for the increased BFR and Registered Nurse notification. 3. Review of the medical record for Patient #5 revealed a 57-year-old female admitted for In-Center Hemodialysis treatments on 07/05/2025. Review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 300 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 09/04/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1025 and ended at 1346 (194 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 380 and average DFR was 507, with no documentation for the increased BFR/decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 09/13/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0956 and ended at 1221 for a duration of 144 minutes (66 minutes shortened treatment) with no documentation of leaving against medical advice form completed. Review of the treatment sheets revealed that Patient #5’s blood flow rate was increased and DFR was decreased in 1 of 4 treatments, with no notification of the registered nurse and treatment duration shortened in 1 of 4 treatments. Interview on 09/16/2025 at 1530 with the Facility Administrator and 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 increased BFR and decreased DFR during the patient treatments. The interview confirmed the medical record findings that patient #5 had an increased BFR and decreased DFR in 1 of 4 treatments, with no documentation for the increased BFR/decreased DFR and Registered Nurse notification. Interview revealed the staff should document the reason for shortened treatments and notify the Registered Nurse. The staff should also complete an Against Medical Advice form and have the patients sign the form indicating that the risks/benefits have been explained by the staff.”

“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 per policy before cannulation of 1 of 1 Arterio-venous fistula/graft (AVF/AVG) cannulation procedure observed (Station #12; PCT #6). Findings included: Review on 09/17/2025 of the facility policy titled “AV (Arterio-venous) Fistula or Graft Cannulation ...” revised April 2025 revealed “ ... Skin Antiseptic: Povidone Iodine; Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site; Effective Contact Time: 30 seconds; Air Drying Time: 2 minutes ... Procedure ... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to the table above). 13. Do not palpate insertion site once area has been prepped.” Observation on 09/17/2025 at 1130 in the patient treatment area revealed PCT #6 entered Station #12 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #6 performed hand hygiene and applied clean gloves. PCT #6 cleansed the arterial and venous access sites with Povidone Iodine pad for 15 seconds at each site. PCT #6 allowed the access sites to dry for 2 minutes before cannulation. The observation revealed PCT #6 palpated the access sites with a gloved hand prior to cannulation. Observation revealed PCT #6 failed to disinfect each access site with Povidone Iodine for 30 seconds and failed to perform a second disinfection after palpating the access sites, per the facility policy. Interview on 09/17/2025 at 1145 with PCT #6 revealed that each site should be disinfected for 30 seconds. Interview revealed that PCT #6 failed to disinfect the access sites per facility policy. Interview on 09/17/2025 at 1330 with the Manager of Clinical Services and Facility Administrator revealed the staff were expected to disinfect each access site for 30 seconds when using Povidone Iodine pads and allow each site to dry for 2 minutes, prior to cannulating. Interview revealed that staff should not palpate/touch the access sites prior to cannulation. The interview revealed that if the staff touch the access sites after disinfecting, then the access sites should be disinfected again prior to cannulation. Interview revealed the staff failed to follow the facility policy.”