Davita Lumbee River Dialysis

“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 disinfect the CVC (Central Venous Catheter) hubs per facility policy in one of two observation during a hemodialysis treatment discontinuation using a CVC (PCT #1, Station #2). Findings include: Review on 01/07/2026 of the facility policy titled “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” revised April 2025 revealed “... 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 01/07/2026 at 1030 in the patient treatment area revealed PCT #1 entered Station #2 and initiated termination of a Central Venous Catheter (CVC). Observation revealed PCT #1 performed hand hygiene and applied clean gloves. Observation revealed PCT #1 cleansed the arterial catheter hub and the venous catheter hubs for less than 15 seconds each. The observation revealed that PCT #1 failed to disinfect each catheter hub for 15 seconds per facility policy. Observation revealed the facility policy was not followed. Interview on 01/07/2026 at 1040 with PCT #1 revealed the PCT stated that the hubs were disinfected for 15 seconds. Interview revealed that PCT #1 did not watch the clock while disinfecting the catheter hubs. Interview on 01/07/2026 at 1230 with the Manager of Clinical Services and Facility Administrator 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-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 V 544 Based on policy review, medical records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 3 of 6 (Patients #1, #2, and #6) in-center hemodialysis patients at the prescribed Blood Flow Rate (BFR)/Dialysate Flow Rate (DFR). Findings include: Review on 01/08/2026 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 on 01/07/2026 of the medical record for Patient #1 revealed a 60-year-old male that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 11/12/2025. A review of the Physician orders revealed Patient #1’s Dialysate Flow Rate (DFR) was ordered at 800 with a treatment duration order for 4 hours (hrs). Review of the Treatment Flowsheet dated 12/31/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1206 and ended at 1605 for a duration of 4 hrs and 1 minute. Review of the Flowsheet revealed Patient #1’s DFR average was 570, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/02/2026 revealed Patient #1’s hemodialysis treatment was initiated at 1202 and ended at 1604 for a duration of 4 hrs and 3 minutes. Review of the flowsheet revealed Patient #1’s DFR average was 500, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Interview on 01/08/2026 at 1100 with the Facility Administrator and Operations Director revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s DFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased DFR during the patient’s treatment. 2. Review on 01/07/2026 of the medical record for Patient #2 revealed a 51-year-old male that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 09/10/2025. A review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) was ordered at 800 with a treatment duration order for 4 hours (hrs). Review of the Treatment Flowsheet dated 12/31/2025 revealed Patient #2’s hemodialysis treatment was initiated at 1105 and ended at 1503 for a duration of 3 hrs and 56 minutes. Review of the Flowsheet revealed Patient #2’s BFR average was 355 and DFR average was 500, with no documentation for the increased BFR and decreased DFR, and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/02/2026 revealed Patient #2’s hemodialysis treatment was initiated at 0943 and ended at 1343 for a duration of 3 hrs and 55 minutes. Review of the flowsheet revealed Patient #2’s BFR average was 305 and DFR average was 500, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Interview on 01/08/2026 at 1100 with the Facility Administrator and Operations Director revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the increased/decreased BFR and decreased DFR during the patient’s treatment. 3. Review on 01/07/2026 of the medical record for Patient #6 revealed a 61-year-old female that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 08/02/2023. A review of the Physician orders revealed Patient #6’s Dialysate Flow Rate (DFR) was ordered at 800 with a treatment duration order for 4 hours (hrs). Review of the Treatment Flowsheet dated 12/31/2025 revealed Patient #6’s hemodialysis treatment was initiated at 0630 and ended at 1032 for a duration of 4 hrs. Review of the Flowsheet revealed Patient #6’s DFR average was 500, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/02/2026 revealed Patient #6’s hemodialysis treatment was initiated at 0630 and ended at 1033 for a duration of 3 hrs and 58 minutes. Review of the flowsheet revealed Patient #6’s DFR average was 500, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Interview on 01/08/2026 at 1100 with the Facility Administrator and Operations Director revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s DFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased DFR during the patient’s treatment.”

“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 2 of 3 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #12; PCT #2 and Station #1; PCT #1). Findings included: Review on 01/07/2026 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). ...” 1. Observation on 01/07/2026 at 0855 in the patient treatment area revealed PCT #2 entered Station #12 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 pad for less than 30 seconds at each site. PCT #2 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #2 failed to disinfect each access site with Povidone Iodine for 30 seconds. Interview on 01/07/2026 at 0900 with PCT #2 revealed that each site should be disinfected for 30 seconds. PCT #2 believed that she had cleaned each site for 30 seconds but admitted that she did not use the clock. Interview revealed that PCT #2 failed to disinfect the access sites per facility policy. Interview on 01/07/2026 at 1230 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 the staff failed to follow the facility policy. 2. Observation on 01/07/2026 at 1055 in the patient treatment area revealed PCT #1 entered Station #1 and initiated access of an Arterio-Venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #1 performed hand hygiene and applied clean gloves. PCT #1 cleansed the arterial and venous access sites with Povidone Iodine pad for 15 seconds at each site. PCT #1 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #1 failed to disinfect each access site with Povidone Iodine for 30 seconds. Interview on 01/07/2026 at 1055 with PCT #1 revealed that each site should be disinfected for 30 seconds and allowed to dry for 1 (one) minute. PCT #1 believed that she had cleaned each site for 30 seconds but admitted that she did not use the clock. Interview revealed that PCT #1 failed to disinfect the access sites per facility policy. Interview on 01/07/2026 at 1230 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 the staff failed to follow the facility policy.”