Davita Albermarle 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 exit site with 2 % Chlorhexidine Gluconate/70 % Isopropyl alcohol per facility policy for 1 of 2 observed CVC exit sites disinfected with Chlorhexidine (PCT #1, Station #9) and failed to disinfect the CVC hubs per facility policy in 1 of 2 observed hemodialysis treatment discontinuation using a CVC (PCT #1, Station #9). Findings include: Review on 01/15/2026 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... ... 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 01/13/2026 at 1132 in the patient treatment area revealed PCT #1 entered Station #9 and initiated CVC exit site care for dialysis treatment with a CVC. PCT #1 cleansed the CVC exit site and area around site with 2% Chlorhexidine for 10 seconds. Observation revealed that the PCT failed to disinfect the CVC exit site for thirty (30) seconds per the facility policy. Observation on 01/13/2026 at 1515 in the patient treatment area revealed PCT #1 entered Station #9 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 hub for less than 10 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 01/13/2026 at 1145 with PCT #1 revealed the PCT stated that the CVC exit site should be cleaned for 15 seconds. Interview revealed that PCT #1 did not watch the clock while disinfecting the catheter exit site. Interview on 01/14/2026 at 1500 with the Manager of Clinical Services and the Clinical Coordinator 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. 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-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 records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 4 of 6 (Patients #5, #6, #7 and #10) in-center hemodialysis patients at the prescribed Blood Flow Rate (BFR)/Dialysate Flow Rate (DFR). Findings include: Review on 01/14/2026 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 01/14/2026 of the medical record for Patient #5 revealed a 71-year-old male that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 12/27/2024. A review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 400 with a treatment duration order for 4 hours (hrs). Review of the Treatment Flowsheet dated 01/02/2026 revealed Patient #5’s hemodialysis treatment was initiated at 1227 and ended at 1505 for a duration of 2 hrs and 36 minutes. Review of the Flowsheet revealed Patient #5’s BFR average was 350, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/07/2026 revealed Patient #5’s hemodialysis treatment was initiated at 1233 and ended at 1636 for a duration of 4 hrs and 1 minute. Review of the flowsheet revealed Patient #5’s BFR average was 348, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s BFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient’s treatment. 2. Review on 01/14/2026 of the medical record for Patient #6 revealed an 80-year-old female that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 09/11/2025. A review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 350 with a treatment duration order for 3 hours (hrs). Review of the Treatment Flowsheet dated 01/06/2026 revealed Patient #6’s hemodialysis treatment was initiated at 1030 and ended at 1332 for a duration of 2 hrs and 59 minutes. Review of the Flowsheet revealed Patient #6’s BFR average was 319, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s BFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient’s treatment. 3. Review on 01/14/2026 of the medical record for Patient #7 revealed a 67-year-old male that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 11/28/2025. A review of the Physician orders revealed Patient #7’s Blood Flow Rate (BFR) was ordered at 350 with a treatment duration order for 4 hours (hrs). Review of the Treatment Flowsheet dated 01/05/2026 revealed Patient #7’s hemodialysis treatment was initiated at 1217 and ended at 1459 for a duration of 2 hrs and 46 minutes. Review of the Flowsheet revealed Patient #7’s BFR average was 328, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/07/2026 revealed Patient #7’s hemodialysis treatment was initiated at 1220 and ended at 1456 for a duration of 2 hrs and 26 minutes. Review of the Flowsheet revealed Patient #7’s BFR average was 340, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s BFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient’s treatment. 4. Review on 01/14/2026 of the medical record for Patient #10 revealed a 42-year-old female that had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 12/22/2022. A review of the Physician orders revealed Patient #10’s Blood Flow Rate (BFR) was ordered at 400 with a treatment duration order for 3 hours (hrs) and 15 minutes. Review of the Treatment Flowsheet dated 12/08/2025 revealed Patient #10’s hemodialysis treatment was initiated at 1044 and ended at 1232 for a duration of 1 hr and 41 minutes. Review of the Flowsheet revealed Patient #10’s BFR average was 250 and average DFR (Dialysate Flow Rate) was 450, with no documentation for the decreased BFR/DFR, and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/10/2025 revealed Patient #10’s hemodialysis treatment was initiated at 1242 and ended at 1606 for a duration of 3 hrs and 19 minutes. Review of the Flowsheet revealed Patient #10’s BFR average was 341, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/15/2025 revealed Patient #10’s hemodialysis treatment was initiated at 1251 and ended at 1638 for a duration of 3 hrs and 19 minutes. Review of the Flowsheet revealed Patient #10’s BFR average was 305, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/17/2025 revealed Patient #10’s hemodialysis treatment was initiated at 1234 and ended at 1459 for a duration of 1 hr and 58 minutes. Review of the Flowsheet revealed Patient #10’s BFR average was 371, with no documentation for the decreased BFR, and no documentation of the Registered Nurse notification. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator revealed that the patient care technicians were expected to notify the nursing staff anytime they increased and/or decreased the patient’s BFR and document in the medical record. The interview revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient’s treatment.”

“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: 26622 Based on facility policy review, medical record review and staff interview, the facility failed to ensure an initial nursing assessment was completed prior to initiation of the patient’s first hemodialysis treatment for 2 of 6 (Patient #5, and #8) sampled ICHD (In-Center Hemodialysis) records. Findings included: Review on 01/15/2026 of the facility policy titled “Initial Patient Nursing Assessment for New Patients” revised April 2024 revealed “... Policy: 1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility. ...” 1. Open medical record review on 01/14/2026 for Patient #5 revealed a 71-year-old male admitted to the facility for ICHD treatments on 12/27/2024. Review of the medical record revealed hemodialysis treatments were initiated for Patient #5 on 12/27/2024. Review of the medical record revealed no documented evidence of an initial nursing assessment completed prior to the initiation of the first hemodialysis treatment. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator during review of the medical records revealed the initial nursing assessment should be completed prior to the initiation of the first hemodialysis treatment. Interview revealed the Manager of Clinical Services, and the Facility Administrator were unable to locate the initial nursing assessment in Patient #5’s medical record or in the facility. 2. Open medical record review on 01/14/2026 for Patient #8 revealed a 48-year-old male admitted to the facility for ICHD treatments on 03/08/2025. Review of the medical record revealed hemodialysis treatments were initiated for Patient #8 on 03/08/2025. Review of the medical record revealed no documented evidence of an initial nursing assessment completed prior to the initiation of the first hemodialysis treatment. Interview on 01/15/2026 at 1200 with the Manager of Clinical Services and Facility Administrator during review of the medical records revealed the initial nursing assessment should be completed prior to the initiation of the first hemodialysis treatment. Interview revealed the Manager of Clinical Services, and the Facility Administrator were unable to locate the initial nursing assessment in Patient #5’s medical record or in the facility.”