Davita Brookshire

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 32003 Based on policy review, observations, and staff interview, the facility staff failed to clean and disinfect the wall boxes and the Hansen connectors between patient use for 3 of 3 observations. Findings included: Review on July 10, 2024 of the facility’s policy, “INFECTION CONTROL FOR DIALYSIS FACILITIES” revised April 2023 revealed, “PURPOSE: ...NOTES: ...POLICY: ...HAND HYGEINE ...1. ...4. ...DISINFECTION ...13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings ...and frequently contacted by healthcare personnel ...i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. ...” 1. Observation on July 8, 2024 at 2:45 PM revealed, CCHT #1 failed to clean and disinfect the wall box and Hansen connectors, between patient use, at dialysis station #24. Interview on July 11, 2024 at about 11:00 AM with the FA revealed, the wall boxes and the Hansen connectors should be disinfected should be disinfected between patient use. 2. Observation on July 9, 2024 at 10:10 AM revealed, PCT # 3 failed to clean and disinfect the wall box and Hansen connectors, between patient use, at dialysis station #14. Interview on July 11, 2024 at about 11:00 AM with the FA revealed, the wall boxes and the Hansen connectors should be disinfected between patient use. 3. Observation on July 9, 2023 at 10:25 AM revealed, Nurse #4 failed to clean and disinfect the wall box and Hansen connectors, between patient use, at dialysis station #11. Interview on July 11, 2024 at about 11:00 AM with the FA revealed, the wall boxes and the Hansen connectors should be disinfected between patient use.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 32003 Based on policy reviews, acid and bicarbonate log reviews, and staff interview, the facility staff failed to enter the time the acid batch was transferred from the mixing tank to the storage tank for 1 of 8 days, failed to enter the hydrometer reading for 2 of 8 days, and failed to enter the number of bags used to mix bicarbonate for 1 of 7 days. Findings included: Review on July 9, 2024 of the facility’s policy, “[acid brand] DRI-SATE DRY ACID CONCENTRATE MIXING” revised April 2023 revealed, “PURPOSE ...POLICY: 1. ...11. A Dri-Sate Batch Production Record is fully completed for each batch of dry acid concentrate that is produced. ...16. The results of the hydrometer test; together with manufacturer’s acceptable range of concentrate specific gravity is recorded on the [acid brand] Batch Production Record ...” Review on July 9, 2024 of the facility’s policy, “BICARBONATE CONCENTRATE SYSTEM MIXING” revised April 2024 revealed, “PURPOSE ...POLICY: 1. ...7. ...13. Preparation of bicarbonate concentrate is documented on a log at the time of preparation and verified by a second teammate prior to dispensing. The log should include: ...The number and expiration date of bags used for that batch ...” 1. Review on July 9, 2024 of the bicarbonate mixing log revealed, from June 17, 2024 through June 22, 2024 (6-days), the number of bags used to mix bicarb was not documented for June 22, 2024. Interview on July 9, 2024 at 11:30 AM with the biomedical technicians revealed, the facility staff should have documented the number of bags used to mix bicarbonate on June 22, 2024. 2. Review on July 9, 2024 of the acid mixing log revealed on May 6, 2024 and June 27, 2024, the hydrometer readings were not documented and on May 8, 2024 and June 30, 2024, the times that the acid mixture was transferred from the mixing tank to the storage tank were not documented. Interview on July 9, 2024 at 11:30 AM with the biomedical technicians revealed, the facility staff should have documented the times that the acid mixture was transferred from the mixing tank to the storage tank.”

“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: 32003 Based on manufacturer’s instructions for use review, observations, and staff interview, the facility staff failed to ensure the arterial drip chamber fluid levels were ¾ full during treatment for 1 of 3 observations. Findings included: Review on July 10, 2024 of the “[brand] Blood Tubing Set” revised March 2022 revealed, “INDICATIONS FOR USE ...GENERAL WARNINGS AND PRECAUTIONS 1. ...10. Maintain drip chamber level at ¾ full to prevent chamber evacuation, causing possible air embolus. Full drip chamber levels can result in stagnation of blood in the upper portion of the drip chamber, resulting in clotting. ...” Observations on July 10, 2024 at 9:45 AM revealed, the arterial drip chamber fluid levels at dialysis stations #5 and #11 were less than ¾ full during patient treatment. Interview on July 10, 2024 at 12:25 noon time with the FA revealed, the blood volume should be at a certain level within the volume chamber as indicated on the dialysis machine.”

“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: 32003 Based on teammate handbook review, observations, and staff interview, the facility staff failed to ensure mobile devices were not use in the patient care area for 1 of 2 observations. Findings included: Review on July 10, 2024 of the facility’s “TEAMMATE POLICIES” effective August 2023 revealed, “SECTION 5: Work Environment ...5.16 Mobile Device Policy [space] To ensure that patient care is our primary focus, use of mobile devices is not permitted in the patient care area. Cell phone use for personal reasons is strictly prohibited on the treatment floor and in other clinical work areas such as the water room, concentrate prep area, and stock room. ...” Observation on July 10, 2024 from 9:25 AM to 11:15 AM (110-minutes) revealed, CCHT #1 was involved in direct patient care with a telephone ear bud in the ear. Interview on July 10, 2024 at 12:25 noon time with the FA revealed, telephone ear buds were not allowed in patient care areas.”