Davita Cannon 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: 27438 Based on policy review, observation, and staff interview, the facility staff failed to performed hand hygiene after removing gloves, after touching patient care equipment and before contact with the patient for 1 of 2 survey days. Findings included: Review of the facility’s policy, “Infection Control for Dialysis Facilities,” revised April 2023, revealed, “Hand Hygiene 1. All teammates, Physicians and Non-Physician (NNP) will perform hand hygiene ...prior to gloving, and immediately after removal of gloves ...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” Observation on February 5, 2024 from 10:35 AM until 11:00 AM (25-minutes) revealed, CCHT #1 was observed providing care at Station 10. During the observation, CCHT #1 was observed moving three times between station 10 and the clean computer keyboard/mouse, removing dirty gloves however, failing to use hand sanitizer or perform hand hygiene prior to touching the clean computer keyboard/mouse. Interview on February 5, 2024 at 11:10 AM with CCHT #1 confirmed the above findings. Interview on February 5, 2024 at 1:30 PM with RN #6 revealed, that after removing gloves and donning new gloves hand hygiene should be performed. RN #6 verbalized that staff are not to touch the clean computer keyboard/mouse without removing gloves and using hand sanitizer or washing hands.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 27438 Based on policy review, observation, interview, the facility staff failed to ensure the handheld instant read thermometers were cleaned appropriately after use for 2 of 2 observations. Findings included: Review of the facility’s policy, “Infection Control Dialysis Facilities,” revised April 2023, indicated, “Disinfection ...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from the treatment area.” 1. Observation on February 5, 2024 at 10:10 AM, at Station 18 CCHT #2 failed to disinfect the thermometer after use then returning it to the clean computer stand. Interview on February 6, 2024 at 1:00 PM, the Facility Administrator confirmed the facility policy for disinfection of the pHoenix meters. 2. Observation on February 5, 2024 at 11:45 AM, at Station 15 CCHT #1 failed to disinfect the pHoenix meter after use. Interview on February 5, 2024 at 11:50 AM with CCHT #1 revealed, he/she failed to disinfect the thermometer prior to returning the thermometer to a designated clean area of the computer cart. CCHT #1 stated the facility policy was to disinfect the thermometer after each use. Interview on February 6, 2024 at 1:00 PM, the Facility Administrator confirmed the facility policy for disinfection of the pHoenix meters.”

“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, in-service training review, and staff interview, the facility staff failed to enter the acceptable low and high ranges on the acid mixing log for 2 of 2 days, failed to enter the batch size on the acid mixing log for 1 of 2 days, failed to ensure a second teammate verified the specific gravity for 2 of 3 days that bicarb was mixed, and failed to ensure the bicarb system daily rinse log was performed for 1 of 4 days. Findings included: Review on February 6, 2024 of the facility’s policy, “DRI-SATE DRY ACID CONCENTRATE MIXING SYSTEM” revised March 2015 revealed, “PURPOSE ...POLICY: 1. ...11. A Dri-Sate Batch Production Record is fully completed for each batch of dry acid concentrate that is produced. ...” Review on February 6, 2024 of the facility’s policy, “CHECKING SPECIFIC GRAVITY VALUES FOR CITRAPURE” revised October 2023 revealed, “Material required: ...D4-116 ...2.00 (potassium) [space] 2.5 (calcium) ...1.184 (lower value) [space] 1.208 (upper value) ...D4-124 ...2.00 (potassium) [space] 3.00 (calcium) ...1.187 (lower value) [space] 1.211 (upper value) ...” Review on February 6, 2024 of the facility’s policy, “BETTER WATER-CENTRAL BICARB MIXING AND DELIVERY” copyright 2012 revealed, “Material required ...Procedure [space] Rational ...18. Document ....Secondary Teammate Verification Signature on the appropriate Bicarb Mixing Log. ...” Review on February 6, 2024 of the facility’s policy, “BETER WATER DUAL TANK BICARB MIXER SYSTEM RINSING” dated February 2013 revealed, “Material required ...Procedure [space] Rationale ...#16. Complete the Documentation on Daily Bicarb Rinse log [space] #14. ‘if it’s not documented, it’s not been done’ ...” 1. Review on February 6, 2024 revealed 1.) on December 18, 2023, the facility staff mixed a batch of acid concentrate of D4-124 but failed to enter the high and low range of the specific gravity on the acid mixing log, and 2.) on January 15, 2024, the facility staff mixed a batch of acid concentrate of D4-116 but failed to enter the high and low range of the specific gravity on the acid mixing log and failed to enter the size of the batch on the acid mixing log. Review revealed the facility staff failed to ensure the completeness of the acid mixing record. Interview on February 6, 2024 at 1:15 PM with the GFA revealed there was no documentation related to monitoring for the completeness of the acid mixing logs. 2. Review on February 6, 2024 revealed 1.) on December 27, 2023 and December 29, 2023, the facility staff failed to obtain the signature of a second teammate as verification for bicarbonate mixing and 2.) on December 4, 2023, the facility staff failed to enter that the bicarb system was rinsed. Review revealed that facility staff failed to ensure the completeness of the bicarb mixing and rinsing log. Review on February 6, 2024 revealed, on November 29, 2024 the GFA provided training related to obtaining a secondary signature during bicarb mixing, because secondary signatures were identified as missing during rounding audits. The action plan was for follow-up audits to be performed over an undocumented span of time. Review revealed a discrepancy with the training date and revealed no follow-up audits were performed. Interview on February 6, 2024 at 1:15 PM with the GFA revealed, the facility staff identified the lack of secondary signature for bicarb mixing during rounding audits. As a result, staff was provided training. Interview revealed, no follow-up audits were performed because, the GFA was unaware that audits were part of the action plan.”

“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: 27438 Based on manufacturer’s DFU review, observations, and staff interviews, the facility staff failed to follow the bloodline manufacturer’s DFU during dialysis treatments by not monitoring and maintaining the arterial drip chamber fluid levels at 75% full during treatment for 1 of 2 survey days. Findings included: Review of the “NIPRO SET Blood Tubing Set,” manufacturer’s DFU used at this facility indicated, “General Warnings and Precautions: 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 February 5, 2024 at 8:30 AM revealed the arterial drip chamber fluid levels were less than 50% full in Stations #10, #18, #20, #21, #22, and #23. Interview on February 5, 2024 at 9:00 AM with CCHT #2 revealed, the arterial chamber levels at Station #20 was below 20% and stated staff were responsible to observe the chamber levels during treatment and adjust the level as needed. Interview on February 5, 2024 at 9:15 AM with CCHT #1 revealed, the arterial chamber level at Station #10 was below 50% and stated the staff should be aware of the arterial level and are responsible to observe the chamber levels during treatment and adjust the level as needed to 75% full.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 32003 Based on policy review, heparin protocol review, medical record review, and staff interview, the facility staff failed to verify the total amount of heparin infused for treatment duration 1 of 6 treatments and failed to ensure heparin was stopped 60-minutes before the end of treatment for 6 of 6 treatments for 1 of 3 patients with a AVF. (Patient #1). Findings included: Review on February 5, 2024 of the facility’s policy, “PRE-INTRA-POST TREATMENT DATA COLLECTIN, MONITORING, AND NURSING ASSESSMENT” revised October 2023 revealed, “NOTE: ...PURPOSE: ...POLICY: [space] 1. Patient data ...2. The Nursing assessment ...3. Patient identity, prescription and machine settings ...j. Heparinization (intradialytic infusing setting) ...” Review on February 5, 2024 of the facility’s protocol, “Heparin Protocol” revised September 2020 revealed, “PURPOSE: ...DOSE ADMINISTRATION: 1. ...600 U/hr during dialysis, administered IV by constant infusion or hour injection, discontinued according to venous access in use: (a) AVF or AVG: Discontinue infusion one hour before end of treatment. ...” Open medical record review on February 5, 2024 revealed, Patient #1 was admitted to the in-center facility in February 2021 and dialyzed three times per week for 270-minutes via AVF. Heparin infusion rate was ordered as 0.6 units/hour with a stop time of 60-minutes before the end of treatment. Treatment sheet review from January 24, 2024 through February 5, 2024 (six treatments) revealed, 1.) on January 24, 2024, the patient dialyzed 287-minutes and was administered 2100 units of heparin via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment. 2.) on January 26, 2024, the patient dialyzed 244-minutes and was administered 2100 units of heparin, via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment. 3.) on January 29, 2024, the patient dialyzed 284-minutes and was administered 2100 units of heparin, via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment. 4.) on January 31, 2024, the patient dialyzed 283-minutes and was administered 2100 units of heparin, via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment. 5.) on February 2, 2024, the patient dialyzed 281-minutes and was administered 2100 units of heparin, via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment, and 6.) on February 5, 2024, the patient dialyzed 283-minutes and was administered 1900 units of heparin, via the heparin pump on the dialysis machine, without a stop time of 60-minutes before the end of treatment. Review revealed the facility staff failed to ensure heparin administration and stop time was according to policy, procedure and prescription. Interview on February 6, 2024 at 1:00 PM with the GFA revealed, the facility went live with CWOW in April 2023 and some kinks were still being worked out. Interview revealed for heparin, the facility staff would utilize the heparin pump on the dialysis machine which should be indicated as “Y” on the treatment sheet in the intradialytic section. At the end of treatment, the staff was responsible for a manual entry of the total amount of heparin infused during treatment. Interview revealed, the GFA believed the heparin documentation errors were personnel-related.”

“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: 32003 Based on policy review, observation, and staff interview, the facility staff failed to ensure a post-treatment nursing assessment was performed before a patient exited the facility for 1 of 2 patients. (Patient #6). Findings included: Review on February 5, 2024 of the facility’s policy, “ PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised October 2023 revealed, “NOTE: ...POST TREATMENT DATA COLLECTION/ASSESSMENT [space] 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings ...17. Licensed nurse will use their clinical judgment based on individual patients needs to determine if any clinical interventions or notification ...is necessary prior to discharge of the patient from the facility. ...” Observation on February 5, 2024 at 10:20 AM revealed, Patient #6 was located at station #8 as treatment was discontinued by CCHT #1. The patient left the treatment area and exited the facility. After questioning from the SA consultant if the nurse had performed a post-treatment nursing assessment, the technician notified the nurse that a post-nursing assessment was needed for the patient. The nurse left the treatment area, went out into the lobby area, brought the patient back into the treatment area, and performed a post-nursing assessment. Review revealed the facility staff failed to communicate to ensure post-treatment nursing assessment was performed. Interview on February 5, 2024 at 10:20 AM with CCHT #1 revealed, the technician failed to communicate to the nurse that a post-treatment nursing assessment was needed for Patient #6 prior to the patient leaving the treatment area and exiting the facility.”