Davita Omaha West Dialysis

“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: 47269 Based on review of facility policies and procedures, medical record review, and staff interviews, the facility failed to ensure heparin maintenance doses were administered as prescribed during dialysis treatments for 5 of 6 patient medical recordsreviewed (Patient 1, 2, 6, 7, 9). This failed practice had the potential to shorten hemodialysis (HD) treatment time by increasing the risk of clotted blood lines. Findings are: A. Review of the facility policy titled Medication Policy, dated 10/2023, revealed medications are to be administered as prescribed. B. Review of Patient 1’s medical record revealed: 1. A heparin maintenance dose prescription of 1.3 milliliters (ml) per hour for 3 and a half hours for a total of 4,550 ml of heparin. 2. Treatment Details Report entry on: a. 7/7/25 at 10:00 AM, Registered Nurse (RN)-E noted due to the heparin pump malfunction, Patient 1 received 3,990 ml of heparin maintenance dose during HD treatment. b. 7/12/25 at 9:22 AM, Patient Care Technician (PCT)-M noted due to the heparin pump malfunction, Patient 1 received 3,550 ml of heparin maintenance dose during HD treatment. c. 7/16/25 at 9:57 AM, PCT-L noted due to heparin pump malfunction, Patient 1 received 0 ml of heparin maintenance dose during HD treatment. C. Review Patient 2’s medical record revealed: 1. A heparin maintenance dose prescription of 1.5 ml per hour for 4 hours for a total of 6,000 ml of heparin. 2. Treatment Details Report entry on: a. 7/9/25 at 9:04 AM, PCT-I noted due to heparin pump malfunction, Patient 2 received 2,000 ml of heparin maintenance dose during HD treatment. b. 7/18/25 at 9:20 AM, PCT-J noted due to heparin pump malfunction, Patient 2 received 2,000 ml of heparin maintenance dose during HD treatment. D. Review of Patient 6’s medical record revealed: 1. A heparin maintenance dose prescription of 0.4 ml per hour for 4 hours for a total of 1,600 ml of heparin. 2. Treatment Details Report entry on 7/15/25 at 2:20 PM, PCT-M noted due to heparin pump malfunction, Patient 6 received 0 ml of heparin maintenance dose during HD treatment. E. Review of Patient 7’s medical record revealed: 1. A heparin maintenance dose prescription of 1,000 ml per hour for 3 hours for a total of 3,000 ml of heparin. 2. Treatment Details Report entry on: a. 7/12/25 at 2:02 PM, PCT-K noted due to heparin pump malfunction, Patient 7 received 2,200 ml of heparin maintenance dose during HD treatment. b. 7/15/25 at 12:59 PM, PCT-M noted due to heparin pump malfunction, Patient 7 received 2,200 ml of heparin maintenance dose during HD treatment. c. 7/19/25 at 1:35 PM, PCT-J noted due to heparin pump malfunction, Patient 7 received 100 ml of heparin maintenance dose during HD treatment. F. Review of Patient 9’s medical record revealed: 1. A heparin maintenance dose prescription of 600 ml per hour for 3 hours for a total of 1,800 ml of heparin. 2. Treatment Details Report entry on 7/16/25 at 9:25 AM, RN-X noted due to heparin pump malfunction, Patient 9 received 600 ml of heparin maintenance dose during HD treatment. G. During staff interview on 7/23/25 at 12:40 PM, the RN Charge Nurse confirmed of the 6 patient records reviewed for a total of 36 treatments, 10 treatments resulted in patients not receiving their heparin maintenance dose as prescribed due to the heparin pump malfunctioning. H. During staff interview on 7/24/25 at 9:18 AM, the Medical Director confirmed it is the expectation that staff follow the facility policy to administer the heparin maintenance dose as prescribed. Additionally, the Medical Director revealed a process did not exist to ensure patients received their full heparin maintenance dose as prescribed when the heparin pump malfunctioned.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 49530 Based on review of facility policies and procedures, observations, and staff interview, 1 of 9 facility staff members, Patient Care Technician (PCT)-J failed to change their gown prior to providing care to hemodialysis (HD) patients, after removal of a biohazard trash bag from the trash receptacle and compressing the bag against their gown. This failure had the potential to expose all 49 patients receiving HD on the day of the failure to infectious pathogens. The total census was 72. Findings are: A. Review of the facility policy and procedure titled Infection Control for Dialysis Facilities,dated 4/2023, revealed gowns were to be removed as soon as possible if contaminated and placed in a biohazard waste container. B. During the observation of cares on 4/2/25 at 10:00 AM, PCT-J removed a red biohazard bag from the trash receptacle adjacent to HD station 11 following treatment, while cleaning the HD station. The biohazard bag contained trash from the provision of HD treatment. PCT-J held the biohazard bag to their gown and compressed the bag with their arms to expel the air from the bag prior to placing the bag in the biohazard trash container in the center of the treatment floor. There was no attempt to change the gown prior to proceeding with the provision of cares to HD patients present in the treatment area. C. During staff interview on 4/2/25 at 11:00 AM, the Facility Administrator confirmed that PCT-J failed to follow the facility policy and procedure for changing their gown prior to providing care to HD patients, after removal of a biohazard trash bag from the trash receptacle and compressing the bag against their gown.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interviews, the facility failed to identify and remove expired medications and supplies. This failed practice had the potential to expose all 72 patients on census to expired medications and supplies. Findings are: A. Review of the facility policy titled Administration of Intradialytic Parenteral Nutrition (IDPN) (a nutritional therapy administered during hemodialysis (HD) to provide essential nutrients to patients), dated 10/2021, revealed IDPN is to be checked for expiration dates. B. Review of the facility policy titled Medication Policy, dated 10/2023, revealed expired medications are to be disposed of per state/local laws. C. Review of the facility policy titled Infection Control for Dialysis Facilities, dated 4/2023, revealed all supplies will be checked for expiration dates prior to use. D. Observation of the medication refrigerator, on 3/31/25 at 1:15 PM, revealed 2 IDPN with expiration date of 3/20/25, and 3 IDPN with expiration date of 3/27/25. E. Observation of supplies stored in the HD treatment area, on 3/31/25 at 1:30 PM, revealed 38 button hole needles with expiration date of 2/28/25. F. During staff interview on 4/7/25 at 1:00 PM, the Registered Nurse Clinical Coordinator (RNCC) confirmed staff failed to remove expired medications and supplies, from the medication refrigerator and from the HD treatment area, for compliance with facility policies.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47269 Based on the review of facility policies and procedures, observations and staff interviews facility failed to maintain the building where hemodialysis (HD) treatments were provided to ensure safe and sanitary conditions for patients and staff. This failed practice increased the risk of microbial growth with the potential for negatively affecting the health and safety of all 72 patients on census. Findings are: A. Review of the facility policy titled Physical Environment, dated 4/2018, revealed the building in which dialysis services are furnished will be constructed and maintained for the safety of patients and staff. B. Observations of the HD facility, on 3/31/25 at 12:00 PM with the Facility Administrator (FA), revealed the following: HD treatment area: 1. The cabinet floor, housing the plumbing for the sink labeled dirty (where reusable supplies and equipment exposed to blood or body fluids are stored until cleaned), located between HD stations 1 and 11, appeared warped and cracked, exposing untreated wood. 2. The cabinet flooring, housing the plumbing for the sink labeled clean (for the purpose of staff hand washing), located between HD stations 1 and 11, appeared warped and cracked, exposing untreated wood. Water Room: 1. A puddle of water was present at the base of the brine tank. 2. A puddle of water was present at the base of the water softener. C. During staff interview on 3/31/25 at 3:15 PM, the FA confirmed the cabinetry flooring housing the plumbing of both the sink labeled dirty and the sink labeled clean were in need of repair and no work order had been placed. The FA also confirmed that a work order had not been placed to investigate the source of the puddles of water present at the base of the brine tank and at the base of the water softener.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interviews, facility staff failed to follow the facility policy and procedure for monitoring and documenting intradialytic blood pressures of 1 of 7 sampled patients (Patient 1) during hemodialysis (HD) treatment. Additionally, the facility policy and procedure failed to have a process for manually entering blood pressures when the automated system failed to transmit blood pressures to the computer. This failed practice provided the potential for a lack of interventions by the Registered Nurse (RN) to prevent negative patient outcomes associated with blood pressure changes. The facility census was 72. Findings are: A. Review of the facility policy titled Pre-Intra-Post Treatment Data Collection, Monitoring and Nurse Assessment, dated 4/2024, revealed intradialytic data collection will be completed every 30 minutes during the HD treatment by facility staff. B. Review of Patient 1’s HD treatment record dated 3/15/25 revealed the following: 1. 6:29 AM, RN-F manually entered blood pressure at initiation of HD treatment. 2. 7:00 AM, Patient Care Technician (PCT)-H manually entered intradialytic blood pressure. 3. 7:41 AM, PCT-H manually entered intradialytic blood pressure. 4. 8:11 AM, staff failed to manually enter intradialytic blood pressure. 5. 8:41 AM, staff failed to manually enter intradialytic blood pressure. 6. 9:11 AM, staff failed to manually enter intradialytic blood pressure. 7. 9:41 AM, staff failed to manually enter intradialytic blood pressure. 8. 10:11 AM, staff failed to manually enter intradialytic blood pressure. 9. 10:21 AM, RN-F manually entered blood pressure at the termination of HD treatment. C. During staff interview on 4/7/25 at 1:00 PM, the Registered Nurse Clinical Coordinator (RNCC) confirmed that RN-F and PCT-H failed to manually enter, on 5 occasions, the intradialytic blood pressures at the 30-minute interval, for Patient 1 during HD treatment on 3/15/25. Additionally, RNCC confirmed a process did not exist to alert staff that manual blood pressure entries were required when the automated system failed to transmit blood pressure readings.”