Davita Cornhusker 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: 49530 Based on review of facility policies and procedures, observations, and staff interview, 1 of 6 staff members, Patient Care Technician (PCT)-J, failed to follow the facility’s policy and procedure for sanitizing hands prior to applying gloves for 1 of 8 sampled patients (Patient 7) observed during the provision of care. This failed practice provided the opportunity for transmission of infectious diseases among the 39 patients on census receiving Hemodialysis (HD) treatments. Findings are: A. Review of the facility policy and procedure titled Infection Control for Dialysis Facilities, dated 4/2023, revealed hand hygiene was to be performed prior to gloving. B. During the observation of initiation of the HD treatment for Patient 7 on 12/17/25 at 9:15 AM, PCT-J failed to sanitize hands after documenting on the computer and prior to applying gloves before connecting the patient’s blood line to the HD machine lines. C. During staff interview on 12/17/25 at 11:30 AM, the Facility Administrator (FA) confirmed PCT-J failed to follow the facility’s policy and procedure to sanitize hands prior to applying gloves during the provision of care to Patient 7.”

“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 interview, the facility failed to identify and remove 5 expired blood culture tubes (used to identify blood stream infections in hemodialysis patients). Additionally, the facility failed to have a formal process to monitor and identify expired lab supplies. These failed practices had the potential to affect lab results of all 39 patients on census if labs were ordered by a physician for suspected blood stream infections. Findings are: A. Review of the policy titled Obtaining A Blood Culture During A Hemodialysis Treatment, dated 4/2024, revealed blood culture bottles should be inspected and discarded if expired. B. Observation of the facility lab area on 12/16/25 at 10:15 AM, revealed 5 blood culture bottles with the expiration date of 12/11/25. C. During staff interview on 12/16/25 at 10:30 AM, the Charge Registered Nurse (RN)-A confirmed the 5 blood culture bottles, located in the facility lab area, were expired. Charge RN-A revealed it is the expectation that lab supplies will be evaluated for expiration dates by the RN on the first of the month. RN-A confirmed a formal process did not exist to evaluate lab supplies for expiration dates.”

“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 review of facility policies and procedures, quarterly checklist, observations, and staff interviews, the facility failed to maintain the building where hemodialysis (HD) treatments were provided. This failed practice had the potential to increase the risk for growth of infectious organisms with the potential for affecting the health and safety of staff and 39 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. Environmental tour of the dialysis facility on 12/16/25 with the Charge Registered Nurse (RN)-A at 9:00 AM, revealed the following areas in need of cleaning, repair, and/or replacement: Waiting Room: 1. The walls appeared dingy with chipped paint throughout. Patient Treatment Area: 1. The walls appeared dingy throughout. 2. The cabinetry and shelves appeared dusty throughout. 3. Two columns presented with jagged, uneven, porous stones with unidentifiable stains. 4. The two porcelain sinks located at the nurses’ workstation appeared corroded with exposed metal at the drains. 5. The two porcelain sinks located at the patient care technician workstation appeared corroded with exposed metal at the drains. Medication Storage Area: 1. The cabinetry and shelves appeared dusty throughout. Lab Area: 1. The cabinetry and shelves appeared dusty throughout. 2. Dust and dirt was present at the base of the laboratory refrigerator (used to store blood prior to shipment for analysis). Isolation Room: 1. The porcelain sink labeled dirty appeared corroded with exposed metal at the drain. 2. The walls appeared dingy throughout. C. Review of the dialysis facility Quarterly OSHA (Occupational Safety and Health Administration) and Safety Checklist, completed by patient care technician (PCT)-E on 9/26/25 and verified by the Facility Administrator (FA) on 10/8/25, failed to include the areas of the dialysis facility identified during the environmental tour of the dialysis facility on 12/16/25 at 9:00 AM, as needing cleaned, repaired and/or replacement. D. During environmental tour and staff interview on 12/16/25 at 3:00 PM, the FA: 1. Confirmed the areas of the dialysis building, identified during the environmental tour of the dialysis facility on 12/16/25 at 9:00 AM, as needing cleaned, repaired and/or replaced. 2. Confirmed the areas of the dialysis building, identified during the environmental tour of the dialysis facility on 12/16/25 at 9:00 AM, were not identified by PCT-E, and were incorrectly verified by the FA on 10/8/25, during PCT-E’s completion of the Quarterly OSHA and Safety Checklist. 3. Revealed it is the responsibility of the FA to verify the accuracy of staff findings documented on the Quarterly OSHA and Safety Checklist.”