Davita Nashua Dialysis

“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: 38218 Based on observation, interview, and policy review, it was determined the dialysis facility failed to ensure the cleaning and disinfection of containinated surfaces, medical devices, and equipment in the treatment area with 22 dialysis stations. Findings include: Observation on 9/17/24 from approximately 9:10 a.m. through 9:30 a.m. of Station 15 revealed a red/brown in color substance adhered to the floor, and Staff F (Certified Clinical Hemodialysis Technician (CCHT)) walking past the area. Interview on 9/17/24 at approximately 9:30 a.m. with Staff F revealed that the red/brown substance was blood. Review on 9/17/24 of the facility policy titled, “Infection Control for Dialysis Facilities”, with a revised date of 4/2023, revealed: “... Disinfection, 12...a. Prior to routine disinfection, remove all visible blood...iii. Cleaning of visible blood should be performed when first observed...” Observation on 9/17/24 at approximately 8:10 a.m. of the dialysis treatment area revealed 4 staff chairs, located in the center of the treatment rooms, observed to have the vinyl coverings worn and the porous area of the cushion part of the chairs was visible. Further observation revealed staff members to be sitting in the chairs between patient interactions with their protective gowns on. Interview on 9/17/24 at approximately 8:10 a.m. with Staff A (Charge Nurse) confirmed the above findings. Observation on 9/17/24 from approximately 8:30 a.m. through 8:45 a.m. of the facility’s computer stands revealed that 5 of the computer stands at the dialysis stations had medical tape attached to them. Further observation of the facility’s computer stands revealed 7 of the computer stands had a visible substance and dust adhered to the legs of the computer stands. Interview on 9/17/24 at approximately 9:20 a.m. with Staff G (CCHT) confirmed the above findings. Review on 9/19/24 of the facility policy titled, “Infection Control For Dialysis Facilities”, with a revision date of 4/2023, revealed: “...15. The chair side cart... are considered to be clean areas...b. The chair side cart components will be cleaned at the end of each treatment day...” 43408 Oxygen Concentrators Observation on 9/18/24 at approximately 9:10 a.m. of the dialysis treatment area revealed an oxygen concentrator, marked #8, with 2 strips of white medical tape across the filter. Further observation revealed Staff C (Registered Nurse) wiping the oxygen concentrator with solution. Staff C did not remove or replace the filter or the white medical tape during disinfection. Interview on 9/18/24 at approximately 9:15 a.m. with Staff C revealed the white medical tape is not changed between uses. Observation on 9/18/24 at approximately 9:20 a.m. of the dialysis treatment area revealed a total of 9 oxygen concentrators in the room and ready for use. Further observation revealed a total of 4 oxygen concentrators that had white medical tape across the filters (Oxygen concentrators #6, #8, #10 and #11). Interview on 9/18/24 at approximately 9:25 a.m. with Staff A confirmed the above observation of white medical tape on 4 of the oxygen concentrators. Staff A stated that the tape is supposed to be changed between patients during the disinfection process.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 43408 Based on record review and interview, the facility failed to identify, determine the root cause, and develop a corrective action plans for 2 of 3 medication errors reviewed. Findings include: Review on 9/19/24 of the June 2024 and July 2024 adverse events report revealed the following medication/treatment events: On 6/11/24: 2 self reported med errors by an Registered Nurse (RN) and 2 reported errors by an RN; On 6/15/24: 1 self reported error by an RN; On 6/29/24: 1 self reported error by a Patient Care Technician (PCT); On 7/16/24: 1 self reported potential medication error; On 7/20/24: 1 self reported prescription error/wrong needle size; On 7/27/24: 2 self reported prescription error/wrong needle size and 1 prescription error corrected when identified. Further review of the June and July 2024 adverse events reports did not identify who made the errors, a root cause or an action plan for the above listed medication/ treatment events. Review on 9/19/24 of the 2 self reported medication errors from 6/11/24 revealed the following information about the errors: On 6/11/24- Pt [patient] was put on for treatment and UF [Ultra Filtration] button was not pressed resulting in most of treatment running with no cleaning of the blood. On 6/19/24 input wrong dosage and time for heparin infusion. Interview on 9/19/24 at approximately 2:00 p.m. with Staff A (Charge Nurse) stated that the staff member who self reported the 6/11/24 error listed above was in orientation and had their orientation extended. Staff A stated that the staff member was an older person and needed more help with time management and reminders. Staff A could not identify the reason for the medication error on 6/19/24. 38218 Patient #8 Review on 9/19/24 of Patient #8’s Treatment Detail Report, dated 9/13/24 revealed the following physician’s order: Ondansetron, 4 milligrams, Intravenous; Push., Every Dialysis Treatment. Not Given, Reason: Missed Administration Interview on 9/19/24 at approximately 10:40 a.m. with Staff A revealed that he/she was unaware of the missed medication and there was no reasoning documented for not administering the dose. Review on 9/20/24 of the facility policy titled, “Medication Policy”, Revision Date 10/23 revealed: “...9. Medications are administered as prescribed and then documented in the patient’s medical record...36. All medication errors are reported to the Facility Administrator/designee. She/he will then notify the patient’s physician of the event and of any adverse changes in the patient’s condition. Physician will be notified of any medication errors prior to patient leaving the facility...37. The Facility Administrator/designee will be responsible, after consultation with the physician, for implementing any necessary action to counteract the error and prevent a reoccurrence...””