Davita Bridgewater

“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: 39223 Based on one of two observations of initiation of hemodialysis through an arteriovenous fistula/graft (AVF/G, a type of vascular access used for dialysis), staff interview, and review of facility documents, it was determined that the facility failed to ensure that staff perform hand hygiene after possible exposure to blood or other infectious material. Findings include: On 06/23/25 at 10:55 AM in Station 3, Staff (S)7 (Patient Care Technician) cannulated (the process of inserting needles into a patient’s vascular access to connect them to the dialysis machine for hemodialysis) the patient’s right arm vascular access. After inserting two needles into the AVF, S7 applied tape to secure both sites. S7 then proceeded to touch the hemodialysis machine’s screen before connecting the patient blood lines to the hemodialysis machine. S7 then typed and clicked the mouse on the mobile computer workstation. Next, S7 adjusted the patient television. S7 did not perform hand hygiene after cannulation and before touching other areas within the patient station. At 11:30 AM in Station 1, S7 was observed moving a wheelchair from inside the patient station to an area adjacent to the nurse’s station. S7 then made contact with a trash can and moved it away from the wheelchair. S7 proceeded to re-enter Station 1 and pressed buttons on the television remote before handing the remote to the patient. S7 did not perform hand hygiene after touching the trash can and before touching patient items upon re-entering Station 1. A review of S7’s education file revealed that on 6/3/25, S7 had satisfactory performance of hand hygiene skills. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “... HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. ...” N.J.A.C. 8:43A-24.8(b)”

“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: 39223 Based on observation of two of three 1:100 (one part bleach to 100 parts water) bleach solution containers, staff interview, and review of facility documents, it was determined that the facility failed to ensure that all surfaces of clamps are exposed to the bleach solution while disinfecting. Findings include: On 06/23/25 at 10:37 AM, the 1:100 bleach solution container, located on the dirty sink counter adjacent to Station 2, was observed to contain two white vascular clamps and five blue scissor clamps soaking in the solution. One white vascular clamp had a blue silicone cover in place over the end of the clamp arm. One blue scissor clamp was in a closed position. During an interview at 10:40 AM, Staff (S)10 (Registered Nurse) stated that the blue silicone covers should be removed from the white vascular clamps before placing both items into the 1:100 bleach solution to soak. S10 also stated that blue scissor clamps should soak in an open position. During an interview on 06/25/25 at 9:53 AM, S4 (Manager of Clinical Services), stated that the blue silicone cover used on white vascular clamps should be removed before both items are placed in the bleach solution to soak. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “... DISINFECTION ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. ... If item cannot be cleaned and disinfected it will be dedicated for use on a single patient. ... b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution. For disinfection of vascular access clamps, please refer to policy: Utilizing Vascular Access Clamps ...” Facility policy titled, “Utilizing Vascular Access Clamps,” revised April 2019, stated, “... 7. Non-occluding spring loaded vascular access clamps are reusable and disinfected between each use with a 1:100 (one to one hundred) bleach solution. ...” N.J.A.C. 8:43A-24.8(b)”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 39223 Based on two of two observations of pH (potential of Hydrogen) testing, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that staff are able to determine if pH testing of dialysate results are within acceptable limits. Findings include: On 06/23/25 at 10:48 AM in Station 3, Staff (S)7 (Patient Care Technician [PCT]) was observed to obtain a sample of dialysate from the hemodialysis machine located in Station 3 to test the pH level. S7 dripped the sample liquid onto the test strip before determining that the result was 7.4. When asked what an acceptable range of the pH results was, S7 was not sure and asked S2 (Biomedical Technician). Upon returning to this surveyor, S7 stated that the acceptable pH test results range was 7.2 to 7.6. A review of S7’s education file revealed that he/she was determined to have satisfactory performance for “ ... properly demonstrates the manual conductivity (as applicable) and pH testing ... “ on 06/03/25. 48966 On 06/23/25 at 10:43 AM, S8 (Patient Care Technician [PCT]) obtained a sample of the machine dialysate in a syringe from the machine in Station 10. S8 removed a RPC E-Z Check pH test strip out of the bottle and proceeded to allow the fluid to flow over the pad of pH test strip for one second. S8 shook off the excess dialysate and waited five seconds to compare the test strip to the color chart on the bottle. The pH strip read 7.4. During an interview on 06/23/25 at 10:45 AM, S8 did not know the acceptable pH range when asked and had to search for the correct information. A review of S8’s education file revealed that he/she was determined to have satisfactory performance for “ ... properly demonstrates the manual conductivity (as applicable) and pH testing ... “ on 06/03/25. Facility policy titled, “Testing pH and Conductivity of Proportioned Dialysate and Verification of Temperature of Proportioned Dialysate,” revised October 2024, stated, “ ... pH testing ... Independent Ph testing is required to be performed prior to each treatment. The acceptable range for final dialysate pH is 6.9-7.6. Check independent pH with approved test method for final dialysate. ... “ N.J.A.C. 8:43A-24.10(a)(7)”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 39223 Based on observation, staff interview, and review of facility policy, it was determined that the facility failed to ensure patients do not use electric heated blankets during treatment. Findings include: On 06/23/25 at 10:22 AM in Station 4, Staff (S)10 (Patient Care Technician) was observed gathering the patient’s personal items and placing them in the patient’s bag. S10 then unplugged a heated blanket and folded it up before placing it in the patient’s bag. At 11:55 AM in Station 10, the patient was observed to be covered in an electric heated blanket while seated in the patient recliner chair. During an interview at 11:56 AM, S6 (Clinical Coordinator) stated that electric heated blankets are not to be used on the treatment floor. Facility policy titled, “Patient Owned Non-Medical Electrical Devices,” revised April 2019, stated, “ ... 1. Non-medical electrical devices must be battery operated if used during patient treatment. 2. Certain non-medical electrical devices should not be used by patients during treatment due to infection control, potential for burns, electrical or other safety concerns. These items include electric blankets, fans, and heating pads. ... “”

“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: 39223 Based on review of two of seven medical records (Medical Record (MR)5 and 6), staff interview, and review of facility documents, it was determined that the facility failed to ensure that the ordered target weight utilized and intradialytic abnormal blood pressures (BP) are assessed by the Registered Nurse (RN) and reported to the Medical Doctor (MD) in accordance with facility policy. Findings include: A review of MR5 was conducted with Staff (S)6 (Clinical Coordinator) on 06/25/25 at 11:58 AM and the following was revealed: The Plan of Care, dated 04/07/25, under the heading “Fluid/BP” stated, “ ... Maintain post [after] weight compared to target weight. Blood pressure within range. ... “ A physician ordered Target Weight of 97.5 kilograms (kg) was active 06/06/25 through 06/19/25. Review of the ‘Treatment Details Reports’ for the same time frame indicated an incorrect target weight of 98.0 kg was utilized for calculating fluid removal on the following dates: 06/09/25, 06/11/25, 06/13/25, 06/16/25, and 06/18/25. During review of this information, S6 confirmed that the ordered target weight was not the target weight used on the above listed dates. Further review of the Treatment Details Reports dated 06/02/25 through 06/20/25 indicated the following: On 06/06/25, hemodialysis treatment started at 06:08 AM. Elevated blood pressures were documented as follows: 06:08 AM - 171/105 - documented by the PCT (Patient Care Technician) 06:38 AM - 173/115 - documented by the PCT 07:08 AM - 170/105 - documented by the PCT 08:07 AM - 164/103 - documented by the PCT 08:37 AM - 162/103 - documented by the RN 09:23 AM - 166/101 There was no documented evidence that the RN was informed of the elevated diastolic blood pressures until one hour and 29 minutes after the first elevated diastolic blood pressure was documented. During review of the above treatment details, S6 stated that the physician should have been notified of the elevated blood pressures. On 06/09/25 Patient (P)5’s pre-treatment blood pressure was 171/104. Hemodialysis treatment was started by the RN at 6:09 AM with a blood pressure of 180/113. Elevated blood pressures were documented as follows: 06:14 AM - 160/101 06:39 AM - 177/105 07:09 AM - 160/95 08:39 AM - 169/104 09:09 AM - 146/100 09:39 AM - 147/103 A post-treatment blood pressure was documented as 147/103. There was no documented evidence to indicate that the physician was notified of the elevated diastolic blood pressures pre-treatment (before treatment), during treatment, and after treatment. During review of the above treatment details, S6 stated that the physician should have been notified of the elevated blood pressures. On 06/13/25, hemodialysis treatment was started at 06:17 AM. Elevated blood pressures were documented as follows: 06:47 AM - 187/122 - by the PCT 06:51 AM - 255/148 - comment by the PCT stated, “ ... Patient states no complaints at this time; BP remains elevated; patient is asymptomatic; re-cuffing and retaking ... “ 06:52 AM - 255/140 - comment by the PCT stated, “ ... BP error; readjusting the cuff and retaking BP ... “ 06:59 AM - 253/139 - comment by the PCT stated, “ ... elevated BP; patient is asymptomatic; retaking BP ... “ 07:02 AM - 210/118 - comment by the PCT stated, “ ... Changing the cuff due to elevated BP; retaking; patient is asymptomatic ... “ 07:03 AM - 171/100 - comment by the PCT stated, “ ... BP improved; will continue to monitor ... “ 07:17 AM - 166/102 - by the PCT 08:17 AM - 171/101 - by the RN 08:47 AM - 176/104 - by the PCT 09:47 AM - 178/107 - by the PCT There was no documented evidence that the RN was notified of the elevated blood pressures until one hour and 30 minutes after the initial elevated blood pressures. There was no documented evidence that the physician was notified of the elevated blood pressures. During review of the above treatment details, S6 stated that the PCT should notify the RN right away for elevated blood pressures. S6 stated that the RN should have notified the physician of the elevated blood pressures. Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, stated, “ ... PRE- TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. ... 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. ... ABNORMAL FINDINGS ... Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg [millimeters of mercury] or less than 90 mmHg Diastolic greater than or equal to 100 mmHg or less than 50 mm/Hg ... “ 51227 A review of MR 6 indicated a Plan of Care, dated 03/12/25, that stated, “ ... Fluid/BP meet and maintain a post weight in relation to ordered target weight to avoid complications related to hyper or hypo-volemic states ... “ MR6’s Treatment Detail Reports were reviewed from 06/03/25 through 06/21/25 and revealed the following: On 06/10/25 the following was documented by a PCT: 11:12 (11:12 AM): BP 151/87; “ ... Treatment started without complications ... “ 11:42 (11:42 AM): BP 130/89 12:12 (12:12 PM): BP 130/89 12:12 (12:12 PM): BP 120/70 12:42 (12:42 PM): BP 99/75; “ ... pt [patient] is asymptomatic ... “ 13:12 (1:12 PM): BP 120/78 13:42 (1:42 PM): BP 113/69 14:13 (2:13 PM): BP 88/56; “ ... rechecking BP ... “ 14:13 (2:13 PM): BP 98/61; “ ... pt asymptomatic; RN aware ... “ 14:42 (2:42 PM): BP 117/76; “ ... Treatment terminated ... “ There was no documented evidence that the RN re-assessed P6 for symptoms of hypotension (low blood pressure) at 2:13 PM, in accordance with facility policy. There was no documented evidence that the physician was notified of the patient’s hypotension, as required by facility policy. On 06/12/25 the following was documented by a PCT: 11:18 [11:18 AM]: BP 136/66; “ ... Treatment started without complications ... “ 11:53 [11:42 AM]: BP 117/76 12:23 [12:23 PM]: BP 97/62 12:23 [12:23 PM]: BP 96/62 12:53 [12:53 PM]: BP 89/49; “ ... rechecking bp ...” 12:54 [12:54 PM]: BP 86/52; “ ... 200ml [milliliters] ns [Normal Saline] given, RN aware; pt asymptomatic ...” 13:01 [1:42 PM]: BP 111/66 13:23 [1:23 PM]: BP 103/55 13:54 [1:54 PM]: BP 243/213; “ ... rechecking ... “ 13:55 [1:55 PM]: BP 96/58 14:23 [2:23 PM]: BP 108/61 14:51 [2:51 PM]: BP 65/40; “ ... Treatment terminated ... “ Documentation indicated that the RN did not re-assess the patient until 15:14 (3:14 PM), two hours and 20 minutes after the normal saline was given at 12:54 PM. There was no documented evidence that the physician was notified of the patient’s hypotension, as required by facility policy. On 06/19/25 hemodialysis treatment was as follows: 11:14 [11:14 AM]: BP 106/63; “ ... Treatment started without complications ... “ documented by a PCT. 11:44 [11:44 AM]: BP 98/64 12:15 [12:12 PM]: BP 89/60; “ ... rechecking ... “ documented by a PCT. 12:45 [12:45 PM]: BP 135/95 13:15 [1:15 PM]: BP 90/53; “ ... Bp decreased, asymptomatic; uf off; legs raised ...” documented by a RN. 13:37 [1:37 PM]: BP 90/54; “ ... pt c/o [complains of] of being lightheaded; 200 mL saline given ...” documented by a RN. 13:38 [1:38 PM]: BP 95/52; “ ... bp improving, pt reports beginning to feel better ...” documented by a RN. 13:44 [1:44 PM]: BP 87/51; “ ... rechecking BP ...” documented by a PCT. 13:59 [1:59 PM]: BP 86/49; “ ... 200 ml of saline given; RN requested ...” documented by a PCT. 14:04 [2:04 PM]: BP 117/67; “ ... RN requested uf on min [ultrafiltration on minimum] ...” documented by a PCT. 14:14 [2:14 PM]: BP 119/77 14:43 [2:43 PM]: BP 61/38; “ ... Treatment terminated ... “ documented by a RN. Documentation indicated that the RN re-assessment was at 14:47 (2:47 PM), 48 minutes after the second saline bolus was given at 1:59 PM. There was no documented evidence that the physician was notified of the patient’s hypotension, as required by facility policy. On 06/21/25 the following was documented by a PCT: 10:48 [10:48 AM]: BP 172/108; “ ... Treatment started without complications ... “ 11:00 [11:00 AM]: BP 141/84 11:19 [11:19 AM]: BP 121/78 11:48 [11:48 AM]: BP 114/68 12:18 [12:18 PM]: BP 121/79 12:48 [12:53 PM]: BP 109/65 13:18 [1:18 PM]: BP 105/65 13:48 [1:48 PM]: BP 78/59; “ ... rechecking bp; uf on min ...” 14:00 [2:00 PM]: BP 59/38; “ ... 200 ns given per RN request; pt asymptomatic ...” 14:03 [2:03 PM]: BP 97/64 14:12 [2:12 PM]: BP 77/49 14:17 [2:17 PM]: BP 73/48; “ ... Treatment terminated; pt is asymptomatic ... “ There was no documented evidence that the physician was made aware of the patient’s hypotension, as required by facility policy. During an interview on 06/25/25 at 9:40 AM, Staff (S) 6 (Clinical Coordinator), stated that the RN should assess a patient after a saline bolus is given for hypotension. S6 also stated that the MD should have been made aware of the abnormal BPs and confirmed the above treatment sheets lacked documented evidence of the MD being aware of changes in BP and the RN assessment after a saline bolus is given. Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring And Nursing Assessment,” revised April 2024, stated, “ ... Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Blood Pressure-Intradialytic: ... Systolic greater than 180 mm/Hg or less than 90 mm/Hg ... “ Facility policy titled, “Hypotension,” revised October 2023, stated, “ ... Signs and Symptoms ... dizziness ... Procedure ... 6. If patient continues to show signs and symptoms of hypotension, the licensed nurse will notify physician and follow physician’s orders.” N.J.A.C. 8:43A-24.13(b)”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 48966 Based on four of nine treatment sheets reviewed for (Patient (P) 1), staff interview, and review of facility documents, it was determined that the facility failed ensure that patients receive the prescribed Blood Flow Rate (BFR, the speed at which blood is pumped through the dialyzer during hemodialysis). Findings include: A review of P1’s Plan of Care, dated 06/05/25, stated, “ ... Adequacy, Maintain adequacy goal ... “ The physician order, dated 06/10/25, stated, “ ... Arterial Access AV [Arteriovenous] Graft-Upper Arm (Right) Arterial Needle Nipro Tulip, 17G [Gauge] x 1 inch, Sharp, Twin, Arterial Access AV Graft-Upper Arm (Right) Venous Needle Nipro Tulip, 17G [Gauge] x 1 inch, Sharp, Twin ... BFR 250 ml/min (milliliters per minute) ... “ A review of P1’s “Treatment Detail Report” from 06/03/25 through 06/21/25 were reviewed and revealed the following: On 06/12/25, the BFR for P1 was set at 350 mL/min from the initiation of treatment at 10:25 AM until the end of treatment at 13:54 (1:54 PM). On 06/14/25, the BFR for P1 was set at 350 mL/min from the initiation of treatment at 10:35 AM until the end of treatment at 13:58 (1:58 PM). On 06/17/25, the BFR for P1 was set at 350 mL/min from the initiation of treatment at 11:34 AM until the end of treatment at 14:03 (2:03 PM). On 06/21/25, the BFR for P1 was set at 250 ml/min at the initiation of treatment at 11:21 AM. At 12:19 PM, the BFR was decreased to 210 ml/min, and to 200 ml/min from 12:49 PM to 14:19 PM (2:49 PM). At 14:49 PM (2:49 PM) the BFR was increased to 220 until the end of treatment at 15:02 PM (3:02 PM). There was no documentation found in the record to indicate the reason for the change in BFR on 06/12/25, 06/14/25, 06/17/25, and 06/21/25. During an interview on 06/25/24 at 10:54 AM, Staff (S) 6, (Clinical Coordinator [CC]), confirmed that the dialysis prescriptions for P1 were not administered according to the physician order on 06/12/25, 06/14/25, 06/17/25 and 06/21/25 and if the BFR is different than the prescribed order there needs to be documentation explaining the reason. Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, stated, “ ... Intradialytic Data Collection/Assessment ... 10. If the dialysis prescription is not met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ... “ N.J.A.C. 8:43A-24.4(a)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51227 Based on one of two observations of the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that the staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 06/23/25 at 11:00 AM, Staff (S)8, a (Patient Care Technician [PCT]), was observed entering Station 15 to initiate hemodialysis through an AVF. S8 cleansed the first site of the AVF with one alcohol preparation (prep) pad in a circular motion for 30 seconds. S8 did not use three new alcohol prep pads to clean the site for 60 seconds, as required by facility policy. S8 proceeded to cleanse the second site with one alcohol prep pad for 40 seconds. S8 did not use three new alcohol prep pads to clean the site for 60 seconds, as required per facility policy. During an interview on 06/23/25 at 11:30 AM, S8 was asked about the procedure on performing skin disinfection of the site for an AVF. S8 stated, he/she should cleanse the site for 30 to 60 seconds using an alcohol prep pad for each site. Facility policy titled, “AV Fistula or Graft Cannulation With Nipro Or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised April 2025, stated, “ ... Skin Antiseptic ... isopropyl Alcohol 70% ... Effective Volume ... At least 4 prep pad per site ... Effective Contact Time ... 60 seconds ... Procedure: ... 12. For patients who have a documented allergy to povidone iodine or ExSept Plus, necessitating alcohol alone, apply alcohol using a circular rubbing motion, center out for 60 seconds and allow to dry for 15 seconds prior to cannulation ... “ N.J.A.C. 8:43A-24.8(b)”