Davita South Edison

“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: 51227 Based on one of two observations of the cleaning and disinfection of a dialysis station, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the dialysis station is cleaned and disinfected before preparing the hemodialysis machine for a new patient. Findings include: On 05/14/25 at 10:20 AM, in Station 9, Staff (S)4 (Patient Care Technician [PCT]), used a bleach-soaked cloth to clean and disinfect the dialysis machine. After cleaning the dialysis machine, S4 placed new dialysis tubing in the machine to prepare for the next patient. After setting up the dialysis machine, S4 proceeded to clean the recliner chair, television, and chase wall. S4 did not wait until the dialysis station was clean and disinfected before setting up for the next patient to prevent cross contamination. During an interview at 10:35 AM, S9 (PCT) stated that a dialysis station should be completely cleaned and disinfected before setting up the dialysis machine for a new patient. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “ ... DISINFECTION ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. A. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by health care personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops) ... b. Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient ... “ N.J.A.C. 8:43A-24.8(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 51227 Based on one of two observations of the initiation of hemodialysis using a central venous catheter (CVC, a type of access used for hemodialysis), staff interviews, and review of facility policy, it was determined that the facility failed to implement infection control practices for cleaning the CVC limbs, caps, and hubs prior to initiating hemodialysis. Findings include: On 05/14/25 at 10:40 AM, in Station 13, Staff (S)6 (Registered Nurse [RN]), initiated hemodialysis through a CVC. After cleaning the exit site, S6 removed the red (arterial) cap and used one alcohol preparation (prep) pad to clean the hub for seven seconds. This was eight seconds less than required by facility policy. With another alcohol prep pad, S6 proceeded to remove the cap from the blue (venous) limb and scrubbed the hub for six seconds. This was nine seconds less than required by facility policy. S6 did not clean and disinfect the limbs of the catheter and both the arterial and venous caps before removing them and cleaning the hubs according to facility policy. During an interview at 10:50 AM, S6 stated, he/she should clean the hubs with an alcohol prep pad for 15 seconds. When S6 was asked if he/she cleansed the limbs and caps, he/she stated, “I did not clean the limbs and caps of the catheter.” Facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” revised October 2024, stated, “ ... 9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap. ... 16. Verify both catheter clamps are closed. Using aseptic technique remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads, and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried ... “ N.J.A.C. 8:43A-24.8(b)”

“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: 49828 Based on observation of the hemodialysis treatment floor and support space, it was determined the facility failed to ensure that a defect free environment is maintained at all times. Findings include: During a tour conducted on 05/15/25 at 10:00 AM with Staff (S)2 (Bio-Medical Technician), the following was observed: Water or liquid-stained ceiling tiles were found in the following areas: in the patient scale area of the Treatment Floor; in Station 5, outside of the Equipment Repair Room; and in the Unisex bathroom on the Treatment Floor. Within Station 4, behind the hemodialysis treatment chair and below the chase wall, there was a red bucket under a white pipe. The bucket was full of liquid which was overflowing onto the floor around it. According to S2, the drain wasn’t draining properly, and it had been leaking since “last month.” S2 confirmed the above findings upon discovery. At 11:27 AM, during a tour of the “Future Home” area of the facility accompanied by S1 (Facility Administrator), and S8 (Manager of Clinical Services), the following was observed: The floor of the area contained various pieces of debris, dust, and pieces of cut ceiling tiles. To the right of the door was six boxes of patient “lab (laboratory) supplies” that were unopened, and three boxes of “airless machine setups” (hemodialysis machine and patient lines) that were also unopened. To the left of the door toward the back wall of the room was a patient bed, and an opened bag that contained more than 10 empty jugs used for bicarbonate. S1 and S8 confirmed the findings above. S8 stated that patient supplies should not be stored in an unclean area. N.J.A.C. 8:43A-17.3(j) N.J.A.C. 8:43A-17.4(a)(15)”

“PR-RECEIVE UNDERSTANDABLE INFORMATION CFR(s): 494.70(a)(2) The patient has the right to- (2) Receive all information in a way that he or she can understand; This Standard is not met as evidenced by: 49828 Based on one of one observation of a non-English speaking patient during hemodialysis treatment (Patient (P) 8), staff interview, and review of facility policy, it was determined that the facility failed to ensure that each patient receives all information in a way that he or she can understand. Findings include: On 05/14/25 at 9:45 AM, in Station 17, P8 was observed asking Staff (S)14 (Patient Care Technician [PCT]) who the surveyors on the unit were. This surveyor attempted to explain to P8 who he/she was and the reason for being on the hemodialysis unit. P8 responded that he/she speaks four languages but does not speak English. P8 proceeded to ask S14 if the surveyor was his/her medical doctor. At that time, the surveyor requested language services to communicate with P8. S14 then went to S3 (Clinical Nurse Manager), who returned with S14 to Station 17, and attempted to explain, while speaking English, who the surveyors were. P8 indicated again that he/she did not understand, by repeating that he/she spoke four languages and English was not one of them. Language services or an interpreter were not used to communicate with P8. At 10:30 AM, P8 was discharged from the unit following his/her hemodialysis. At 1:30 PM during an interview, S1 (Facility Administrator) stated that the language line was available for use, however, the language line phone’s battery was dead. S1 further explained that in this instance, the language line was still available for use by dialing the phone number from any phone, and could still be used. Facility policy titled, “Communication with Individuals with Limited English Proficiency,” revised April 2025 stated, “ ... Purpose: To verify patients and Responsible Parties with limited English proficiency (LEP) have meaningful access to [facility’s] care and services by providing [facility’s] process for providing language assistance services to individuals with LEP ... Policy: ... C. Language assistance services will be provided either through: ... All teammates will be provided notice of this policy and procedure, and teammates that may have contact with individuals with LEP will be trained in effective communication techniques, including the effective us of a Qualified interpreter ... “ N.J.A.C. 8:43A-16.2(a)(4)”

“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: 51227 Based on medical record review, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that abnormal blood pressures (BP) occurring during six of nine hemodialysis treatments for Patient (P)3 are reported to the Medical Doctor (MD) in accordance with physician orders and facility policy. Findings include: A review of P3’s Plan of Care, dated 03/26/25, stated, “ ... Fluid/BP Maintain post weight compared to target weight. Blood pressure within range ... “ Physician orders dated 05/07/25, stated, “ ... Treatment Parameter Orders ... notify provider if intradialytic BP change of 20 mmHg [millimeters of mercury] from last reading ... “ A review of P3’s Treatment Detail Reports dated 04/23/25 through 05/14/25 revealed the following: On 04/28/25, the following was documented by the RN and a Patient Care Technician (PCT): 05:11 [5:11 AM]: BP 141/89; “ ... Treatment started without complications ... “ 05:46 [5:46 AM]: BP 147/97 06:16 [6:16 AM]: BP 121/78 06:46 [6:46 AM]: BP 126/86 07:16 [7:16 AM]: BP 109/68 07:46 [7:46 AM]: BP 109/69 08:16 [8:16 AM]: BP 106/64 08:47 [8:47 AM]: BP 80/57 08:57 [8:57 AM]: BP 80/52 08:59 [8:59 AM]: BP 90/51 09:15 [9:15 AM]: BP 99/63 09:16 [9:16 AM]: BP 107/60; “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the physician that P3’s intradialytic BP decreased more than 20 mm/Hg at 06:16 [6:16 AM] and 08:47 [8:47 AM]. On 04/30/25, the following was documented by the RN and PCT: 05:16 [5:16 AM]: BP 147/102; “ ... Treatment started without complications ... “ 05:36 [5:36 AM]: BP 146/96 06:06 [6:06 AM]: BP 130/80 06:37 [6:37 AM]: BP 126/63 07:07 [7:07 AM]: BP 123/75 07:37 [7:37 AM]: BP 96/62 07:59 [7:59 AM]: BP 100/62 08:07 [8:07 AM]: BP 89/62 08:18 [8:18 AM]: BP 91/56 08:37 [8:37 AM]: BP 88/61 08:42 [8:42 AM]: BP 96/64 09:07 [9:07 AM]: BP 106/64 09:17 [9:17 AM]: BP 95/64; “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the MD that P3’s intradialytic BP decreased more than 20 mm/Hg at 07:37 [7:37 AM]. On 05/2/25, the following was documented by the RN and PCT: 05:09 [5:09 AM]: BP 151/98; “ ... Treatment started without complications ... “ 05:38 [5:38 AM]: BP 149/99 06:08 [6:08 AM]: BP 141/89 06:39 [6:39 AM]: BP 116/76 07:09 [7:09 AM]: BP 120/68 07:39 [7:39 AM]: BP 86/55 07:47 [7:47 AM]: BP 100/61 08:09 [8:09 AM]: BP 109/37 08:15 [8:15 AM]: BP 77/51 08:21 [8:21 AM]: BP 86/52 08:39 [8:39 AM]: BP 86/58 08:57 [8:57 AM]: BP 86/56 09:08 [9:08 AM]: BP 124/64; “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the MD that P3’s intradialytic BP decreased more than 20 mm/Hg at 06:39 [6:39 AM], 07:09 [7:09 AM] and 08:15 [8:15 AM]. On 05/5/25, the following was documented by the RN and PCT: 05:07 [5:07 AM]: BP 137/82; “ ... Treatment started without complications ... “ 05:38 [5:38 AM]: BP 115/61 06:08 [6:08 AM]: BP 110/65 06:38 [6:38 AM]: BP 98/65 06:40 [6:40 AM]: BP 96/62 07:08 [7:08 AM]: BP 88/57 07:38 [7:38 AM]: BP 86/46 07:44 [7:44 AM]: BP 74/35 07:55 [7:55 AM]: BP 77/50 08:08 [8:08 AM]: BP 76/47 08:31 [8:31 AM]: BP 86/54 09:06 [9:06 AM]: BP 92/47; “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the MD that P3’s intradialytic BP decreased more than 20 mm/Hg at 05:38 [5:38 AM]. On 05/9/25, the following was documented by the RN and PCT: 05:12 [5:12 AM]: BP 151/99; “ ... Treatment started without complications ... “ 05:42 [5:42 AM]: BP 130/73 06:12 [6:12 AM]: BP 88/63 06:42 [6:42 AM]: BP 98/63 07:15 [7:15 AM]: BP 108/42 07:46 [7:46 AM]: BP 100/63 08:12 [8:12 AM]: BP 96/49 08:39 [8:39 AM]: BP 98/46 08:42 [8:42 AM]: BP 101/45 09:12 [9:12 AM]: BP 113/56 “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the MD that P3’s intradialytic BP decreased more than 20 mm/Hg at 05:42 [05:42 AM] and 06:12 [6:12 AM]. On 05/14/25, the following was documented by the RN: 05:09 [5:09 AM]: BP 142/79; “ ... Treatment started without complications ... “ 05:39 [6:35 AM]: BP 129/86 06:09 [6:09 AM]: BP 134/91 06:40 [6:40 AM]: BP 110/64 07:10 [7:10 AM]: BP 101/66 07:40 [7:40 AM]: BP 98/66 08:16 [8:16 AM]: BP 96/61 08:30 [8:30 AM]: BP 80/41 08:56 [8:56 AM]: BP 89/58 09:09 [9:09 AM]: BP “Treatment terminated; Patient blood returned without complication.” There was no documented evidence that the RN notified the MD that P3’s intradialytic BP decreased more than 20 mm/Hg at 06:40 [6:40 AM]. During an interview on 05/16/25 at 10:05 AM, Staff (S)3 (Charge Nurse) stated that the RN should notify and document that the MD is aware of the change in intradialytic BP of 20 mm/Hg even if the patient is asymptomatic. S3 also stated that the MD should have been made aware of the abnormal BP and confirmed the above treatment sheets lacked documented evidence that the MD was aware of changes in the BP. 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 Diastolic greater than or equal to 100 mm/Hg [millimeters of mercury] or less than 50 mm/Hg ... “ N.J.A.C. 8:43A-24.4(b) N.J.A.C. 8:43A-24.13(b)”

“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: 48966 Based on one of one observation of pre-drawn syringes of medications, staff interview, and a review of facility documents, it was determined the Medical Director failed to ensure medication is prepared by staff members in accordance with facility policy. Findings include: On 5/14/25 at 11:23 AM, in the medication prep (preparation) area, six pre-drawn heparin syringes were observed in the top drawer labeled “low dead space syringes” located next to the white refrigerator. On the countertop above the drawer was a prepared pack of supplies for catheter care that contained two pre-drawn heparin syringes. The labels affixed to all eight syringes observed stated, “1” on the line designated for the time. During an interview at 11:39 AM, Staff (S)7 (Registered Nurse[RN]) stated that the heparin syringes were prepared at 9:00 AM, but the affixed labels indicated 1:00 PM because that is when the patients are scheduled for hemodialysis treatment. S7 stated heparin should not be drawn up more than one hour before administration. S7 discarded the eight pre-drawn heparin syringes. Facility policy titled, “Medication Policy,” revision date: October 2023, stated, “ ... Policy: ... 18. All syringes prepared from single use vials/ampoules (without preservatives) or multidose vials should be prepared and administered within a four (4) hour [within one (1) hour for States of Florida, New Jersey and South Carolina] period, unless there is specific testing and documents on file which extends dating ...” N.J.A.C. 8:43A-9.3(b)”