Davita Four Corners Dialysis Center

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in a dialysis treatment station were disinfected at the end of each dialysis treatment for 1 (Station #14) of 2 station disinfection observations. Findings included: The facility’s policy titled, “Infection Control For Dialysis Facilities,” revised 12/2023, revealed, “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. [exempli gratia, for example], dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” During infection control observations on 09/24/2024 at 12:21 PM, Certified Clinical Hemodialysis Technician (CCHT) #14 began cleaning and disinfecting dialysis Treatment Station #14. The observation revealed CCHT #14 did not clean the sharps container and biohazard waste bins located in the treatment station. During an interview on 09/26/2024 at 9:30 AM, the Facility Administrator indicated that the sharps containers and biohazard bins located in each treatment station were considered part of the dialysis treatment station and required cleaning and disinfection after each patient treatment. During an interview with the Medical Director on 09/26/2024 at 12:47 PM, he stated that it would be reasonable for the biohazard bins and sharps containers to be disinfected as part of treatment station disinfection.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50873 Based on record review, interview, and facility policy review, the facility failed to follow the individualized dialysis prescription as determined by the medical provider for 4 (Patients #1, #2, #7, and #10) of 10 sampled patients. Findings included: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised 04/2024, revealed, “3. Patient identify, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not limited to:” “d. UFR [ultrafiltration rate] and Max [maximum] UFR” and “f. Blood flow rate. g. Dialysate flow rate.” The policy revealed, “10. If the dialysis prescription is not being 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.” 1. Patient #2’s physician “Orders,” dated 09/07/2024, revealed the patient’s ordered blood flow rate (BFR) was 450 milliliters per minute (mL/min) and the ordered dialysate flow rate (DFR) was 600 mL/min. Patient #2’s “Treatment Details Report,” dated 09/07/2024, also revealed the ordered “Dialysis Prescription” BFR was 450 mL/min. The report revealed at 3:30 PM on 09/07/2024, staff documented that the BFR was decreased to 300 mL/min and remained at 300 mL/min from 3:30 PM until 4:30 PM. The report revealed no documented evidence indicating the reason the patient’s BFR was changed during this time. Patient #2’s “Treatment Details Report,” dated 09/14/2024, also revealed the “Dialysis Prescription” for the BFR was 450 mL/min and the DFR was 600 mL/min. The report revealed treatment was started at 8:30 AM, at a BFR of 400 mL/min and a DFR of 500 mL/min and continued until 10:32 AM. The report revealed no documentation regarding the reason the patient’s BFR and DFR were not set as ordered. During an interview on 09/25/2024 at 3:55 PM, the Facility Administrator indicated that the patient’s treatments were not run per the provider’s orders and that the expectation was for the dialysis orders to be followed. The Facility Administrator further stated that there was no reason for the DFR to deviate from the prescription. The Facility Administrator stated that if the staff was unable to achieve the ordered BFR, it should be noted with a rationale. According to the Facility Administrator, if a certified clinical hemodialysis technician (CCHT) made the notation, the registered nurse (RN) should be notified. 2. Patient #10’s physician “Orders,” dated 09/12/2024, revealed the patient’s ordered blood flow rate (BFR) was 350 milliliters per minute (mL/min). Patient #10’s “Treatment Details Report,” dated 09/20/2024, also revealed the “Dialysis Prescription” for the BFR was 350 mL/min. Per the report, staff documented the BFR was lowered to 270 mL/min from 11:04 AM until 12:01 PM; however, no reason for lowering the BFR was documented. During an interview on 09/25/2024 at 5:23 PM, the Facility Administrator confirmed that there was no note regarding the reason why Patient #10’s BFR was decreased. 3. Patient #1’s “Treatment Details Report,” dated 09/07/2024, revealed the “Pre-Treatment Fluid Calculation” ordered maximum UFR was 13.0 milliliters/kilogram/hour (mL/kg/hr). The Treatment Details Report revealed the actual UFR for the patient treatment on 09/07/2024 was 15.1 mL/kg/hr. Patient #1’s “Treatment Details Report,” dated 09/10/2024, revealed the “Pre-Treatment Fluid Calculation” ordered maximum UFR was 13.0 mL/kg/hr. The Treatment Details Report revealed the actual UFR for the patient’s treatment on 09/10/2024 was 15.1 mL/kg/hr. During an interview with the Facility Administrator on 09/25/2024 at 2:54 PM, she confirmed that the facility expectation was for the treatment to be run at the prescribed UFR unless there were doctor’s orders otherwise. She confirmed that there were no doctor’s orders to exceed a UFR of 13.0 mL/kg/hr for Patient #1’s treatment dates. 4. Patient #7’s “Treatment Details Report,” dated 09/07/2024, revealed the “Pre-Treatment Fluid Calculation” ordered maximum UFR of 13.0 milliliters/kilogram/hour (mL/kg/hr). The report revealed the actual UFR for the patient’s treatment on 09/07/2024 was 15.3 mL/kg/hr. Patient #7’s “Treatment Details Report,” dated 09/10/2024, revealed the “Pre-Treatment Fluid Calculation” ordered maximum UFR of 13.0 mL/kg/hr. The report revealed actual UFR for the patient’s treatment on 09/10/2024 was 13.5 mL/kg/hr. Patient #7’s “Treatment Details Report,” dated 09/19/2024, revealed the “Pre-Treatment Fluid Calculation” ordered maximum UFR of 13.0 mL/kg/hr. The actual UFR for the patient’s treatment on 09/19/2024 was 15.5 mL/kg/hr. During an interview with the Facility Administrator on 09/25/2024 at 4:55 PM, she stated that the facility expectation was for the patient’s treatment to be run at the prescribed UFR unless there were doctor’s orders otherwise. She stated that there were no doctor’s orders to exceed a UFR of 13.0 mL/kg/hr for Patient #7’s treatment dates. During an interview on 09/26/2024 at 12:47 PM, the Medical Director stated that deviations from the dialysis prescription should be documented.”

“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: 50873 Based on record review, interview, and facility policy review, the facility failed to provide the necessary care and services to manage the volume status for 3 (Patients #1, #6, and #7) of 10 sampled patients. Findings included: The facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated “9. Intradialytic treatment monitoring and data collection which may be performed by the PCT [patient care technician] or licensed nurse includes: a. Vital signs and treatment monitoring,” and “iii. Non-nocturnal treatments are completed at least every thirty (30) minutes.” Patient #1’s “Treatment Details Report,” dated 09/10/2024, revealed staff checked the patient’s vital signs at 1:05 PM, when treatment was initiated. The report revealed no documented evidence staff obtained the patient’s vital signs again until 1:57 PM (52 minutes between checks). Patient #6’s “Treatment Details Report,” dated 09/09/2024, revealed staff checked the patient’s vital signs at 1:08 PM, when treatment was started. The report revealed no documented evidence staff obtained the patient’s vital signs again until 2:00 PM (52 minutes between checks). Patient #7’s “Treatment Details Report,” dated 09/03/2024, revealed staff checked the patient’s vital signs at 12:09 PM, when treatment was initiated. The report revealed no documented evidence staff obtained the patient’s vital signs again until 1:19 PM (1 hour and 10 minutes between checks). Patient #7’s “Treatment Details Report,” dated 09/07/2024, revealed treatment was initiated at 12:10 PM. The report revealed staff checked the patient’s vital signs at 1:51 PM. The report revealed no documented evidence staff obtained the patient’s vital signs again until 3:36 PM (1 hour and 45 minutes between checks). Patient #7’s “Treatment Details Report,” dated 09/12/2024, revealed treatment was initiated at 12:32 PM. The report revealed that at 1:03 PM the patient reported “stabbing pain” to the chest and at 1:05 PM stated they felt “ok.” The report revealed staff checked the patient’s vital signs at 1:33 PM and there was no documented evidence staff obtained the patient’s vital signs again until 3:05 PM (1 hour and 32 minutes between checks). During an interview on 09/25/2024 at 4:55 PM, the Facility Administrator stated the facility expectation was that patient vital signs be checked every 30 minutes. During an interview on 09/26/2024 at 12:47 PM, the Medical Director indicated that the facility expectation was that patients be monitored every 15 to 30 minutes during treatment.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure staff followed the facility procedure for cannulation of a dialysis access site during 1 of 2 observations of cannulation. Findings included: The facility policy’s titled, “AV [Arteriovenous] Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula edles (SFN) and Administration of Heparin Loading Dose,” with a last revision date of October 2022, instructed staff to “11. While maintaining aseptic technique, cleanse the [cannulation] sites by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.” It further instructed staff, “13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” During an observation on 09/24/2024 at 8:16 AM, Certified Clinical Hemodialysis Technician (CCHT) #15 initiated dialysis at Treatment Station #20. CCHT #15 applied antiseptic to the patient’s dialysis access site then palpated the access and inserted the cannulation needle. CCHT #15 touched the cannulation site after disinfection. During an interview on 09/26/2024 at 9:30 AM, the Facility Administrator confirmed that the skin should not be touched after the application of antiseptic and prior to cannulation, per policy. During an interview on 09/26/2024 at 12:47 PM, the Medical Director stated that during cannulation, the skin should not be touched after the antiseptic has been applied and that staff were expected to follow the facility’s policy when performing cannulation.”