Davita Suburban Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, the facility does not ensure staff follow the facility process for verification of emergency equipment. Findings include: Review on 09/10/24 of the policy “Emergency Equipment Checks,” last revised 04/2024, indicated the emergency cart (crash cart) will be checked weekly to ensure supplies/medications have not expired. Additionally, the facility administrator or designee will review the contents of the emergency evacuation kit and replace missing or expired supplies at least monthly. Observation on 09/10/24 at 11:00 AM, on the in-center patient treatment floor, revealed an emergency crash cart that contained two D batteries with an expiration date of 03/2019. Staff (M), Registered Nurse, verified this finding. Observation on 09/10/24 at 11:15 AM, on the in-center treatment floor, revealed an emergency evacuation kit/box that contained three D batteries with an expiration date of 03/2019; four C batteries that expired 2017; one 12-ounce bottle of Purell hand sanitizer that expired 05/2023; two 10 milliliter (ml) prefilled normal saline syringes that expired 05/31/24; and ten 10 ml syringes with glide needles that expired 04/30/24. Interview on 09/12/24 at 09:40 AM with Staff (M), Registered Nurse, and at 10:00 AM with Staff (F), Facility Administrator, verified these findings.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34528 Based on policy review, observation, and interview, staff did not wear personal protective equipment (PPE) appropriately while performing procedures during which the spurting or spattering of blood might occur. Findings include: Review on 09/10/24 of the policy “Infection Control For Dialysis Patients,” last revised 04/2023 revealed appropriate personal protective equipment (gowns, gloves, eye protection, face shield) will be worn whenever there is the potential for contact with body fluids and hazardous chemicals. Observation on 09/10/24 at 11:00 AM revealed Staff (L), Licensed Practical Nurse, stripped the used blood lines off the hemodialysis machine at Station #4 with their face shield located up on their forehead and not covering their nose and mouth. Observation on 09/10/24 at 11:45 AM revealed Staff (L), Licensed Practical Nurse, cannulated a fistula hemodialysis access with needles and initiated treatment for Patient #3 at Station #6 with their face shield located up on their forehead and not covering their nose and mouth. Interview on 09/12/24 at 11:30 AM with Staff (F), Facility Administrator, verified these findings.”

“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: 16136 Based on observation and interview, the facility does not ensure that bicarbonate (used to neutralize or buffer acids produced by the ingested proteins) containers are labeled the with the solution contained within the container. Findings include: Observation on 09/10/24 at 10:50 AM in the incenter patient treatment area across from Station #18 revealed a rectangular container, containing a solution, that was placed on a white rack, was not labeled with the contents. The container had a significant amount of white precipitate on the sides and bottom. Interview on 09/12/24 at 01:30 PM Staff (H), Biomedical Technician, verified this finding and stated that the solution was from the staff emptying the Solcarts (bicarbonate containers) in the container to allow them to drain.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 34528 Based on policy review, observation, and interview, nursing staff did not ensure that aseptic technique was used to prepare intravenous medications. Findings include: Review on 09/11/24 of the policy “Preparation and Administration of Parenteral Medications (Non-Esa, Non-Parsabiv),” last revised 04/2024 indicated if the medication is in a vial, clean vial stopper with an alcohol prep pad. A new alcohol prep pad will be used prior to each time a vial is entered. Observation on 08/11/24 at 08:45 AM at the medication preperation counter revealed Staff (P) Registered Nurse, was drawing up heparin (medication used to prevent blood clotting during dialysis) into two syringes for Patient #17 and #18 but did not swab the vial stopper with an alcohol pad during the initial entry or for a subsequent entry into the vial with a needle. Observation on 09/12/24 at 09:55 AM at the medication preperation counter dication preperation revealed Staff (M) Registered Nurse, was drawing up one syringe of Zofran (medication to prevent nausea and vomiting) and did not swab the vial stopper before entering the vial with a needle. Interview on 09/12/24 at 11:30 AM with Staff (F), Facility Administrator, verified these findings.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 16136 Based on policy review, document review, and interview, the facility does not ensure that the water hardness level is maintained within the facility parameters. Findings include: Review on 09/10/24 of the policy “Hardness Test Using RPC Water Hardness Test Strips,” last revised 09/2015 indicated to notify the Biomedical Technician and Facility Administrator if the end of day hardness test results are greater than one grain/gallon and corrective action will be taken. Review on 09/10/24 of the “Daily Water Log,” dated from 06/03/24 through 08/24/24 revealed that the end of day hardness test was documented at seven grain/gallon on 06/03/24 and at three grain/gallon on 07/08/24, 08/05/24, 08/12/24, and 08/19/24. There was no documentation that the Biomedical Technician or Facility Administrator were notified or if corrective action had been performed. Interview on 09/11/24 at 01:45 PM Staff (H), Biomedical Technician, verified this finding.”

“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: 16136 Based on observation, document review, and interview, the facility does not ensure nameplates (lists the fire rating resistance timeframe) of the fire-resistant doors are visible for two of two fire doors per National Fire Protection Association (NFPA) 80-2010 edition and/or that penetrations are sealed in the one-hour fire wall per Life Safety Code (LSC) 101-2012 edition. Findings include: Observation on 09/12/24 at 11:00 AM revealed that the nameplates on the frames for the two one-hour fire doors were painted over with dark brown paint. These doors were located at the entrance into the regulated medical waste room and entering the water room. Review on 09/12/24 of the “Fire Door Inspection Annual Report,” dated 05/10/24 indicated that the nameplate labels were clearly visible. Observation on 09/12/24 at 11:15 AM in the social worker’s office revealed a penetration was present in the one-hour fire rated wall above the ceiling tiles. This penetration consisted of a three-inch hole in the drywall with a half inch conduit passing through the drywall. The penetrations must be filled with a fire rated compound to prevent the spread of smoke and fire in the event of an emergency. Interview on 09/12/24 at 11:20 Staff (H), Biomedical Technician, verified these findings.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 16136 Based on document review and interview, the facility does not ensure that records for testing and inspection of the fire alarm and sprinkler systems are available for review per the National Fire Protection Association (NFPA) 72 and NFPA 25. Findings include: Review on 09/11/24 of facility documents and work orders related to the fire alarm system and the sprinkler system revealed no evidence that the systems were tested and inspected per National Fire Protection Association (NFPA) 72 and NFPA 25. Review of the documentation indicated that the landlord is responsible for maintaining the systems. Interview on 09/12/24 at 11:00 AM with Staff (H), Biomedical Technician, verified this finding.”

“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: 16136 Based on policy review, observation, medical record review, and interview, nursing staff did not ensure that the dialysis prescription was verified by another teammate prior to initiation of the hemodialysis treatment for one of two patients (Patient #2) and did not ensure blood flow rates were maintained per physician order for one of six patients (Patient #23). Findings include: Review on 09/10/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/2024 revealed patient identity, prescription and machine settings are verified prior to initiation of treatment. The prescription components are confirmed by a licensed nurse within one hour of treatment initiation. 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 will be informed. Observation on 09/10/24 at 11:40 AM at Station #1 for Patient #2 revealed that the acid concentration, solution used during hemodialysis that contains various electrolytes, being utilized was a 3 K (Potassium) 2.5 Ca (Calcium). Review of the physician orders dated 09/10/24 indicated that the prescribed acid concentrate for Patient #2 was a 2 K 2.5 Ca. Interview with Staff (K), Licensed Practical Nurse, verified this finding. Review on 09/11/24 of the hemodialysis treatment flowsheets for Patient #2 dated 09/10/24 indicated treatment was initiated by a Staff (J), Patient Care Technician at 10:47 AM, but the ordered treatment prescription was not verified by Staff (I), Registered Nurse until 12:33 PM. Review on 09/11/24 of the hemodialysis treatment flowsheets for Patient #23 from 08/17/24 to 09/07/24 revealed the ordered blood flow rate of 450 ml/min was not maintained for two of ten treatments (08/17/24 & 09/07/24). There was no documentation in the medical record indicating why the blood flow was not maintained. Interview on 09/11/24 at 10:15 and on 09/12/24 at 11:30 AM with Staff (F), Facility Administrator, verified these findings.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 34528 Based on policy review, medical record review, and interview, post treatment assessments were not completed timely and/or not signed off as completed by a registered nurse for three of six patients (Patient #16, #24, and #25). Findings include: Review on 09/11/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/2024 revealed the registered nurse will assess the patient prior to discharge. Review on 09/11/24 of the hemodialysis treatment flowsheets Patient #16 from 08/14/24 to 09/09/24 revealed on 08/30/24, treatment was terminated at 10:37 AM. The registered nurse post treatment assessment was signed off as completed at 11:51 AM. Review on 09/11/24 of the hemodialysis treatment flowsheets for Patient #24 from 07/19/24 to 08/30/24 revealed on 07/24/24, treatment was terminated at 10:51 AM. There is no documented registered nurse post treatment assessment. On 08/26/24, treatment was terminated at 10:36 AM. The registered nurse post treatment assessment was signed off as completed at 12:18 PM. Review on 09/11/24 of the hemodialysis treatment flowsheets for Patient #25 from 08/19/24 to 09/06/24 revealed on 09/06/24, treatment was terminated at 10:14 AM. There is no documented registered nurse post treatment assessment. Interview on 09/12/24 at 11:30 AM with Staff (F), Facility Administrator, verified these findings.”