Davita Jamestown Dialysis Center

“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 do not wear personal protective equipment (PPE) appropriately while performing procedures during which the spurting or spattering of blood might occur. Findings include: Review on 10/04/24 of policy “Infection Control for Dialysis Facilities,” last revised April 2023 indicated appropriate personal protective equipment (gowns, gloves, eye protection, face shield) will be worn whenever there is a potential for contact with body fluids, hazardous chemicals, contaminated equipment, and environmental surfaces. Observation on 10/04/24 at 09:15 AM at Station #10 for Patient #4 revealed Staff (L), Registered Nurse wore their mask under their nose while cleaning the central venous catheter line connections. Observation on 10/04/24 at 09:30 AM at Station #5 for Patient #10 revealed Staff (O), Licensed Practical Nurse wore their mask under their nose while removing the blood lines off the hemodialysis machine post treatment. Observation on 10/04/24 at 09:45 AM at Station #6 for Patient #8 revealed Staff (O), Licensed Practical Nurse, wore their mask under their nose while removing the blood lines off the hemodialysis machine post treatment. Observation on 10/04/24 at 10:05 AM at Station #7 for Patient #9 revealed Staff (O), Licensed Practical Nurse, wore their mask under their nose when removing the arterial and venous access needles from the fistula post treatment. Interview on 10/04/24 at 02:00 PM with Staff (G), Regional Coordinator, verified these findings.”

“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 do not use aseptic technique 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 April 2024 indicated if the medication is in a vial, staff are to clean the 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 10/02/24 at 11:55 AM at the medication preparation counter revealed Staff (Q), Registered Nurse, did not swab the stopper of a Venofer (medication used for iron deficiency) vial with an alcohol prep pad prior to inserting a needle into the vial to draw the medication up into a syringe. Observation on 10/02/24 at 12:00 PM at the medication preparation counter revealed Staff (P), Registered Nurse, did not swab the stopper of a Heparin (medication used to prevent blood clotting during dialysis) vial with an alcohol prep pad prior to inserting a needle into the vial to draw the medication up into a syringe. Interview on 10/04/24 at 02:00 PM with Staff (G), Regional Coordinator, 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: 25545 Based on document review, observation, and interview, the facility did not ensure that the results of the water hardness testing are less than one grain per gallon and the brine tank (container that uses water to dissolve salt. The salt water (brine) is used clean the water softener resin inside of the water softener tank so that the resin can remove more hardness from the water) was not maintained. Findings include: Review on 10/04/24 of the “Water Equipment Log,” reveled the end of day water hardness test exceeded one grain per gallon (gr/gal) on 09/26/24 7gr/gal 09/27/24 7gr gal, and 10/02/24 7gr/gal. Observation on 10/04/24 at 11:30 PM of the brine tank revealed a layer of crusty salt build up in the brine tank. Interview with Staff (E), Biomed Technician, verified the water hardness findings and revealed that the brine tank was salt bridged (when salt pellets join in the brine tank and form a hard crust layer that prevents salt and water from mixing and producing brine). Staff (E) stated they were breaking up the salt layer with a tool and pouring water on it periodically to break the salt bridge.”

“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: 25545 Based on observation and interview, the facility failed to maintain three of eight sinks in the patient treatment area. Findings include: Observation on 10/02/24 at 11:00 AM revealed the two sinks across from Station #5 had “out of order,” signs posted on them. The sink across from Station #16 had a water leak located at the sink trap that dripped approximately one drop every 10 seconds. Interview on 10/03/24 at 01:45 PM with Staff (F), Facility Administrator, verified these findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 40430 Based on policy review, observation, medical record review, and interview, staff do not ensure all hemodialysis access sites and blood line connections are visible and uncovered throughout the hemodialysis treatment for three of 12 patients (Patient #5, Patient # 22, and Patient #23). Findings include: Review on 10/04/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 indicated that the vascular access site and blood line connections should be visible throughout the dialysis treatment. Observation on 10/02/24 from 11:30 AM to 12:45 PM at Station #1 for Patient #22 revealed their fistula (access used to provide hemodialysis) and bloodline connections were covered by their blanket. At Station #2 from 11:30 AM to 12:45 PM, Patient #5’s fistula and bloodline connections were covered by their blanket. Observation on 10/04/24 from 08:30 AM to 09:30 AM at Station #8 for Patient #23 revealed their fistula and bloodline connections were covered by their blanket. Medical record review on 10/04/24 for Patient #5, Patient #22, and Patient #23 revealed no documentation that the staff addressed the covered access sites and/or that any of the patients refused to uncover their access and/or blood line connections on 10/02/24 or 10/04/24. Interview on 10/04/24 at 02:00 PM with Staff (H), Facility Administrator, and Staff (G), Regional Coordinator, verified these findings.”

“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: 34528 Based on policy review, medical record review, and interview, nursing staff did not ensure did not ensure blood flow rates were maintained per physician order for four of seven patients (Patient #4, Patient #15, Patient# 16, and Patient #18) Findings include: Review on 10/04/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 indicated 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. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #4 dated 09/09/24 to 09/30/24 revealed the ordered blood flow rate of 350 milliliters (ml)/minute (min) was not maintained on 09/20/24. There was no documentation in the medical record indicating why the blood flow was not maintained. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #15 dated 09/09/24 to 09/30/24 revealed the ordered blood flow rate of 450 ml/min was not maintained on 09/20/24. There was no documentation in the medical record indicating why the blood flow was not maintained. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient # 16 dated 09/06/24 to 09/30/24 revealed the ordered blood flow rate of 400 ml/min was not maintained on 09/11/24 and the ordered dialysate flow rate of 500 ml/min was not maintained on 09/06/24. There was no documentation in the medical record indicating why the blood flow and dialysate flow were not maintained. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #18 dated 09/09/24 to 09/30/24 revealed the ordered blood flow rate of 350 ml/min was not maintained on 09/30/24. There was no documentation in the medical record indicating why the blood flow was not maintained. Interview on 10/04/24 at 02:00 PM with Staff (G) Regional Coordinator, 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 by a registered nurse for four of seven patients (Patient #15, Patient #16, Patient #17, and Patient # 18). Additionally, the patient care technician did not notify the licensed nurse of abnormal findings for one of seven patients (Patient #6). Findings include: Review on 10/04/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 revealed the patient care technician or licensed nurse will obtain and document basic data on each patient pre, during, and post dialysis. The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record: intradialytic (during dialysis) systolic blood pressures (BP) less than 90 millimeters of mercury (mm/Hg) and diastolic blood pressure less than 50 mm/Hg. The registered nurse will assess the patient prior to discharge. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient#15 dated 09/09/24 to 09/30/24 revealed on 09/18/24, treatment was terminated at 09:46 AM by a patient care technician. There is no documented registered nurse of a post-treatment assessment. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #16 dated 09/06/24 to 09/30/24 revealed on 09/06//24, treatment was terminated at 09:48 AM by a patient care technician. The registered nurse post-treatment assessment was signed off as completed at 11:53 AM. On 09/11/24 treatment was terminated on 09:50 AM by a patient care technician. The registered nurse post-treatment assessment was signed off as completed at 03:52 PM. On 09/30/24 treatment was terminated at 10:21 AM by a patient care technician. The registered nurse post-treatment assessment was signed off at 12:50 PM. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #17 dated 09/03/24 to 09/26/24 revealed on 09/21/24, treatment was terminated at 02:27 PM by a licensed practical nurse. The registered nurse post-treatment assessment was signed off as completed at 04:24 PM. On 09/24/24 treatment was terminated at 02:54 PM by a licensed practical nurse. The registered nurse post-treatment assessment was signed off at 04:27 PM. Review on 10/04/24 of the hemodialysis treatment flowsheets for Patient #18 dated 09/09/24 to 09/30/24 revealed on 09/11/24, treatment was terminated at 02:49 PM by a patient care technician. The registered nurse post-treatment assessment was signed off as completed at 04:28 PM. On 09/13/24 treatment was terminated on 11:24 AM by a patient care technician. The registered nurse-post treatment assessment was signed off as completed at 06:05 PM. Review on 10/04/24 of hemodialysis treatment flowsheets for Patient #6 dated 09/02/24 to 09/30/24 revealed the following: -On 09/06/24, a patient care technician documented at 02:02 PM, a blood pressure (BP) of 103/43 and at 03:03 PM, a BP of 87/42. There was no documentation in the medical record that the patient care technician notified the licensed nurse of the abnormal findings/blood pressures. -On 09/25/24, a patient care technician documented at 02:19 PM, a BP of 89/53; at 02:35 PM, a BP of 96/46; at 02:46 PM, a BP of 99/49; at 03:16 PM, a BP of 89/46; and at 03:17 PM, a BP of 80/50. There was no documentation in the medical record that the patient care technician notified the licensed nurse of the abnormal findings/blood pressures on 09/06/24 and 09/25/24. Interview on 10/04/24 at 02:30 PM with Staff (G), Regional Coordinator, verified these findings.”