Davita Niagara Dialysis Center

“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: 40430 Based on policy review, observation, and interview, staff do not follow standard infection control practices regarding the use of gloves and hand hygiene. Failure to follow standard infection control practices places patients and staff at risk for a potential infection. Findings include: Review on 05/07/24 of the policy “Infection Control for Dialysis Facilities,” last revised April 2023 indicated that all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, and before touching clean areas such as supplies. Review on 05/07/24 of the policy “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” last revised October 2023 indicated that staff are to remove gloves, perform hand hygiene and re-glove after removing the old dressing, prior to cleaning the CVC exit site. Observation on 05/07/24 at 01:45 PM at Station #6 revealed Staff (K), Patient Care Technician was discontinuing treatment for Patient #21. Staff (K) grabbed the sharps container (container for contaminated supplies/needles on wheels), with their clean gloved hand, to move it closer. Staff (K) proceeded to handle clean gauze pads to remove Patient #21’s fistula (access used for dialysis) needles and hold pressure to the needle insertion sites. Staff (K) did not remove gloves, perform hand hygiene, and apply new gloves after touching the sharp’s container. Observation on 05/08/24 at 10:30 AM, at Station #12 revealed Staff (I), Registered Nurse was completing catheter exit site care for Patient #16. Staff (I) removed the old dressings covering the catheter exit site and ports, but did not change gloves, perform hand hygiene, and apply clean gloves prior to continuing with catheter care. Staff (I) proceeded to place a clean gauze pad under the catheter ports. Staff (I) reached for the sharp’s container, grabbed the handle with their gloved hand to move it closer, and continued with catheter care. Staff (I) did change gloves, perform hand hygiene, and/or apply clean gloves after touching the sharp’s container. Observation on 05/08/24 at 11:10 AM at Station #8 revealed Staff (I), Registered Nurse, was completing catheter exit site care (site where the catheter enters the body) for Patient #18. Staff (I) removed the old dressings covering the catheter exit site and ports, but did not change gloves, perform hand hygiene, and apply clean gloves prior to continuing with catheter care. Interview on 05/09/24 at 01:15 PM with Staff (F), Facility Administrator, verified these findings.”

“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: 40430 Based on policy review, observation, and interview, nursing staff did not standard aseptic technique while performing central venous catheter (catheter-access used for dialysis) care. This has the potential for exposing patients and staff to infections. Findings include: Review on 05/07/24 of the policy “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” last revised October 2023 indicated that upon completion of dialysis, staff are to discard the existing barrier and place a new, clean moisture proof barrier under the catheter to prevent contamination, prior to aseptically disconnecting the blood lines from the catheter ports. Observation on 05/07/24 at 01:40 PM at Station #5 for Patient #19 and at 01:50 PM at Station #11 for Patient #5 revealed Staff (B), Nurse Manager discontinued treatment via catheter for both patients. Staff (B) did not place a clean, moisture proof barrier under the catheter ports while disconnecting the blood lines from the catheter ports. Observation on 05/08/24 at 09:35 AM at Station #9 revealed Staff (G), Licensed Practical Nurse discontinuing treatment via catheter for Patient #23. Staff (G) did not place a clean, moisture proof barrier under the catheter ports while disconnecting the blood lines from the catheter ports. Interview on 05/09/24 at 01:15 PM with Staff (F), Facility Administrator, verified these findings.”

“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: 42572 Based on observation and interview, the building is not maintained, free from defects and/or hazards, to ensure safety and functionality for patients, staff, and visitors. Findings include: Observation on 05/07/24 at 10:45 AM in the water room revealed there was water leaking from the threaded plumbing fittings on both sides of the deionization filter. There was an approximately one square foot puddle on the floor below the leak. Observation on 05/07/24 at 01:30 PM in information technology room on the second floor revealed a two-inch round penetration in the floor with cables running through it without a fire stop sealing system (prevent the spread of fire and smoke) in place. Observation on 05/07/24 at 02:00 PM in the elevator machine room on the second floor revealed that above the drop ceiling, there was a four-inch sprinkler line, two-inch sprinkler line, and a two-inch by four-inch hole, creating penetrations in the two-hour fire barrier wall without a fire stop sealing system in place. Observation on 05/07/24 at 02:05 PM on the second floor revealed a 90-minute fire rated door to the elevator machine room that did not have an automatic closing device installed. Interview on 05/07/24 at 02:15 PM with Staff (E), Biomed Technician, 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: 40430 Based on policy review, medical record review, and interview, the facility does not ensure that blood flow rates are maintained per physician order for one of five patients (Patient #1). Failure to maintain the ordered blood flow rate has the potential for an inadequate hemodialysis treatment and/or a delay in identifying an issue with the access. Findings include: Review on 05/08/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024 indicated that if the dialysis prescription is not being met, including dialysis blood flow rate, the reason will be documented. Review on 05/08/24 of the treatment flow sheets for Patient #1 from 04/13/24 to 05/07/24 revealed the prescribed blood flow rate of 400 ml/minute was not maintained on 04/25/24 and 04/27/24. There was no documentation in the medical record to indicate why the blood flow rate was not maintained as prescribed. Interview on 05/09/24 at 01:15 PM with Staff (F), Facility Administrator, verified these findings.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 40430 Based on medical record review, policy review, and interview, the facility does not ensure orders are promptly placed in the medical record for 1 of 5 patients. (Patient #2). This practice can lead to an inadequate dialysis prescription for patients and an adverse patient outcome. Findings include: Review on 05/08/24 of the policy “Non-Physician Practitioner (NPP) Order Policy,” revised April 2024 indicated verbal orders may only be taken by a licensed nurse teammate authorized to accept physician/provider verbal orders. All orders must be entered into the electronic health record. Review on 05/08/24 of the medical record for Patient #2 revealed the following: -On 04/23/24, the provider ordered the bicarbonate to be changed from 38 to 32. -On 04/25/24 and 04/27/24 (two of seven treatments), staff documented the bicarbonate as 38.). -Medical record review found no documentation to indicate why the bicarbonate was not at the prescribed setting. Interview on 05/09/24 at 10:15 AM with Staff (I), Registered Nurse, revealed the provider was in to see Patient #2 during dialysis on 04/23/24 and changed the bicarbonate order for treatment. Interview on 05/09/24 at 01:15 PM with Staff (F), Facility Administrator, verified these findings.”