Davita Dunkirk Dialysis

“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, nursing staff do not follow standard infection control practices regarding the use of gloves and hand hygiene. Findings include: Review of the policy “Infection Control for Dialysis Facilities,” revised April 2023, indicated all teammates will perform hand hygiene prior to gloving and immediately after the removal of gloves, after patient and dialysis delivery system contact, and before touching clean areas such as supplies, supply cart, and chairside keyboard/mouse. Review of the policy “Medication Policy,” revised October 2023, indicated all teammates administering medications must utilize aseptic (practices to prevent spread of infection) technique. An aseptic environment and aseptic technique are used when preparing medications. Careful attention to proper handwashing is performed at this time. Observation on 12/02/25 from 12:35 PM to 12:55 PM in the patient care area revealed the following: -At 12:35 PM, Staff (L), Registered Nurse, wore gloves to prepare and label medications at the medication counter/prep area. Without removing their gloves, Staff (L) exited the medication prep area to deliver oral medications to Station #4 for Patient #9. Without removing gloves, Staff (L) returned to the medication prep area, retrieved medication from the medication fridge and opened a drawer to retrieve a syringe. Staff (L) removed their gloves but did not perform hand hygiene and exited the unit to the supply storage area. -At 12:45 PM, Staff (L), entered Station #1 for Patient #11. Without performing hand hygiene, Staff (L) applied clean gloves and administered medications intravenously (IV-into the vein) through the hemodialysis machine. Staff (L)removed their gloves and exited the station without performing hand hygiene. Staff (L) returned to the medication prep area, did not perform hand hygiene, and applied a new pair of gloves before delivering/administering IV medication to Station #6 for Patient #10. Staff (L) removed their gloves, but did not perform hand hygiene before touching the computer keyboard to document in the electronic medical record. -At 12:55 PM, Staff (L) was preparing to discontinue treatment for Patient #10 at Station #6. Without removing their gloves, Staff (L) exited Station #6 and entered the nursing station area, across from Station #7 & #8, to move a medication infusion pump/pole that they stated needed to be disinfected “when they were done with Patient #10.” Staff (L) returned to Station #6, removed/changed their gloves but did not perform hand hygiene. Staff (L) discontinued (returned blood) Patient #10’s treatment, removed their gloves, but did not perform hand hygiene before applying a new pair of clean gloves to remove Patient #10 needles and hold gauze on the needle insertion sites until bleeding stopped. Staff (L) then removed gloves but did not perform hand hygiene and applied a new pair of clean gloves to tape gauze to the needle insertion sites. Interview on 12/04/25 at 10:45 AM with Staff (B), Registered Nurse, 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: 40430 Based on policy review, observation, and interview, the facility failed to ensure personal protective equipment (PPE-equipment worn for protection from workplace hazards such as blood) such as gowns, face shields, eye wear, or masks were worn properly when performing procedures during which spurting or splattering of blood may occur. Findings include: Review of the policy “Personnel Protective Equipment,” dated August 2006, indicated teammates will wear PPE including, but not limited to full face shields or mask and goggles. Review of the policy “Infection Control For Dialysis Facilities,” April 2023, indicated appropriate PPE (i.e., gown, gloves, eye protection, face shield) will be worn whenever there is the potential for contact with body fluids. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. Observation on 12/02/25 at 12:40 PM, at the lab supply/processing counter/area revealed Staff (L), Registered Nurse, without wearing gloves, removed two blood filled lab specimen tubes from the centrifuge (device used to separate the contents of blood in blood tubes for diagnostic tests) and placed them in the laboratory refrigerator. Staff (L), then placed two blood filled tubes into the centrifuge without wearing gloves. At 01:00 PM at Station #6 for Patient #10, Staff (L) discontinued treatment for Patient #10. Staff (L) removed their gloves and packed up Patient #10 personal belongings. Staff (L) reset a machine alarm two times without wearing gloves. Observation on 12/03/25 at 09:55 AM at Station #9 for Patient #8 revealed Staff (M), Patient Care Technician, cannulated (inserted needles) Patient #8’s fistula (surgically created access for dialysis) and initiated dialysis treatment. Staff (M) was wearing eye protection/goggles, but their surgical mask was below their nose with their nostrils exposed. At 10:20 AM at Station #11 for Patient #15 and at 02:36 PM at Station #8 for Patient #16 Staff (M) discontinued Patient #15 and Patient #16 treatment, removed their needles, and held the needle sites until the bleeding stopped. Staff (M) was wearing eye protection/goggles, but their surgical mask was below their nose with their nostrils exposed. Interview on 12/04/25 at 10:45 AM with Staff (B), Registered Nurse, verified the findings.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 25545 Based on observation and interview, for four of 14 hemodialysis machines observed, the facility did not ensure that all hemodialysis machines on the treatment floor are cleaned and disinfected between patients (hemodialysis machine #4, #8, #11, and #16). Findings include: Observation on 12/03/25 at 01:20 PM on the treatment floor revealed hemodialysis machines #4, #8, #11 and #16 had medical tape on the fold-down keyboard, and the fold-down touch pad. The medical tape was not changed between patient treatments, and it is not a fluid resistant material that is capable of being decontaminated. Staff (K), Registered Nurse, stated the tape on the hemodialysis machines is to hold the lower piece of the keyboard to the upper piece (of the hemodialysis machine). Interview on 12/04/25 at 10:00 AM with Staff (E), Biomedical Staff, verified these findings.”

“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: 25545 Based on observation, document review, and interview, the facility does not ensure there is hot water at 12 of 12 sink faucets and there is not tepid water at one of one eye wash stations on the treatment floor. Findings include: Observation on 12/02/25 at 11:15 AM on the treatment floor revealed 12 of 12 sink faucets had a temperature of 58.1 degrees Fahrenheit from the hot water. The eyewash had a temperature of 58.1 degrees Fahrenheit. The “Facilities Guidelines Institute- 2018 edition,” requires a minimum temperature of 105 degrees Fahrenheit for faucets at sinks and requires eye wash stations to be tepid with a minimum of 60 degrees Fahrenheit. Review of the work order document number “WEB-681939,” revealed an entry dated 09/18/25 that indicated “...there’s no hot water on the treatment floor.” Interview on 12/03/25 at 1:15 PM with Staff (E), Biomedical Staff, verified these findings.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 40430 Based on policy review, observation, document review, and interview, the facility does not maintain equipment according to the manufacturer instructions Specifically, the facility does not ensure expired supplies are not available for use. Findings include: Review of the policy “Obtaining Patient Lab Specimens,” revised October 2025, indicated teammates are to verify the expiration date on all laboratory specimen tubes. Expired laboratory specimen tubes are not to be used and are to be discarded. Review of the policy “Blood Glucose Testing,” revised April 2025, indicated the monitor and test strips are stored and used according to monitor manufacturer instructions. Expired control solutions and test strips are not used. Observation on 12/02/25 at 11:00 AM in the nursing station and lab supply area/cupboards revealed one bottle of “Glucose Meter Test Strips (used to test blood sugar levels)” were opened but not labeled with “opened on” date. The “notice” printed on the side of the bottle indicated the test strips expire four months after opening; one “control solution one” bottle and one control solution two (solutions used to check if glucose meter is working accurately)” bottle were not labeled with “opened on” date. The “notice” printed on the side of the bottle indicated the control solutions expire three months after opening; 13 dark blue/navy top blood tubes (used for laboratory tests) expired on 04/01/25; and eight light blue top blood tubes expired on 10/31/25. Interview on 12/03/25 at 09:30 AM with Staff (H), Registered Nurse, 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, for one of six medical records reviewed, nursing staff did not ensure the hemodialysis prescription was implemented and/or maintained as ordered by the physician. Specifically, the duration of treatment/time, dialysate flow rate (DFR- the rate solution used during dialysis to clean blood and maintain electrolyte/mineral balance in the body), and blood flow rate (BFR- the rate blood is processed during dialysis) were not implemented/maintained as ordered (Patient #20). Findings include: Review of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” 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 of the medical record flowsheets for Patient #20, dated 11/11/25 to 12/02/25, revealed a physician order for 210-minute (3.5 hours) duration/treatment time, a BFR of 400 milliliters per minute (ml/min), and DFR of 600ml/min. The BFR and DFR were not implemented/maintained as ordered on 11/14/25. The treatment time was not implemented as ordered on 12/02/25. There was no documentation in the medical record to indicate why the BFR, DFR and/or time were not implemented as ordered. Interview on 12/04/25 at 10:45 AM with Staff (B), Registered Nurse, verified the findings.”