Davita Stilwell 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: 34696 Based on observation and interview, the facility failed to ensure that all staff washed or sanitized their hands between each patient, station, and/or glove removal, citing one of five staff (Personnel #3), Findings included: A review of the “Infection Control for Dialysis Facilities” policy dated 04/2023 included, “Hand hygiene ...All teammates ...will perform hand hygiene ...prior to gloving and immediately after removal of gloves ...after patient and dialysis delivery system contact ...before touching clean areas such as supplies, supply cart, and chair side keyboard/mouse ...PPE (personal protective equipment) ...i.e. gown, gloves, eye protection, face shield ...appropriate PPE will be worn where there is the potential for contact with body fluids ...contaminated equipment, and environmental surfaces.” On 06/19/2024, during observation of care in the hemodialysis treatment area, the following was observed: ~ At 10:15 AM, a PCT (Patient Care Technician, Personnel #3) was observed providing care to Patient #3 at hemodialysis station #12. The PCT was observed cannulating Patient #3’s left upper arm vascular access. She did not have on a face shield. The PCT was observed removing and changing her gloves five times without washing or sanitizing her hands. At 10:30 AM, during an interview, the PCT said she had worked at the facility for three months. The PCT was asked if her glasses were prescribed eye wear. She said, “Yes.” She said that she had forgotten to put on her face shield that was sitting at the nurse’s station. The PCT was asked when and how often she was supposed to sanitize or wash her hands. She said she was supposed to sanitize here hands every two glove changes. On 06/19/2024 at 10:35 AM, the Charge Nurse (Personnel #5) said a face shield should be worn every time patients’ treatments were initiated. The Charge Nurse said personnel should wash or sanitize their hands before and after every glove change. At 10:50 AM, the PCT (Personnel #3) was further observed setting up the dialysis machine at station #16. She removed her gloves and did not wash or sanitize her hands. She went to station #14 and put on clean gloves. The surveyor asked to remove her gloves and sanitize her hands.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 34696 Based on record review and interview, the facility failed to ensure that one of five (Personnel #8) received annual infection control and OSHA training. Findings included: ~ On 06/19/2024 at 10:20 AM, during observation of care in the hemodialysis treatment area, RN (Registered Nurse, Personnel #8) said she worked as a floater at the facility. Review of the Personnel #8’s training record did not include documented evidence of an annual infection control training. On 06/20/24 at 9:25 AM, the Manager of Clinical Services (Personnel #4) said the RN did not have a current annual infection control training. At 10:00 AM, the Group Facility Administrator (Personnel #2) said she was responsible for ensuring that float personnel training is up to date.”

“BICARB JUGS RINSED DAILY/STORED DRY CFR(s): 494.40(a) 6.5 Concentrate distribution: bicarb jugs rinsed daily/stored dry Bicarbonate concentrate jugs should be rinsed with treated water and stored inverted at the end of each treatment day. Pick-up tubes should also be rinsed with treated water and allowed to air dry at the end of each treatment day. This Standard is not met as evidenced by: 34696 Based on observation, interview, and record review, the facility failed to ensure that bicarbonate concentrate jugs that were found in two of two areas (Exam room and Biomed Repair area) were rinsed with treated water and stored inverted at the end of each treatment day. Findings included: On 06/19/2024, during a tour of the facility, the following was observed: ~ At 9:35 AM, it was observed that five bicarbonate jugs were sored in an overhead cabinet in the facility’s exam room. The jugs were dusty and not inverted. At the time of the findings, the FA (Facility Administrator, Personnel #1) said the jugs should not have been stored in the room. ~ At 10:00 AM, it was further observed that three bicarbonate jugs were in the Biomed Repair area. The jugs were not clean and stored inverted. At the time of the findings, the Biomed (Personnel #6) said the facility had not used the jugs since getting new dialysis machines in 12/2023.”

“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: 34696 Based on observations, interviews, and record review, the building in which dialysis services are furnished was not maintained to ensure the safety of the patients, the staff, and the public in three of three areas (Supply Loading area, Water Treatment area, Storage area, Hemodialysis Treatment area, Findings included: A review of the “Contracted Housekeeping Services” policy dated 10/2023 included, “Each dialysis treatment facility shall establish organized housekeeping services that are planned, operated, and maintained to provide a safe, and sanitary environment. The contracted services should be under the supervision of a person competent in environmental sanitation and management. A review of the “Bicarbonate Concentrate System Mixing” policy dated 04/2024 included, “If individual reusable bicarbonate containers are used to supply dialysis delivery systems ...the containers should be rinsed with dialysis quality water at the end of the treatment day and then stored inverted to dry.” On 06/19/2024, during a tour of the facility, the following was observed: ~ At 9:35 AM, it was observed that the floor in the supply loading area was dirty and had black streaks. ~ At 9:40 AM, it was observed in the Water Treatment area that the floor had not been maintained. The floor had dried acid splattered on the floor between acid mixer and the 2 K+ (potassium) holding tank. ~ At 9:50 AM, the floor in the Storage area was gritty and dirty with trash underneath the rolling storage shelves. ~ At 10:10 AM, the water and ice dispenser in the Hemodialysis Treatment area, available for patient use, was dirty and unclean. The dispenser was labeled “Clean air filter twice a month.” The shoot in which water and ice was dispensed was unclean with white stains and crust. The drain tray underneath the dispense shoot was unclean and had white stains. The side of the machine where the filter was located had white streaks. At the time of the finding, the FA (Facility Administrator, Personnel #1) said there was no documented evidence of a cleaning and/or maintenance log for the machine.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 34696 Based on record review and interview, the Interdisciplinary Team (IDT) failed to complete a monthly Plan of Care (POC) for one of one patient (Patients #2) who was deemed unstable. Findings included: A review of the “IDT Patient Assessment and Plan of Care” policy dated 07/2023 included, “Monthly (unstable patients) ...Assessment ...Monthly until patient is deemed by the IDT to be stable ...Plan of Care ...Complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC.” ~ Patient #2: The clinical record indicated that Patient #2 was made unstable on 04/16/2024 by the Social Worker, “Reason ...psychosocial/uninsured.” On 06/20/24 at 9:55 AM, The Manager of Clinical Services (Personnel #4) said there was no documented evidence of a follow up monthly POC for Patient #2 in May 2024 to deem them stable or unstable.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure that the necessary care and services was provided to one of one patient (Patient #5) to achieve and sustain a clinically appropriate hemoglobin/hematocrit level. Findings included: ~ Patient #5: A review of the facility’s “IDT Rounding Report” dated from 04/01/2024 to 06/19/2024 indicated Patient #5 had a low Hgb (hemoglobin) on 04/23/2024 was 6.6. A “one time lab order” dated from 05/06/2024 to 05/17/2024 indicated that the Hgb should have been drawn one day during that date range. Patient #5 missed some treatments in May but presented for treatments on 05/112024 and 05/14/2024. There was no documented evidence that the Hgb was drawn during the time of the lab order. On 06/20/2024 at 12:35 PM, the Group Facility Administrator (Personnel #1) said Patient #5’Hgb was not drawn during that time when the patient presented for treatment.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure that all care was performed and documented in the dialysis flow sheet for one of four patients (Patient #1). Findings included: A review of the “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy dated 04/2024 indicated, “Patient data will be obtained and documented by the PCT (patient care technician) or a licensed nurse...Sitting and standing blood pressure measurement required pre and post treatment (if patient unable to stand, documentation in the patient electronic record or flow sheet)... Blood pressure post treatment...If patient is not able to stand, document reason and sitting blood pressure.” ~ Patient #1: A Review of the hemodialysis records indicated that the treatment records were incomplete. The treatment records indicated in the “Pre-Treatment Vitals” and “Post-Treatment Vitals” sections, “Mobility ...Ambulates, No assistance needed ...Ambulatory ...Ambulatory, No assistance needed.” There was no documented evidence of the pre and post treatment standing vitals dated from 05/20/2024 to 06/19/2024. On 06/20/2024 at 11:00 AM, the Group Facility Administrator (Personnel #2) said patients who are ambulatory should have documented pre and post standing vitals.”