Davita Hermiston Community Dialysis Center

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on interview and review of fire drill documentation, it was determined the facility failed to ensure fire drills were conducted according to the facility’s policies and procedures. Findings: Review of the facility’s fire drill documentation from 01/01/2023 through 03/08/2024 revealed: - During Q1 of 2023, a fire drill was completed on Thursday, 02/16/2023. The facility failed to provide documentation that a fire drill was completed for staff and patients receiving treatments on MWF. - During Q2 of 2023, a fire drill was completed Wednesday, 06/28/2023. The facility failed to provide documentation that a fire drill was completed for staff and patients receiving treatments on TTS. Review of the facility policy “04-07-04” titled, “Facility Emergency Management Plan,” dated as last revised April 2022 stipulated in the section titled “Emergency Drills ... 3. Fire safety drills ... b. Required on a QUARTERLY basis c. One drill to be conducted for each shift of patients ... Document training for both teammates and patients.””

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 37237 Based on observation and review of documentation, it was determined that the facility failed to ensure that the water treatment and storage system was located in a secure area. Findings: Observation from the treatment floor area on 03/11/2024 at 1235 revealed a propped-open hallway door into a storage area. Visible through the door from the hall was the water purification and storage system room. The water room was accessed through the storage area. The accordion-style security door in place to restrict access from unauthorized users into the water room was left opened. The water purification and storage area room could be accessed from anyone allowed entrance inside the treatment area without proper observation by staff. Review of the facility policy “2-03-01” titled, “Water Treatment Systems Minimum Component Requirement,” dated as last revised October 2021, stipulated in the section “General” that “Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system and supply ordering.””

“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: 31224 Based on observation, interview and review of documentation it was determined that the facility failed to ensure that the building was constructed and maintained to ensure the safety of the patients, staff and the public. Findings: Observations of the facility on 03/11/2024 beginning at 1230 revealed: * One box containing 3 cc luerlock syringes that expired on 01/31/2023. * Three boxes containing 3 cc luerlock syringes that expired on 04/30/2023. * An open container of pH test strips that expired on 12/31/2023. * A box containing single-dose pneumococcal vaccines, “Pneumovax 23,” that expired on 01/31/2024. * An opened MDV of “Tubersol,” (for tuberculosis testing) had a handwritten label with “opened 01/24 ... expires 02/24” attached to the vial. The opened date lacked the specific date the MDV had been opened, so the 28-day BUD required for MDVs could not be determined. * The glucometer kit lacked the vial of “Control Solution 1,” and “Control Solution 2” expired on 02/19/2024. Accurate glucometer testing could not be done without both control solutions. - Review of the glucometer logs for March 2024 revealed staff documented “2-19-24” as the expiration date for both the “Low Control” and “High Control” solutions between 03/01/2024 and 03/11/2024. No “Low Control” data was recorded for 03/11/2024. “Control Solution 1” and “Low Control” are the same and are used to check the accuracy of the lower glucose range. - Review of the glucometer logs for 02/01/2024 - 02/07/2024 revealed staff documented “1-5-24” as the expiration date for the “High Control” solution. * The lids on the eyewash were flipped open and the nozzle holes were exposed and dirty. * The walls in the Home Training room, and in a few other areas of the facility, had compromised integrity as a result of unpatched holes and chipped paint. * The backs of three of the treatment chairs were observed to have an accumulation of white precipitate, dirt and debris on the upholstery and metal components. * The metal connections in the wall boxes inside the chases were showing signs of rust and corrosion with an excessive accumulation of white precipitate. * There were excessive amounts of white precipitate build up inside the chases, both around the metal connectors to the wall box and at connections along the acid and bicarbonate lines. * The connections for acid and bicarbonate line hookups on the outside of the wall box had a white precipitate accumulation on the metal plates and on the connector threads. Some had rust accumulating around the metal connector and box substrate. * Some of the black drain catches under the wall boxes into the floor had excessive amounts of white precipitate and other yellow-colored buildup accumulated on both the outside and inside surface. Review of the facility policy “1-06-01” titled, “Medication Policy,” dated as last revised October 2023 stipulated “29. Medications containing a preservative must be discarded 28 days after opening or accessed ... unless the manufacturer specifies a different date ... All medications are checked monthly for expiration dates.” Review of the facility policy “1-05-01” titled, “Infection Control for Dialysis Facilities,” dated as last revised April 2023 stipulated “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected ... Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs ... The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. Pressurized washers, spray bottles, or sprayers for cleaning purposes will not be used on wall boxes or the adjoining area[.] Teammates will monitor and address wall box residue/build up and patency issues.” The policy also stipulated “Supplies ... Supplies will be stored in a manner that maintains their integrity ... Expiration date and package integrity will be verified prior to use.” Review of the facility policy “1-08-06” titled, “Blood Glucose Testing,” dated as last revised December 2019 stipulated “Quality Control ... Expired control solutions and test strips are not used to perform QC procedures.” During interview with the FA and MCS on 03/13/2024 at approximately 1300, the above findings were confirmed.”

“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: 31224 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring or that the dialysis prescription was followed for 2 of 8 patients (Patients #s 5 and 6). Findings: 1. Review of Patient #5’s dialysis orders and treatment sheets dated 02/13/2024 through 03/09/2024 (12 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected vital signs and access checks were missed: - On 02/15/2024, the PCT documented a VS and access check at 1230. The patient was taken off of HD and received a NS flush at 1257. At 1303, the PCT documented the patient was placed back on HD, however no VS, access, or machine settings were documented as checked. The PCT documented treatment was terminated and only a BP and HR was documented 69 minutes later at 1339. - On 02/21/2024, the PCT documented a VS and access check at 1201. The next VS and access check was documented 65 minutes later at 1306. - On 02/29/2024, the PCT documented a VS and access check at 1307. The PCT documented a VS and access check 117 minutes later when treatment was terminated at 1457. * The treatment flowsheets reflected the physician orders for Max UFR was not followed: - On 02/17/2024, the physician order for the Max UFR was 10.0 mL/kg/hr. The actual UFR was 13.4 mL/kg/hr. - There was no documentation that indicated this was identified or addressed by the PCT or RN at the time of treatment. 2. Review of Patient #6’s dialysis orders and treatment sheets dated 02/13/2024 through 03/09/2024 (10 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected the physician orders for Max UFR was not followed: - On 02/15/2024, the physician order for Max UFR was 13.0 mL/kg/hr. The actual UFR was 19.8 mL/kg/hr. - On 02/17/2024, the physician order for Max UFR was 13.0 mL/kg/hr. The actual UFR was 13.4 mL/kg/hr. - On 03/05/2024, the physician order for Max UFR was 13.0 mL/kg/hr. The actual UFR was 16.7 mL/kg/hr. - There was no documentation that indicated these issues were identified or addressed by the PCT or RN at the time of treatment. * Review of the facility policy “1-03-08” titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as last revised 10/2023, stipulated: - “Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... Prescription components include but are not necessarily limited to: ... UFR and Max UFR ...” - “Intradialytic treatment monitoring and data collection which my be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring for non-nocturnal treatments is completed at least every thirty (30) minutes” and includes vital signs and access checks. During an interview on 03/13/2024 at 1000, the FA reported staff were expected to contact the physician when the UFR exceeded the ordered Max UFR but was unable to locate any documentation to show this was done. The FA confirmed the above findings.”