Davita Lebanon County Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 47219 Based on review of agency policy, emergency AED cart logs, and interview with facility administrator, agency clinical staff failed to document completed daily AED equipment checks in nineteen (19) of ninety-one (91) calendar open clinic days in four (4) calendar months of AED logs reviewed. Findings include: Review conducted of agency policy 1-02-08 Emergency Equipment Checks revealed: “3. The following equipment checks will be performed by a licenses nurse teammate to verify the designated equipment is available and functional: Daily - Check Status Indicator for green check for Zoll AED.” Review conducted on May 17, 2024, at approximately 9:30 AM, of Daily Zoll AED Logs #1- 4 revealed: Log #1 February 2024, missing AED checks on 2/17/24 (Saturday), and 2/28-29/24 (Wednesday, Thursday). Log #2 March 2024, missing AED checks on 3/16/24 (Saturday), 3/20-21/24 (Wednesday, Thursday), 3/26/24 (Tuesday), 3/28/24 (Thursday) and 3/30/24 (Saturday). Log #3 April 2024, missing AED checks on 4/3-4/24 (Wednesday, Thursday), 4/11/24 (Thursday), 4/15/24 (Monday), 4/18/24 (Thursday), 4/25-26/24 (Thursday, Friday), and 4/29/24 (Monday). Log #4 May 2024, 5/4/24 (Saturday) and 5/7/24 (Tuesday). Interview conducted on May 17, 2024, at approximately 10:00 AM, with facility administrator confirmed above findings.”

“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: 47219 Based on observation, review of agency policy, and an interview with the End Stage Renal Disease (ESRD) administrator, the ESRD clinic failed to ensure the patient care technicians (PCTs) changed gloves and performed hand hygiene while being observed providing dialysis treatments (Observations #1- #4,). Findings include: Observations conducted on May 13, 2024, at approximately 9:00 AM to 12:35 AM, on dialysis treatment floor revealed: Observation #1 - at approximately 9:10 AM, PCT (EF#5) was observed at treatment station #6 was wearing disposable gloves, picked up an used IV cap from the floor, removed the patient’s blanket and placed it in patient’s home bag, touched the dialysis machine’s screen several times with no change of gloves or hand hygiene performed, and then applied a new set of disposable gloves (double gloves now worn) over soiled set of gloves to continue patient care. Observation #2 - at approximately 9:42 AM, PCT (EF#2) was observed in treatment station #2 engaged in initiation of patient dialysis treatment; EF#2 set-up chairside table with items need for initiation of treatment, proceeded to assess and clean patient’s left lower arm fistula site, no change of disposable gloves or hand hygiene performed, opened inserting catheters, and proceeded to initiate dialysis treatment. Observation #3 - at approximately 10:35 AM, PCT (EF#5) was observed at treatment station #11, initiating a patient’s dialysis treatment wearing clean disposable gloves, then touching dialysis machine’s screen, her stethoscope, and cleaned patient’s fistula site with no glove change or hand hygiene observed; applied a new set of disposable gloves (double gloves now worn) over soiled set of gloves and proceeded with the treatment initiation. Observation #4 PCT (EF#2) observed at approximately 10:15 - 10:45 AM, silencing several dialysis treatment machines’ alarms with a bare hand using a loose glove only covering her three or four finger tips. Review conducted on May 13, 2024, at approximately 1:30 PM, of agency policy 1-05-01 Infection Control for Dialysis Facilities revealed: (page 1) “HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NNP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... d. after patient and dialysis delivery system contact, ... f. between patients even if the contact is casual, g. before touching clean areas such a supplies, supply cart, and chairside keyboard/mouse. ...; 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station ... a. Gloves should be changed when: ii. When going from a “dirty” area or task to a “clean” area or task ... .” Interview conducted on May 13, 2024, at approximately 1:45 PM, with agency administrator confirmed the above 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: 47219 Based upon observation, review of agency policies, and an interview with the ESRD administrator, it was determined the ESRD agency failed to ensure preventative maintenance or replacement of one (1) out of one (1) expired medication refrigeration temperature thermometer device (Observation 1). Findings include: Observation conducted on May 13, 2024, at approximately 11:30 AM, of dialysis treatment floor medication refrigerator revealed the Excursion-Trac refrigerator thermometer sticker on back of device expired on 3/29/24. Review conducted on May 13, 2024, at approximately 1:00 PM, of agency policy 1-06-06 Medication Requiring Refrigeration revealed: (page 1) “Policy: ... 3. The refrigerator (temperature) is checked during normal operating hours, ... a. Twice daily temperature checks located on the Digital Data Logger (DDL) display at the beginning and end of the day.”; and policy 8-04-01 Physical Environment reveals “...4. The dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment, dialysis delivery systems and the water treatment systems are maintained and operated in accordance with the manufacturer’s recommendations... .” Interview conducted on May 13, 2024, at approximately 1:30 PM, with agency administrator confirmed above findings. Duplicate finding from last survey of 5/2023.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 47219 Based on observation and review of employee files (EFs), agency policies, and interview with agency administrator, the medical director failed to ensure that clinical staff fully documented prepared patient intravenous (IV) medication labels on pre-drawn medication syringes in two (2) of two (2) observations; failed to ensure all clinical staff had current cardiopulmonary resuscitation certification (CPR) training in one (1) of four (4) EFs reviewed (EF#4). Findings include: Observation conducted on May 13, 2024, at approximately 9:30 AM, of prepared IV medications revealed: -MR#4’s medication labeled syringes for Heparin Pork insulin 2400 units and 2000 units were missing the clinical registered nurse’ initials and time of preparation. -MR#8’s medication labeled syringes for Heparin Pork insulin 2000 units and 1200 units were missing clinical registered nurse’ initials and time of preparation. Review conducted on May 13, 2024, at approximately 12:30 PM, of agency 1-06-01 Medication Policy revealed: (page 4 of 7) “... 20. ... If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose, and initials of teammate preparing the medication.”; and policy 8-02-04 Cardiopulmonary Resuscitation Certification (CPR) ... “Policy: 1. All direct patient care teammates (i.e. nurses and patient care technicians) except patient care technician trainees must have current BLS CPR/AED certification.” Review conducted on May 13, 2024, at approximately 2:00 PM, of employee files (EFs) revealed: EF#4, date of hire 9/27/21, expired CPR card 3/2024. Interview conducted on May 13, 2024, at approximately 2:15 PM, with agency administrator confirmed above findings.”