Davita Jefferson Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 46886 Based on a review of facility policy, interviews with staff (EMP), and onsite observations (OBS) the facility failed to follow standard infection control practices for the cleaning and disinfection of medical devices for one (1) of two (2) observation periods. (OBS2) Findings include: A review of agency policy Infection Control for Dialysis Facilities on 6/12/24 revealed: Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. ... Disinfection ...12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. “ During a treatment floor observation conducted on 6/12/24 at approximately 9:45 am it was noted that Employee #10 brought a non-disposable thermometer to station #13 and performed a temperature check on a patient. The thermometer was not disinfected after patient use but returned to a common storage area. The finding was reviewed with EMP3 (MCS) and EMP1 (GFA) on 6/12/24 immediately after the observation. During an exit interview conducted on 6/13/24 at approximately 2:30 pm the finding was presented to EMP11 (Regional Operational Director), EMP12 (Director of Clinical Services), EMP1 (GFA), and EMP3 (MCS).”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46886 Based on interviews with staff (EMP), medical record (MR) reviews, and policy reviews, the facility failed to follow policies created to provide the necessary care and services to manage a patient ’ s volume status for two (2) of seven (7) medical records reviewed. (MRs 1&2) Findings include: A review of agency policy Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment on 6/13/24 revealed: Purpose: ...This information will be used in planning and documenting the patient ’ s dialysis treatment, monitoring during treatment and for reviewing the patient ’ s response to the treatment ...Intradialytic Data Collection/Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed flow rate) the reason will be documented and the licensed nurse informed... “ A personnel File review form dated 6/10/24 revealed: EMP9: Date of Hire (DOH): 7/23/10, RN EMP10: DOH: 11/6/17, certified clinical hemodialysis technician (CCHT) EMP13: DOH: 12/27/21, CCHT EMP14: DOH: 12/4/23, PCT EMP15: DOH: 7/8/19, CCHT A medical record review conducted on 6/12/24 at approximately 2:30 pm revealed: MR1: Admission Date: 3/14/24. Treatment Details Reports for 6/7/24 and 5/20/24 noted dialysis prescriptions with an ordered Blood Flow Rate (BFR) of 400 mL/min. Intradialytic Vitals Stat Line (dialysis notes) on 6/7/24 recorded a BFR decrease to 200 mL/min at 12:00 pm by EMP13 (PCT). Dialysis notes on 5/20/24 recorded a BFR decrease to 250 mL/min at 11:01 am by EMP9 (RN). The reason that the prescribed flow rate was unable to be maintained in each instance was not documented as per facility policy. A medical record review conducted on 6/13/24 at approximately 11:30 am revealed: MR2: Admission Date: 10/27/23. Treatment Details Reports for 6/3/24, 6/5/24, and 5/20/24 noted dialysis prescriptions with an ordered BFR of 400 mL/min. Intradialytic Vitals Stat Line (dialysis notes) on 6/3/24 recorded a BFR decrease to 370 mL/min at 13:33 by EMP14 (PCT). Dialysis notes on 6/5/24 recorded a BFR decrease to 350 mL/min at 12:00 by EMP10 (PCT). Dialysis notes on 5/20/24 recorded a BFR decrease to 300 mL/min at 12:33 by EMP15 (PCT). The reason that the prescribed flow rate was unable to be maintained in each instance was not documented as per facility policy. The findings were reviewed on 6/12/24 and 6/13/24 with EMP1 (GFA) at the completion of each medical record review. The finding was reviewed on 6/13/24 at approximately 2:30 pm during an exit interview with EMP1 (GFA), EMP11 (Regional Operational Director), EMP12 (Director of Clinical Services), and EMP4 (MCS).”