Davita Lewistown 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: 39671 Based on review of facility policy/procedure, observations of hemodialysis (HD) treatment area during patient care and interview with facility administrator (EMP# 1), it was determined the facility failed to ensure staff performed hand hygiene at the appropriate times during ten (10) of ten (10) treatment floor observations (TFO). (TFO #1, TFO #2, TFO #3, TFO #4 , TFO #5, TFO #6, TFO #7, TFO #8, TFO #9 and TFO #10) Findings Included: Review of ‘INFECTION CONTROL FOR DIALYSIS FACILITIES’ policy/procedure on 8/19/25 at approximately 11:00 a.m. revealed, “HAND HYGIENE: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene...a. upon entering and exiting the patient treatment area...b. prior to gloving and immediately after removal of gloves...after patient and dialysis delivery system contact...f. between patients even if the contact is casual...” HD Treatment area observation conducted on 8/1825 between approximately 11:00 a.m. and 2:36 p.m., on 8/19/25 between approximately 11:26 a.m. and 12:44 p.m., and on 8/20/25 at 9:48 a.m. revealed the following: Treatment Floor Observation (TFO) #1: On 8/18/25 at approximately 10:37 a.m. surveyor observed employee# 10 put one glove on, touch dialysis machine at station #19, then walk over and touch the dialysis machine at station #20 and then walk over and touch the dialysis machine #21. Employee failed to change gloves and perform hand hygiene between each dialysis station and prior to touching the dialysis machine at each dialysis station. TFO #2: On 8/18/25 at approximately 11:40 a.m. surveyor observed employee #10 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #3: On 8/18/25 at approximately 11:48 a.m. surveyor observed employee #11 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #4: On 8/18/25 at approximately 11:53 a.m. surveyor observed employee #6 put on gloves, removed a sticky note from dialysis machine at station #12, then walk over to remove a sticky note from dialysis machine at station #13 and then walk over to remove a sticky note from dialysis machine at station #14. Employee failed to change gloves and perform hand hygiene between each dialysis station and prior to touching the sticky note on the dialysis machines at each dialysis station. TFO #5: On 8/18/25 at approximately 12:06 p.m. surveyor observed employee #2 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #6: On 8/19/25 at approximately 10:48 a.m. surveyor observed employee #6 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #7: On 8/19/25 at approximately 11:03 a.m. surveyor observed employee #16 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #8: On 8/19/25 at approximately 11:05 a.m. surveyor observed employee #16 exit the treatment floor without performing hand hygiene. TFO #9: On 8/19/25 at approximately 11:29 a.m. surveyor observed employee #16 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. TFO #10: On 8/19/25 at approximately 11:31 a.m. surveyor observed employee #6 removed gloves and failed to perform hand hygiene prior to performing additional tasks in the treatment floor. An interview with the facility administrator on 8/20/22 at approximately 1: 00 p.m. confirmed the above findings and confirmed the above policy as current.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 39671 Based on review of facility policy/procedure, observations of hemodialysis (HD) treatment area during patient care and interview with facility administrator (EMP# 1), it was determined the facility failed to ensure medications were labeled appropriately for six (6) of six (6) medication observations. (Medication Observation #1, Medication Observation #2, Medication Observation #3, Medication Observation #4, Medication Observation #5 and Medication Observation #6) Findings Included: Review of ‘PREPARATION AND ADMINISTRATION OF PARENTERAL MEDICATIONS (NON-ESA-NON-PARSABIV’ policy/procedure on 8/19/25 at approximately 12:00 P.m. revealed, “Procedure:...16. Label the syringe with the patient’s name, name of the prescribed medication, dose, date, time and initials of licensed teammate preparing the dose. Preprinted labels may be used if available...” HD Treatment area observation conducted on 8/1825 between approximately 11:00 a.m. and 2:36 p.m., on 8/19/25 between approximately 11:26 a.m. and 12:44 p.m., and on 8/20/25 at 9:48 a.m. revealed the following: Medication Observation #1: For patient #23 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,600 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,100 units hourly dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. Medication Observation #2: For patient #24 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,000 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,200 units hourly dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. Medication Observation #3: For patient #25 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 3,000 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. - One (1) 10 mL (milliliter) syringe with Heparin Pork 4,500 units hourly dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. Medication Observation #4: For patient #26 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 1,600 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,400 units hourly dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. Medication Observation #5: For patient #27 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,600 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. Medication Observation #6: For patient #8 the following drawn up medication syringes were observed on the medication section - One (1) 10 mL (milliliter) syringe with Heparin Pork 2,600 units loading dose- the section on the label ‘time’ was left blank and section ‘initials’ was left blank. An interview with the facility administrator on 8/20/22 at approximately 1: 00 p.m. confirmed the above findings and confirmed the above policy as current.”