Davita Waynesburg 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: 42178 Based on review of facility policy, direct observation, and interview with staff (EMP), the facility failed to ensure staff emptied prime waste containers, disinfected external side chair surfaces, and fully reclined chair while cleaning sides of seat cushions for four (4) of four (4) observations for Cleaning and Disinfection of the Dialysis Station (Observation #1-#4). Findings included: Review of facility policy on October 16, 2024, at approximately 1:00pm revealed: “...Policy: 1-05-01 ...TITLE: INFECTION CONTROL FOR DIALYSIS FACILITIES ...DISINFECTION...13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. 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) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops) ...ii. Priming containers are to be emptied prior to disinfection...” Observation #1 conducted on October 16, 2024, at approximately 10:25 am at station #2. Patient Care Technician (PCT) failed to fully recline and wipe sides of seat cushions and exterior side surfaces of dialysis chair. PCT also failed to empty prime waste container. Observation #2 conducted on October 16, 2024, at approximately 10:50 am at station #9. Registered Nurse (RN)/ EMP #1 failed to fully recline and wipe sides of seat cushions and exterior side surfaces of dialysis chair. RN/EMP #1 also failed to empty prime waste container. Observation #3 conducted on October 16, 2024, at approximately 11:00 am at station #8. RN failed to fully recline and wipe sides of seat cushions and exterior side surfaces of dialysis chair. RN also failed to empty prime waste container. Observation #4 conducted on October 16, 202,4 at approximately 11:00 am at station #13. RN failed to fully recline and wipe sides of seat cushions and exterior side surfaces of dialysis chair. RN also failed to empty prime waste container. Findings confirmed October 16, 2024, at approximately 1:30 pm with Facility Administrator.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 46886 Based on a review of policies and medical records (MR) and interviews with staff (EMP) the facility failed to implement an initial care plan within 30 days of admission for one (1) of five (5) MRs reviewed. (MR1) Findings included: A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 10/17/24 revealed: “ The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs ...New Patient ...Assessment within 30 days of admission to facility ...Plan of Care ...If patient is an external transfer without a completed IDT assessment with POC ...the facility will complete the Comprehensive Assessment and POC within 30 days ... “ An interview conducted with EMP1 on 10/18/24 during the medical record review revealed that MR1, an HD patient, had transferred from an outside facility to continue treatments on 7/21/23. EMP1 stated that a Plan of Care was not received from the transferring facility. A review of medical records between 10/17/24 and 10/18/24 revealed: MR1: transfer date 7/21/23. MR1 contained a consent to treat dated 7/24/23 and a treatment details report verifying a completed HD treatment on 7/24/23. MR1 failed to contain a completed IDT assessment and POC from the transferring facility. The facility failed to follow policy and complete a Comprehensive Assessment and POC within 30 days of admission. An interview with EMP1 on 10/18/24 revealed that MR1 contained an IDT assessment dated 10/18/23. The findings were reviewed with EMP1 Facility Administrator, EMP2 MCS, EMP3 DCS, and EMP4 ROD during an exit conference on 10/18/24 at approximately 3:15 pm.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 46886 Based on a review of policies and medical records (MR) and interviews with staff (EMP) the facility failed to complete a comprehensive reassessment within 90 days of admission for one (1) of five (5) MRs reviewed. (MR2) Findings included: A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 10/17/24 revealed: “ The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs ...90 Day ...reassessment initiated on Day 91, completed within 30 days ...Plan of Care ...complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC ... “ An interview conducted with EMP2 on 10/17/24 at approximately 11:00 am revealed that MR2, a PD patient began treatments on 2/13/23. A review of MR2 on 10/17/24 at approximately 11:00 am revealed: MR2: admit date 2/13/23. MR2 contained a consent to treat dated 2/13/23 and an initial nursing assessment dated 2/13/23. MR2 contained a 90 day Plan of Care IDT meeting dated 10/18/23, approximately 8 months after the admission date. The facility failed to follow policy and complete the Plan of Care meeting 15 days after the 90 day [3 month] reassessment. The findings were reviewed with EMP1 Facility Administrator, EMP2 MCS, EMP3 DCS, and EMP4 ROD during an exit conference on 10/18/24 at approximately 3:15 pm.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 42178 Based on reviews of facility policy and medical records, direct observations, and interviews with staff (EMP), the facility failed to ensure dialysis was administered as per prescription for two (2) of twelve (12) observations (Observation #2 & #5) and one (1) of five (5) medical record reviews (MR1). Findings included: Review of agency policy on October 16, 2024, at approximately 1:00pm revealed: “...Policy 10-03-08 ... TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT ...POLICY: ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model, b. Treatment time, c. Target weight, d. UFR and Max UFR, e. UF Profiling, f. Blood flow rate, g. Dialysate flow rate, h. All accesses evaluated, i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings, j. Heparinization (intradialytic infusion setting) ...” Observation #2 conducted on October 16, 2024, at approximately 2:00pm at station #2. In-center Hemodialysis Treatment prescription specified, “...Dialyzer-Nipro, Elisio, 15H, 1264...” Observation revealed patient being dialyzed with Elisio 17H dialyzer. Review of October 16, 2024 Treatment Details Report (TDR) for MR#6 on October 17, 2024, at approximately 10:00 am revealed Registered Nurse (RN1) documented verification that dialysis administered matched dialysis prescription at 11:14 am. Observation #5 conducted on October 16, 2024, at approximately 2:05pm at station #5. In-center Hemodialysis Treatment prescription specified, “...Dialyzer-Nipro, Elisio, 15H, 1264...” Observation revealed patient being dialyzed with Elisio 17H dialyzer. Review of October 16, 2024 Treatment Details Report (TDR) MR#7 on October 17, 2024, at approximately 10:00 am revealed RN2 documented verification that dialysis administered matched dialysis prescription at 11:23 am. Interview with EMP #5, Administrative Assistant on October 16, 2024 at approximately 2:30pm confirmed that Elisio 15H ’ s “are no longer available and have not been used for awhile...” Findings confirmed October 16, 2024, at approximately 1:30 pm with Facility Administrator. A medical record review conducted on 10/18/24 at approximately 1:00 pm with EMP1 revealed: MR1: Admit date 7/21/23. MR1 contained Treatment Details Report (TDR) sheets dated 4/29/24, 5/3/24, and 5/6/24 with Dialysis Prescriptions listing a Dialysis Flow Rate (DFR) of 600 milliliters per minute. TDR sheet dated 4/29/24 documented a DFR = 500 milliliters per minute between approximately 6:30 am to 7:30 am, an hour into the treatment, and the prescription was verified by RN1 at 6:35 am. Facility staff failed to correctly verify MR1’s prescribed DFR on 4/29/24 and provided the incorrect DFR for an hour into the treatment. TDR sheet dated 5/3/24 documented a DFR = 500 milliters per minute between approximately 6:30 am and 7:00 am, approximately 30 minutes into the treatment, and the prescription was verified by RN2 at 6:25 am. Facility staff failed to correctly verify MR1’s prescribed DFR on 5/3/24 and provided the incorrect DFR for 30 minutes into the treatment. TDR sheet dated 5/6/24 documented a DFR = 500 milliters per minute between approximately 6:30 am and 7:00 am, approximately 30 minutes into the treatment. The prescription was verified by PCT1 at 5:29 am. Facility staff failed to correctly verify MR1’s prescribed DFR at treatment initiation and provided the incorrect DFR for 30 minutes into the treatment. The incorrect DFR rates and prescription verifications were reviewed on 10/18/24 with EMP1, Facility Administrator. The findings were reviewed with EMP1 Facility Administrator, EMP2 MCS, EMP3 DCS, and EMP4 ROD during an exit conference on 10/18/24 at approximately 3:15 pm.”

“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: 46886 Based on a review of facility procedures and medical records (MR) and interviews with staff (EMP) the medical director failed to ensure that the facility ’ s procedure for completing patient Plans of Care was followed for two (2) of five (5) MRs reviewed. (MR 1 and 2). Findings included: A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 10/17/24 revealed: “ The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs ...New Patient ...Assessment within 30 days of admission to facility ...Plan of Care ...If patient is an external transfer without a completed IDT assessment with POC ...the facility will complete the Comprehensive Assessment and POC within 30 days ... “ An interview conducted with EMP1 on 10/18/24 during the medical record review revealed that MR1, an HD patient, had transferred from an outside facility to continue treatments on 7/21/23. EMP1 stated that a Plan of Care was not received from the transferring facility. A review of medical records between 10/17/24 and 10/18/24 revealed: MR1: transfer date 7/21/23. MR1 contained a consent to treat dated 7/24/23 and a treatment details report verifying a completed HD treatment on 7/24/23. MR1 failed to contain a completed IDT assessment and POC from the transferring facility. The facility failed to follow policy and complete a Comprehensive Assessment and POC within 30 days of admission. An interview with EMP1 on 10/18/24 revealed that MR1 contained an IDT assessment dated 10/18/23. A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 10/17/24 revealed: “ The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs ...90 Day ...reassessment initiated on Day 91, completed within 30 days ...Plan of Care ...complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC ... “ An interview conducted with EMP2 on 10/17/24 revealed that MR2, a PD patient began treatments on 2/13/23. MR2: admit date 2/13/23. MR2 contained a consent to treat dated 2/13/23 and an initial nursing assessment dated 2/13/23. MR2 contained a 90 day Plan of Care IDT meeting dated 10/18/23, approximately 8 months after the admission date. The facility failed to follow policy and complete the Plan of Care meeting 15 days after the 90 day [3 month] reassessment. The findings were reviewed with EMP1 Facility Administrator, EMP2 MCS, EMP3 DCS, and EMP4 ROD during an exit conference on 10/18/24 at approximately 3:15 pm.”