Davita Bloomfield Pittsburgh

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 38039 Based on review of policy, observations and interview with the facility administrator the facility did not ensure precautions were in place to maintain a clean environment to prevent the possibility of spreading infectious diseases for seven (7) of eight (8) observations. (OBS#1, OBS#2, OBS#3, OBS#4, OBS#5, OBS#6, OBS#8) and the facility failed to ensure visitors were provided PPE while in the treatment area for one (1) of eight (8) observations (OBS#7). Findings include: Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-05-01 with last revision date of April 2023. TITLE: Infection Control for Dialysis Facilities. PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment... POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients.... PPE (i.e., gown, gloves, eye protection, face shield). 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area...c. PPE is not to be worn in non-treatment areas...6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-physicians and visitors when in the treatment area... 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 infection materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from the treatment area. Review of facility policy completed on 4/25/24 at approximately 2:00 p.m. revealed: Policy: 4-08-09 with last revision date of October 2019. TITLE: Eyewash Station/Sink/Drench Shower/Hose Checks. POLICY: 1. Plumbed eyewash stations/sinks/drench showers/hoses are to be activated weekly to flush the line and verify proper operation. Self-contained stations are to be inspected according to manufacturer’s specification...DEFINITION:...7. Nozzles are to be protected from airborne contaminants... Observations of dialysis treatment and care completed on 4/23/24 between approximately 9:30 a.m. and 11:00 a.m. and 4/24/24 between approximatley 9:30 a.m. and 2:30 p.m. revealed the following: OBS#1 on 4/23/24 at 10:21 a.m. revealed a suction machine located on the top of the code cart. Suction machine found to have a brown substance on the back of the machine. Found beside the suction machine was an unwrapped 60 cc syringe. Surveyor observed an orange colored backboard on the floor between the wall and the code cart. OBS#2 on 4/23/24 at 10:29 a.m. in the lab area, the shelf under the refrigerator with brown dusty area. OBS#3 on 4/23/24 at 10:45 a.m. an eye wash station without the cover on. This was on the side of the clinical floor that is closest to dialysis stations 8 and 9. OBS#4 on 4/24/24 at 9:45 a.m. on clinical floor. Surveyor observed EMP7 toss gloves toward garbage bin that was located outside of station #19. Gloves landed on the floor. During discontinuation of dialysis, surveyor observed EMP7 took a sharps container from a common clean area to station # 19. Following use, the sharps container was returned to the common clean area without being wiped down. OBS#5 on 4/24/24 at 9:55 a.m. on clinical floor. During discontinuation of dialysis, surveyor observed EMP8 take a sharps container and a biohazard bin from a common clean area to station # 14. Following use, the sharps container and the biohazard were returned to the common clean area without being wiped down. OBS#6 on 4/24/24 at 10:00 a.m. on clinical floor. During discontinuation of dialysis, surveyor observed EMP5 take a sharps container and a biohazard bin from a common clean area to station # 10. Following use, the sharps container and the biohazard were returned to the common clean area without being wiped down. OBS#7 on 4/24/24 at 10:55 a.m. surveyor witnessed two (2) emergency medical technicians (EMTs) from a local ambulance service bringing a bed-bound patient into the facility. EMTs at chair side and transferred patient from stretcher to dialysis chair. Neither EMT was provided a gown to cover their clothing. Interview with manager of clinical services on 4/24/24 at 11:00 a.m. stated “ should have gowns on but masks are personal preference. “ OBS#8 on 4/25/24 at 1:30 p.m. observed EMP7 leave the clinical floor with gown, face mask and face shield on. Observed EMP7 enter the water room and conduct a water test. Complete water test and exit the water room with all PPE on. Review of the findings was completed on 4/25/24 at approximately 3:00 p.m. with the facility administrator and manager of clinical services.”

“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: 38039 Based on direct observations and staff interview it was determined the facility failed to maintain a safe, clean and comfortable environment for patients and staff, specifically the treatment area for four (4) of four (4) observations. (OBS#1-OBS#4). Findings include: Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy 4-07-01 with revision date of April 2024. TITLE: Facility Emergency Management Plan...Fire Safety Preparedness...3...b. Fire extinguishers shall be...located such they are readily accessible to teammates without subjecting the teammates to possible injury...c. Fire extinguishers shall be checked monthly to verify it is:...v. There are no obstructions to access or visibility... OBS#1 on 4/23/24 at 930 a.m. upon entrance to the clinical floor, observed a hoyer lift in front of the fire extinguisher. This was confirmed at 9:40 am by facility administrator. OBS#2 on 4/23/24 at 10:32 a.m. four (4) Pharmvac refrigerators. Pharmvac #1 with white substance on the top. IV (intravenous) pump sitting on the top of it. Pharmvac #2 with boxes on the top of it. Pharmvac #3 with a rack on the top of it. Hoyer lift positioned in front of the Pharmvac refrigerators. Multiple IV pumps on poles in front of Pharmvac refrigerator area. Dialysis station #1 observed a large amount of white, powder like, substance in the corner behind the chair. OBS#3 on 4/23/34 at 10:38 a.m. Under the sink on the side of the clinical floor that is closest to dialysis station 4, a plastic jug like container sitting on the floor. The black spray wand that was attached to it was on the floor. The container had the words “ Steri-lab “ written on the side/top. OBS#4 on 4/23/24 at 10:50 a.m. observed white, powder like, substance in the corners of dialysis stations #15 and #16 behind the chairs. Review of the findings was completed on 4/23/24 at approximately 3:00 p.m. with the facility administrator and manager of clinical services.”

“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: 38039 Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure to assess and/or manage patient’s blood pressure for one (1 ) of ten (10) MRs reviewed (MR8). Findings include: Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-08 with last revision date of April 2024. TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, iii. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ... Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed: MR8-Admission date 1/17/2020. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/5/24: blood flow rate (BFR) 500 and dialysate flow rate (DFR) 500. Treatment sheet dated-4/8/24 revealed patient was assessed at 7:05 a.m. Patient was not assessed again until 8:01 a.m. (56 minutes between assessments). Treatment sheet dated-4/19/24 revealed patient was assessed at 7:06 a.m. Patient was not assessed again until 8:00 a.m. (54 minutes between assessments). Interview completed on 4/25/24 at approximately 12:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.”

“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: 38039 Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure blood flow rate (BFR) and/or dialysate flow rate (DFR) were delivered in accordance with the dialysis prescriptions ordered by the physician for five (5) of ten (10) MRs reviewed (MR1, MR2, MR3, MR7, MR8). Findings include: Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-08 with last revision date of April 2024. TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, iii. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ... Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed: MR1-Admission date 3/7/24. Review of treatment sheets dated between 4/6/24-4/13/24. Review of patient orders dated 3/19/24: blood flow rate (BFR) 400 and dialysate flow rate (DFR) 600. Treatment sheet dated-4/9/24 DFR ran at 500 the entire treatment time. MR1 did not contain documentation as to why the DFR was changed. MR2- Admission date 8/16/21. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/9/24: blood flow rate (BFR) 500, dialysate flow rate (DFR) 500. Treatment sheet dated-4/12/24 BFR ran at 450 the entire treatment time. Treatment sheet dated-4/15/24 BFR ran at 355 at initiation of treatment and 400 the rest of the treatment time. Treatment sheet dated-4/17/24 BFR ran at 400 the entire treatment time. MR2 did not contain documentation as to why the BFR was changed. MR3- Transfer date 11/12/18. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/16/24: blood flow rate (BFR) 400, dialysate flow rate (DFR) 500. Treatment sheet dated-4/19/24 BFR initated at 400 and was dropped down to 350 at 12:31 p.m. and remained at 350 for the rest of the treatment time. MR3 did not contain documentation as to why the BFR was changed. MR7-Admission date 6/14/22. Review of treatment sheets dated between 4/6/24-4/23/24. Review of patient orders dated 4/6/24: blood flow rate (BFR) 400 and dialysate flow rate (DFR) 500. Treatment sheet dated-4/9/24 BFR ran at 300 from initiation of treatment until 1:21 p.m and until the end of treatment at 1:27 p.m. BFR ran at 250. MR7 did not contain documentation as to why the BFR was changed. MR8-Admission date 1/17/2020. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/5/24: blood flow rate (BFR) 500 and dialysate flow rate (DFR) 500. Treatment sheet dated-4/8/24 BFR ran at 350 at initiation of treatment and 450 for the rest of the treatment time. MR8 did not contain documentation as to why the BFR was changed. Interview completed on 4/25/24 at approximately 12:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.”

“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: 38039 Based on review of medical records (MR), review of facility policies and procedures, and interview with the facility administrator, it was determined the facility did not ensure to receive from patients or their representative a signed, dated consent form for early termination of patient’s treatment time per policy for one (1) of ten (10) MRs reviewed (MR1) and signed, dated consent form for dialysis treatment for one (1) of ten (10) MRs reviewed (MR3). The facility failed to ensure the nurse performed an assessment per policy prior to the patient starting treatment for three (3) of ten (10) MRs reviewed (MR7, MR8, MR9). Findings include: Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy:1-01-09 with a revision date of April 2024. TITLE: Prescribed treatment time not met. POLICY: A. Completion of the early termination of treatment against medical advice form. 1. The Registered Nurse (RN) will verify that a patients signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time...5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date... Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-07 with revision date of April 2024. TITLE: Initial Patient Nursing Assessment for New Patients. POLICY: 1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility... Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed: MR1-Admission date 3/7/24. Patient treatment orders dated 3/19/24 listed treatment time of 210 minutes. Treatment Details Report for treatment on 4/9/24 revealed patient dialysis start time 11:43 a.m. Patient terminated treatment at 2:16 p.m. 153 minutes difference. There was no documented evidence of a Early Termination of Treatment Against Medical Advice form signed by the patient. MR3- Transfer date 11/12/18. Patient’s initial treatment flow sheet was dated 12/23/10. Transfer first treatment sheet 11/12/18. Documentation revealed that a dialysis consent was signed by MR3 but did not include the date of the signature. MR7-Admission date 6/14/22. Initial dialysis treatment was started on 6/14/22 at 11:11 a.m. The initial RN assessment was conducted on 6/14/22 at 11:20 a.m., 9 minutes after start of treatment. MR8-Admission date 1/17/2020. Initial dialysis treatment was started on 1/17/2020 at 11:46 a.m. The initial RN assessment was conducted on 1/17/2020 at 11:52 a.m., 6 minutes after start of treatment. MR9-Admission date 3/14/24. Initial dialysis treatment was started on 3/14/24 at 11:06 a.m. The initial RN assessment was conducted on 3/14/24 at 11:13 a.m., 7 minutes after start of treatment. Interview completed on 4/25/24 at approximately 2:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.”

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 38039 Based on review of facility policy, review of facility documents and interview with the facility administrator, it was determined that the governing body failed to ensure complete documentation of the Daily Zoll AED and Emergency Medication Lock Log for four (4) of seven (7) months reviewed in 2023 and 2024. (October, November, December 2023 and January 2024), failed to ensure that the communication book that is used to correspond with the dialysis facility and the skilled nursing facility is filled out after dialysis treatment for one (1) of one (1) patient with a communication book (P15). The governing body failed to ensure complete documentation of the Weekly Eyewash and Drench Shower/Hoses Inspection for one (1) week in the month of April 2024 (week of April 8, 2024). Findings include: 1. Review of facility policy completed on 4/26/24 at approximately 1:30 p.m. revealed: Policy: 1-02-08 with revision date of April 2024. TITLE: Emergency Equipment Checks. PURPOSE: Verify that emergency is maintained in a ready-to-use condition. POLICY: ...3. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily:..Break away lock is intact...Weekly...Emergency cart (crash cart) is clean, operational and supplies/medications have not expired. 4. The Emergency Equipment Checklist may be used for documentation of emergency equipment checks. 5. The emergency checklist will be developed by the facility based on Medical Director input as to the supplies needed on the emergency (crash) cart and will be used to verify that the cart has been checked... Review of Daily Zoll AED and Emergency Medication Lock Log on 4/23/24 approximately 10:15 a.m. revealed a lack of documentation for Zoll AED illuminated green for 2023-10/5, 10/14, 11/4, and 11/18. Lack of documentation for Emergency Medication Breakaway Lock intact for 2023-10/5, 10/9, 10/14, 10/16, 10/17, 10/18, 10/19, 10/20, 10/30, 10/31, 11/2, 11/3, 11/4, 11/7, 11/8, 11/10, 11/11, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/24, 12/8, 12/9, 12/11, 12/12, 12/13, 12/15, 12/16, 12/18, 12/19, 12/22, 12/23, 12/27, 12/28 and 12/29. Lack of documentation for Emergency Medication Breakaway Lock intact for 2024- 1/2, 1/3, 1/4, 1/6, 1/9, 1/11 and 1/12. Interview completed on 4/24/24 at approximately 8:30 a.m. with the facility administrator confirmed the above findings. 2. Review of the communication book for P15 on 4/24/24 at approximately 1:35 p.m. revealed the dialysis facility did not complete the dialysis communication form for the following dates: 4/12/24, 4/16/24, 4/17/24 and 4/19/24. Interview completed on 4/24/24 at approximately 1:40 p.m. with the manager of clinical services confirmed the above findings. 3. Review of Procedure: 4-08-09A last revised November 2015 on 4/26/24 at approximately 11:00 a.m.. TITLE: Weekly Eyewash and Drench Shower/Hoses Inspection. All eyewash and drench showers/hoses must be inspected weekly. The inspection for each eyewash and drench shower/hoses must be documented... Review of the Weekly Eyewash and Drench Shower/Hoses Inspection log on 4/26/24 at approximatley 11:00 a.m. revealed the log did not show an inspection for the required areas for the week of April 8, 2024. Interview completed on 4/26/24 at approximately 11:30 a.m. with the facility administrator and manager of clinical services confirmed the above findings.”