Davita Franklin Commons Dialysis

“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: 37972 Based upon staff observations (OBS) in the treatment area, facility policy and procedure review, and an interview with the facility staff, it was determined the facility failed to ensure hand hygiene and donning of new gloves during during discontinuation of dialysis and post dialysis access care for the AV fistula for one (1) of two (2) observations (OBS #2). Findings include: Review of facility policy: 1-05-01 “Infection Control for Dialysis Facilities” on May 14, 2025, at approximately 2:45 P.M. stated, “Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, and when exchanging a dialysis machine), f. between patients even if the contact is casual, and g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” PPE (i.e., gowns, gloves, eye protection, face shield): 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites. a. Gloves should be changed when: i. When soiled with blood, dialysate or other bodily fluids, ii. When going from a “dirty” area or task to a “clean” area or task, iii. when moving from a contaminated body site to a clean body site of same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” Observation in the treatment area was conducted on May 12, 2025, from approximately 9:30 A.M. to 12:30 P.M. and 3:00 P.M. to 4:00 P.M. OBS #2 on May 12, 2025, at approximately 10:28 A.M. at Station #16. During discontinuation of dialysis with an AV fistula, the patient care technician (PCT) #2 was observed performing hand hygiene and donning gloves. They then began reinfusing the extracorporeal circuit, set up the supplies on the chairside table, pushed down the foot rest of the chair, and then removed the dialysis needles, all without changing gloves and performing hand hygiene. An interview with the Regional Operations Director and Facility Administrator on May 14, 2025, at approximately 3:00 P.M. confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 37972 Based upon review of facility policy, medical records (MR), and an interview with facility staff, the dialysis facility failed to ensure in-center hemodialysis patient assessments, including blood pressures and machine parameters, were assessed and documented at minimum every 30 minutes, while on hemodialysis, as per facility policy, for six (6) of seven (7) in-center hemodialysis MR reviewed (MR#1, 2, 4, 5, 6 ,and 7). The dialysis facility failed to ensure that the registered nurse (RN) performed an assessment of the patient prior to discharge when abnormal findings were identified, as per facility policy, for one (1) of seven (7) MR reviewed (MR#4). Findings include: Review of facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” on May 14, 2025, at approximately 3:00 P.M. stated, “Policy: Intradialytic Data Collection /Assessment: 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring: ... iii. Non-nocturnal treatments are 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, iv. Fluid removal and/or replacement, v. Vascular access visible and line connections intact, vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints... Post Treatment Data Collection/Assessment: 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge... Abnormal Findings: ... Blood Pressure- Intradialytic: Systolic greater than 180 mm/Hg (millimeters of Mercury) or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” A review of MR conducted on May 13, 2025, from approximately 9:30 A.M. to 3:00 P.M. and May 14, 2025, from approximately 9:30 A.M. to 12:30 P.M. revealed the following: MR#1, start of care March 30, 2022. Treatment records from April 23, 2025, through May 9, 2025, revealed the following: No blood pressure (BP), heart rate (HR), blood flow rate (BFR), dialysate flow rate (DFR), arterial pressure (AP), venous pressure (VP), volume removed (VR), vascular access visualization, or events and comments documented on March 23, 2025, between 11:32 A.M. and 12:32 P.M. (1 hour), and between 1:02 P.M. and 2:02 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 25, 2025, between 12:08 P.M. and 12:54 P.M. (46 minutes), and between 2:14 P.M. and 3:14 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on May 2, 2025, between 12:32 P.M. and 1:32 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on May 9, 2025, between 11:32 A.M. and 12:32 P.M. (1 hour). MR #2, start of care March 18, 2025. Treatment records from April 24, 2025, through May 10, 2025 revealed the following: No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 26, 2025, between 1:01 P.M. and 2:01 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 29, 2025, between 12:33 P.M. and 1:32 P.M. (59 minutes). MR #4, start of care September 4, 2024. Treatment records from April 24, 2025, through May 10, 2025, revealed the following: No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 26, 2025, between 12:32 P.M. and 1:38 P.M. (1 hour, 6 minutes). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 29, 2025, between 11:42 A.M. and 12:32 P.M. (50 minutes). On April 26, 2025, during the dialysis treatment, the patient’s BP ranged from systolic 67 to 84 mmHg (millimeters of Mercury), diastolic 36 to 41 mmHg. There was no documentation of an RN assessment post treatment, prior to discharge. BP at discharge was 87/43. MR#5, start of care February 17, 2025. Treatment records from March 28, 2025, through April 9, 2025, revealed the following: No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 9, 2025, between 12:05 P.M. and 1:03 P.M. (58 minutes) and between 2:03 P.M. and 3:03 P.M. (1 hour). MR#6, start of care September 26, 2023. Treatment records from April 23, 2025, through May 9, 2025, revealed the following: No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on May 7, 2025, between 6:32 A.M. and 7:32 A.M. (1 hour) MR#7, start of care June 10, 2020. Treatment records from April 23, 2025, through May 9, 2025, revealed the following: No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on April 25, 2025, between 12:32 P.M. and 1:32 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, or events and comments documented on May 5, 2025, between 11:43 A.M. and 12: 35 P.M. (52 minutes), and between 2:02 P.M. and 3:02 P.M. (1 hour). No BP, HR, BFR, DFR, AP, VP, VR, vascular access visualization, r events and comments documented on May 7, 2025, between 11:39 A.M. and 12:35 P.M. (56 minutes) and 12:35 P.M. and 1:36 P.M. ( 1 hour, 1 minute). An interview with the Regional Operations Director and Facility Administrator on May 14, 2025, at approximately 3:00 P.M. confirmed the above findings.”