Davita Budfield Street Home Dialysis

“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: 37471 Based on review of facility policy and procedure, observations (OBV) and staff (EMP) interview the facility staff failed to use proper personal protective equipment (PPE) during a procedure for one (1) of two (2) observations conducted (OBV1). Findings included: Review of facility policy and procedures on 4/8/2024 at approximately 3:30 PM revealed, “TITLE: PERIPHERAL VENIPUNCTURE PROCEDURE Materials required ...*PPE-personal protective equipment (face protection, mask, gloves, fluid resistant/fluid impervious barrier garment) NOTES: Procedure 1. Dialysis Precautions and aseptic technique are used when performing this procedure. 2. Explain the procedure to the patient. Perform hand hygiene and gather supplies. Put on PPE ...Rationale 1. Dialysis Precautions, including the use of personal protective equipment, are used to prevent exposure to blood/body fluids. 2. Hand hygiene protects patient and teammate from cross contamination. PPE is worn for teammate protection ... “ Observations of patient care was conducted on 4/5/2024 at approximately 11:05 AM which revealed, EMP4 was conducting a venipuncture procedure with the patient. EMP4 completed the venipuncture procedure. EMP4 was not waring a mask during the procedure. An exit interview with group facility administrators on 4/8/2024 at approximately 1:25 PM confirmed the findings.”

“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: 37471 Based on review of the facility policy and procedures, observations (OBV) and staff (EMP) interview it was determined the facility failed to ensure labeling and disposal of expired medications for one (1) of one (1) facility tour. Findings included: Review of facility policy and procedures on 4/8/2024 at approximately 3:30 PM revealed, “TITLE: MEDICATION POLICY ...POLICY: 1. The Facility Administrator/designee is responsible for supervising the handling ,storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory...12. All open or unopened medication packages (i.e. vials, ampules etc.) are stored according to the manufacturer’s directions. Do not use any medication that has been stored improperly or has expired. k. Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer...l. All medications in the facility are checked monthly...n. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations...” A tour was conducted with EMP1 on 4/5/2024 at approximately 10:05 AM, observation of clinic room 3 was conducted. The following medication vial was found opened without a date or initials labeled: Heparin 30,000 units Exp 04/2021 NDC 11288-402-30, Lot A6R3609M. A tour was conducted with EMP1 on 4/5/2024 at approximately 10:21 AM, observation of clinic room 1 was conducted. The following medication vial was found opened with initial’s and a date of 2/14/2024, 30 ml Multidose vial HEPARIN sodium Inj. USP 30,000 USP units/ml Exp Lot HH6290 Exp 01-Jul-2025. An exit interview with group facility administrators on 4/8/2024 at approximately 1:25 PM confirmed the findings.”