Davita University City 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: 46632 Based on observation of the clinical area, facility policy and an interview with the facility administrator and clinical services manager, the facility did not ensure infection control procedure regarding glove removal and handwashing for two (2) of ten (10) observations (OBS). (OBS# 1 and 2). Findings include: A review of policy 1-05-01 “Infection Control For Dialysis Facilities” on December 11, 2023 at 1:30 PM states: “ 1. All teammates...will perform hand hygiene 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,,,7a Gloves should be changed when: ii. When going from a “dirty” area or task to a “clean” area or task. iii. When moving from i. contaminated body site to a clean body site of the 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 of the clinical area was conducted on 12/11/23 between 9:04 am-12:19 pm. OBS # 1 Machine 10 PCT 1, after locating and palpating cannulation site, did not discard gloves, perform hand hygiene and don new gloves prior to prior to inserting the fistula needle into the patient’s vascular access. OBS # 2 Machine 16 PCT 2 , after locating and palpating cannulation site did not discard gloves, perform hand hygiene and don new gloves prior to inserting the fistula needle into the patient’s vascular access. An interview with the facility administrator conducted on December 11, 2023 at 1:00 pm 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: 46632 Based on a review of medical records (MR), facility policy, and an interview with the facility administrator, the facility did not follow its policy for heart rate management for two (2) of fifteen (15) MRs. (MR # 14 and 15). Findings include: A review of facility policy 1-03-08 “-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” conducted on December 13, 2023 at 1:25 PM states: “Intradialytic Data Collection/Assessment 11. Abnormal findings...will be reported to the licensed nurse immediately. Abnormal Findings: Heart or pulse rate -Intradialytic- Less than 60 beats per minute or greater than 100 beats per minute ...........” Findings include: MR # 14 admission date 12/19/2022. A review of treatment sheet for 11/28/2023 revealed the following: Pre Pulse sitting 81 18:31 Pulse 101 “Patient appears to be tolerating treatment well at this time” 19:01 Pulse 103 “Patient appears to be tolerating treatment well at this time” 19:31 Pulse 102 “Patient appears to be tolerating treatment well at this time” 20:02 Pulse 102 “Patient monitored: watching TV no complications” 20:32 Pulse 106 “Patient monitored: watching TV no complications” 21:01 Pulse 104 “Patient monitored: watching TV no complications” 21:31 Pulse 100 “Patient monitored: eyes closed patient resting” 22:01 Pulse 104 “Patient appears to be tolerating treatment well at this time” 22:34 Pulse 103 “Patient face; vascular access and blood line connection visible” 23:01 Pulse 105 “Patient appears to be tolerating treatment well at this time” 23:31 Pulse 108 “Patient awake, alert and states no complaints at this time.” 00:01 Pulse 90 “Patient face; vascular access and blood line connection visible” 00:21 Pulse 108 “Treatment terminated”. Post heart rate 107 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. A review of treatment sheet for 12/03/2023 revealed the following: Pre Pulse sitting 98 18:29 Pulse 104 “Patient monitored: watching TV no complications” 19:00 Pulse 103 “”Patient monitored: watching TV no complications” 19:29 Pulse 84 “Patient monitored: watching TV no complications” 19:59 Pulse 83 “Patient appears to be tolerating treatment well at this time” 20:29 Pulse 104 “Patient appears to be tolerating treatment well at this time” 21:00 Pulse 105 “Patient face; vascular access and blood line connection visible” 21:29 Pulse 102 “Patient appears to be tolerating treatment well at this time” 22:00 Pulse 102 “Patient monitored: eyes closed patient resting” 22:30 Pulse 98 “”Patient appears to be tolerating treatment well at this time” 22:59 Pulse 108 “Patient monitored: watching TV no complications” 23:29 Pulse 105 “”Patient monitored: eyes closed patient resting” 23:59 Pulse 109 “Patient appears to be tolerating treatment well at this time” 00:03 Pulse 107 “Treatment terminated”. Post heart rate 102 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. A review of treatment sheet for 12/05/2023 revealed the following: Pre Pulse sitting 103 18:06 Pulse 102 “Treatment started without complications. Normal saline prime given: Heparin pump is on and working” 18:29 Pulse 100 “Patient monitored: watching TV no complications” 18:59 Pulse 100 “Patient appears to be tolerating treatment well at this time” 19:29 Pulse 101 “Patient appears to be tolerating treatment well at this time” 19:59 Pulse 103 “Patient monitored: watching TV no complications” 20:31 Pulse 103 “Patient appears to be tolerating treatment well at this time” 20:59 Pulse 102 “Patient monitored: watching TV no complications” 21:30 Pulse 107 “Patient appears to be tolerating treatment well at this time” 21:59 Pulse 100 “Patient monitored: eyes closed patient resting” 22:30 Pulse 102 “”Patient appears to be tolerating treatment well at this time” 22:59 Pulse 100 “Patient appears to be tolerating treatment well at this time” 23:30 Pulse 108 “Patient face; vascular access and blood line connection visible” 23:59 Pulse 109 “Patient monitored: watching TV no complications” 00:08 Pulse 110 “Treatment terminated”. Post heart rate 98 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. MR # 15 admission date 12/03/2019. A review of treatment sheet for 11/27/2023 revealed the following: Pre Pulse sitting 103 8:31 am Pulse 113 “Patient monitored: watching TV no complications” 9:01 am Pulse 127 “Patient monitored: watching TV no complications” 9:31 am Pulse 111 “Patient face, vascular access; and blood line connection visible” 10:01 am Pulse 98 “Patient states no complaints at this time” 10:31 am Pulse 102 Patient states no complaints at this time” 11:01 am Pulse 102 “Patient stable” 11:31 am Pulse 94 “Patient appears to be tolerating treatment well at this time” 11:51 am Pulse 101 “Treatment terminated Patient blood returned without complications” Post heart rate 93 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. A review of treatment sheet for 11/29/2023 revealed the following: Pre Pulse sitting 120 7:16 am Pulse 107 “Treatment started without complication. Normal saline prime given, Patient face, vascular access; and blood line connection visible” 7:17 am Pulse 111 “Patient verbalized no complaints” 7:32 am Pulse 132 “Patient appears to be tolerating treatment well at this time” 8:02 am Pulse 132 “Patient appears to be tolerating treatment well at this time” 8:32 am Pulse 128 “Patient stable” 9:02 am Pulse 125 “Patient monitored: watching TV no complications” 9:32 am Pulse 120 “Patient appears to be tolerating treatment well at this time” 10:02 am Pulse 114 “Patient awake, alert and states no complaints at this time” 10:17 am Pulse 128 “Treatment terminated Patient blood returned without complications” Post heart rate 103 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. A review of treatment sheet for 12/01/2023 revealed the following: Pre Pulse heart rate 103 9:32 am Pulse 116 “Patient awake, alert and states no complaints at this time” 10:02 am Pulse 104 “Patient awake, alert and states no complaints at this time” 10:23 am Pulse 122 “Treatment terminated” Post heart rate 120 The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment. An interview with the facility administrator conducted on December 13, 2023 at 1:32 pm confirmed the above findings.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 46632 Based on a review of facility policy, observations, and an interview with the facility administrator, the facility failed to utilizes the vascular access clamp procedure was seen by staff member throughout the dialysis treatment for one (1) of ten (10) treatment floor observations OBS (OBS # 1). Findings include: A review was conducted of facility policy/procedure on December 11, 2023 approximately 12:39 pm. In center hemodialysis policy and procedure 1-04-08A #2 following termination of treatment and removal of fistula needle............... 8 clamp may remain in place for five-10 minutes before checking to see if bleeding has stopped 12. clamp may remain in place for an additional 5 to 10 minutes before checking to see if bleeding has stopped. Access clamp should not be left on longer than 20 minutes. Observations conducted in patient treatment area on 12/11/23 between 9:04 am-12:19 pm revealed the following: OBS # 1 Machine 7 PCT 1, During treatment floor observations the patients access site was clamped between 9:40 am to 10:04 am before clamp was taken off ( approximately 24 minutes) An interview with the facility Facility Administrator on December 11, 2023 at approximately 1:00 pm. confirmed the above findings.”