Davita Suburban Campus Dialysis

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This Standard is not met as evidenced by: 30411 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting the entire component. Findings include: 1. Observation on July 30, 2024, at 9:25 AM, revealed the door to the Soiled Utility Room failed to automatically close and positively latch within the door frame. Interview with the Administrative Assistant on July 30, 2024, at 9:25 AM, confirmed the door did not automatically close and positively latch within the frame. 2. Observation on July 30, 2024, at 9:30 AM, revealed the rear door, to the Soiled-Linen (Biohazard) Room failed to automatically close and positively latch within the door frame. Interview with the Administrative Assistant on July 30, 2024, at 9:30 AM, confirmed the door did not automatically close and positively latch within the frame.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 30411 Based on document review and interview, it was determined the facility failed to provide documentation verifying quarterly fire drills were performed within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on July 30, 2024, at 9:51 AM, revealed the facility failed to provide documentation verifying fire drills had been completed between 2/1/23 and 1/16/24. Interview with the Administrator on July 30, 2024, at 9:51 AM, confirmed the lack of documentation verifying quarterly fire drills were performed within the previous twelve months.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 30411 Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting the entire component. Findings include: 1. Observation on July 30, 2024, at 9:40 AM, revealed a surge suppressor supplying electrical power to a microwave and a toaster within the Employee Break Room. Interview with the Administrative Assistant on July 30, 2024, at 9:40 AM, confirmed the high draw appliances were plugged into a surge suppressor.”

“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: 47219 Based on review of medical records (MR), agency policy, and interviews with facility administrator, agency failed to complete failed to timely required nursing pre-treatment patient assessments as per agency policy in sixteen (16) out of eighty (80) patient in-center dialysis treatments reviews medical records (MR #1-10). Findings include: Review conducted on July 24, 2024, at approximately 8:45 AM, of in-center hemodialysis medical records revealed pre treatment assessments that were over one hour late per policy: MR #1, start of care (soc) 5/28/24, dialysis treatment (TX) report 7/4/24, TX initiated 10:29 AM, nurse documentation of pre-treatment assessment was 11:48 AM, 19 minutes late. MR #2, soc 2/12/24, TX report 7/3/24, TX initiated 5:37 AM, nurse documentation of pre-treatment assessment was 7:19 AM, 41 minutes late; -TX report 7/15/24 initiated at 5:45 AM, nurse documentation of pre-treatment assessment was 7:07 AM, 22 minutes late. MR#3, soc 9/13/13, TX report 7/12/24, TX initiated 5:33, nurse documentation of pre-treatment assessment was 7:32 PM, 59 minutes late. MR#4 soc - transferred into this center on 6/17/24, TX report 7/8/24, TX initiated 1:29 PM, nurse documentation of pre-treatment assessment was 5:56 PM, 3 hours 27 minutes late. MR#5 soc 12/22/20, Tx report 6/25/24, Tx initiated 5:36 AM, nurse documentation of pre-treatment assessment was 8:56 AM, 2 hours 20 minutes late; and TX report 7/4/24, TX initiated 5:15 AM, nurse documentation of pre-treatment assessment was 7:24 AM, 1 hours 9 minutes late. MR#6 soc 5/9/22, TX report 7/12/24, TX initiated 10:57 AM, nurse documentation of pre-treatment assessment was 12:24 PM, 31 minutes late; TX report 7/15/24, TX initated at 11:05 AM, nurse documentation of pre-treatment assessment was a 12:27 PM, 22 minutes late; and TX report 7/19/24, TX initiated 10:57 AM, nurse documentation of pre-treatment assessment was 12:11 PM, 14 minutes late. MR#7 soc 6/4/24, TX report 7/3/24, TX initiated 1:35 PM, nurse documentation of pre-treatment assessment was 4:02 PM, 1 hour 27 minutes late; and TX report 7/19/24, TX initiated 12:54 PM, nurse documentation of pre-treatment assessment was 2:11 PM, 17 minutes late. MR #8, soc 4/25/24, TX report 7/4/24, TX initiated 5:54 AM, nurse documentation of pre-treatment assessment was 7:28 AM, 14 minutes late; TX report 7/18/24, TX initiated 5:45 AM, nurse documentation of pre-treatment assessment was 7:26 AM, 41 minutes late. MR#9, soc 11/2/23, TX report 7/2/24, TX initiated 6:33 AM, nurse documentation of pre-treatment assessment was 9:40 AM, 2 hours 7 minutes late. MR#10 soc 5/28/19, TX report 7/5/24, TX initiated 5:15 AM, nurse documentation of pre-treatment assessment was 7:14 AM, 59 minutes late. Review conducted on July 25, 2024, at approximately 1:00 PM, agency policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing assessment revealed: Page 3 of 7 “Intradialytic Date Collection/Assessment 18.The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law.” Interview conducted on July 24, 2024, at approximately 3:00 PM, with agency facility manager confirming the above findings.”