Davita Cedar Grove 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: 48280 Based on a review of facility policy/procedure, staff observations (OBS) in the treatment area, and an interview with the facility administrator, manager of clinical services and regional operations director, it was determined that the facility failed to ensure to follow its policy on infection control for three (3) observations: OBS # 1, 2 and 3. Findings include: A review of the agency ’ s policies was conducted on 8/22/25 starting at 12 pm. A policy titled, “ INFECTION CONTROL FOR DIALYSIS FACILTIES “ reads, “ ...HAND HYGEINE: 1. All teammates, Physicians and Non-Physician (NPP) 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 ... 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 body fluids, ii. When going from a “ dirty “ area to or task to a “ clean “ area or task. iii. When moving from a 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 system ... “ Observation in the treatment area was conducted on 8/20/25 from approximately 10:40 am to 12:30 pm and again from approximately 2 pm to 3 pm. OBS #1 on 8/20/25 at approximately 10:55 am, at station#6, the PCT (Patient Care Technician) #4 did not remove gloves or perform hand hygiene after removing old dressing during CVC (central venous catheter) exit site care. OBS #2 on 8/20/25, at approximately 2:45 pm, at station#17, the nurse #1 did not remove gloves or perform hand hygiene after discontinuation of CVC dialysis and prior to touching patient and patient ’ s belongings. OBS #3 on 8/20/25, at approximately 11:25 am, at the isolation room, the nurse #1 did not remove gloves or perform hand hygiene after touching sharps cart handle and prior to touching patient ’ s designated medical tape and removing an arteriovenous fistula/graft needle. An interview with the facility administrator, manager of clinical services and regional operations director on 8/22/25 starting at 1:45 pm.”

“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: 48280 Based on review of facility policy, medical records (MR) and an interview with the facility administrator, manager of clinical services and regional operations director, the facility to ensure that 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 for two (2) of five (5) MRs: MR# 2 and 5. Findings include: A review of the agency ’ s policies was conducted on 8/22/25 starting at 12 pm. A policy titled, “ PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT “ reads, “... POLICY: ... PRE-TREATMENT COLLECTION/ASSESSMENT: 4. Any abnormal findings or findings outside of any patient specific digestion order the parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “ Abnormal Findings “ section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis ... INTRADIALYTIC DATA COLLECTION/ASSESSMENT: 8. 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 ... 10. If the dialysis the prescription is not being met including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “ Abnormal Findings “ section in this policy). The licensed nurse will use his/her clinical judgment based on individual patients needs to determine if any clinical interventions are necessary ... 13. All findings, interventions and the patient response will be documented in the patient ’ s medical record ... POST TREATMETN DATA COLLECTION/ASSESSMENT: ... 16. If a abnormal finding(s) or concern is identify the post the treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use their clinical judgment to based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility ... ABNORMAL FINDINGS: ... Blood Pressure - Pre-dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... Blood Pressure - Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... Blood Pressure Post Treatment: ... Sitting BP (blood pressure) for patient ’ s that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ... Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or irregular beat ... Pre/Intra/Post Patient Records/Complaints and/or teammate observation of: pain, chest pain; bleeding or blood in stool; diarrhea, nausea or vomiting; chills; new onset of rash, skin lesions, ulcers or changes in skin color, new bruising or cuts; weakness or numbness; cramping; changes in mobility, ambulation, or reports of falls; changes in level of consciousness, ability to communicate ... “ A review of patient medical records (MR) was conducted on 8/20/25 starting at 3 pm, 8/21/25 starting at 10 am and again on 8/22/25 starting at 8:15 am. MR #2: Admission Date:4/19/24. Treatment record for 8/11/25 showed Intra-treatment Blood Pressure of 149/107 at 1 pm and 176/100 at 1:31 pm. A nurse note from 1 pm reads, “ patient awake; alert; and states no complaints at this time. “ There is no documentation that the nurse used their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician were indicated per policy. Treatment record for 8/13/25 showed A PCT note from 12:01 pm reads, “ Patient reports cramping; Patient reports dizziness; uf turned off; RN notified. “ There is no documentation that the nurse used their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician were indicated per policy. MR #5: Admission Date:5/30/25. Treatment record for 8/11/25 showed Intra-treatment Blood Pressure of 183/82 at 12:30 pm, 190/82 at 1:01 pm, 197/87 at 1:31 pm, 200/83 at 2:01 pm and 194/83 at 2:03 pm. PCT notes from 12:30 pm and 1:01 pm reads, “ patient monitored; watching tv no complications. “ A PCT note from 2:01 pm reads, “ patient monitored; watching tv no complications; b/p (blood pressure) elevated; will recheck. “ Post treatment blood pressure reads 184/93 at unknown time and treatment ended at 2:03 pm. Treatment record did not indicate that the nurse was notified according to policy. An interview with the facility administrator, manager of clinical services and regional operations director on 8/22/25 starting at 1:45 pm.”

“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: 48280 Based on a review of facility policy/procedure, observations, and an interview with the facility administrator, manager of clinical services and regional operations director, the facility failed to follow its policy to ensure that the staff performed proper aseptic technique while initiating treatment for one (1) of two (2) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ observations: Observation #1. Findings include: A review of the agency ’ s policies was conducted on 8/22/25 starting at 12 pm. A policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose 1-04-01E” stated, “procedure...Do not palpate insertion site once area has been prepped. Rationale. Once the access site has been prepped, touching it will contaminate the site and possible allow for the introduction of bacteria during cannulation...” Observation in the treatment area was conducted on 8/20/25 from approximately 10:40 am to 12:30 pm and again from approximately 2 pm to 3 pm. Observation #1: On 8/20/25 at approximately 10:40 am, station #22, PCT #1 began to initiate dialysis treatment. PCT #1 cleansed the insertion site then palpated site with gloved hands. PCT #1 then inserted needle without re-cleansing site. An interview with the facility administrator, manager of clinical services and regional operations director on 8/22/25 starting at 1:45 pm.”