Davita Central Bamberg 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: 41879 Based on observation, interview, and review of the clinic policy “Infection Control for Dialysis Facilities”, Physician #1, one of one physicians observed, failed to perform hand hygiene between glove changes. The findings included: On 03/18/2024 between 11:20 AM and 11:29 AM, observation in the treatment area of the Dialysis clinic revealed Physician #1 rounding on patients. Physician #1 donned new gloves and made rounds with a patient at Station 13, touching the patient and dialysis machine. Physician #1 doffed his/her gloves and retrieved a phone from a pant pocket. Physician #1 typed in numbers and made notes on the phone. Physician #1 donned new gloves, and rounded on a patient at station 14. Physician #1 touched the machine and the patient. Physician #1 doffed his/her gloves and retrieved the phone from a pants pocket. Physician #1 made calculations on the phone and placed the phone back in his/her pant pocket under the gown. No hand hygiene was observed between glove changes. The observations related to lack of hand hygiene between patients was verified with Physician #1 during an interview on 03/18/2024 at 11:30 AM. Review on 3/20/24 at 10:30 AM of the clinic policy, titled, “Infection Control For Dialysis Facilities,” read, “Hand Hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, and before touching clean areas such as supplies.””

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 41879 Based on record review, interview, and review of the policy “CWOW-PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, the clinic’s nursing staff failed to follow physician orders for the Blood Flow Rates (BFR) for two of five In Center Hemodialysis (ICHD) patient records reviewed; for Patients #1 and #2. The nursing staff failed to document patient safety checks/monitoring of blood pressure and heart rate every 30 minutes for Patient #5, one of five ICHD patient records reviewed. Findings included: Review of Patient 1’s treatment sheets on 03/19/24 at 12:00 PM revealed three of ten treatment sheets documented incorrect Blood Flow Rates (BFR). “Hemo Treatment Orders” dated 03/18/2024 read, “Blood Flow Rate: 350 and Dialysis Flow Rate: 500.” On 02/23/2024, Patient 1’s treatment started at 7:24 AM with a BFR of 350. The BFR ran at 350 until 8:01 AM when the BFR was decreased to 250. The BFR ran at 250 the rest of the treatment which ended at 11:00 AM. On 02/28/2024, Patient 1’s treatment started at 7:42 AM with a BFR of 400. The BFR ran at 400 until the end of treatment at 11:29 AM. On 03/08/2024, Patient 1’s treatment started at 8:09 AM with a BFR of 350. At 9:02 AM the BFR is increased to 300. The BFR ran at 300 the rest of the treatment ending at 112:03 AM. Review of Patient 2’s treatment sheets on 03/19/2024 at 1:00 PM revealed one of ten treatment sheets documented an incorrect BFR. “Hemo Treatment Orders” dated 02/08/2024 read, “Blood Flow rate 450 and Dialysis Flow Rate 500”. On 03/08/2024, Patient 2’s treatment started at 9:49 AM with a BFR of 400. The BFR ran at 400 the entire treatment which ended at 1:17 PM. Review of Patient 5’s treatment sheets on 3/19/2024 at 1:35 PM revealed four of ten treatment sheets showed vital signs and safety checks documented greater than thirty minutes. On 3/15/2024, the vitals for Patient 5 were documented at 6:06 AM. The next set of vitals and safety check had not been documented until 7:48 AM. On 3/13/2024, vitals were documented at 7:09 AM. The next set of vitals and safety checks had been documented at 8:06 AM. On 3/11/2024, vitals were documented at 6:40 AM. The next set of vitals and safety checks were documented at 7:38 AM. On 3/01/2024, Patient 5’s vitals were documented at 7:33 AM. The next set of vitals and safety checks had been documented at 8:28 AM. The above findings were verified with Registered Nurse #1 and the Facility Administrator during an interview on 03/20/2024 at 10:36 AM. The nurse stated there were no physician orders to adjust blood flow rates or documentation of a reason for adjustments. Review on 3/20/24 at 10:30 AM of the clinic policy, “CWOW-PRE- INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT,” reads, “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain blood flow rate) the reason will be documneted and the licensed nurse informed. The policy included information that “Vital signs and treatment monitoring for non-nocturnal treatments is completed every thirty minutes.””