Davita Pageland Dialysis

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 22313 Based on observations, interview, and facility policy, entitled, “Segregation of Medical Waste”, the staff failed to ensure medical waste was placed in the proper container. (RN#1) The Findings include: Observations in the dialysis treatment room on 01/31/2024 at 10:30 AM revealed Registered Nurse (RN)#1 attending to a patient at dialysis station 6 with Patient Care Technician (PCT) #3. The patient begins bleeding at the discontinuation of his/her dialysis treatment. During patient care, a gauze pad soaked with blood was tossed into the chairside regular trash container by RN#1. On 01/31/2024 at 11:00 AM, RN #1 stated, “It (blood soaked gauze)should go into the red container.” The finding was confirmed in an interview with the Facility Administrator on 01/31/2024 at 1:15 PM, the FA stated, “That was wrong. It goes in the red container.” Facility policy, entitled, “Segregation of Medical Waste”, read, “1. Medical waste is contained separately from other noninfectious waste generated in the facility”.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 41743 Based on observations, interviews, and review of facility policy, the dialysis staff failed to properly clean and empty the prime waste container by 2 of 3 Patient Care Technicians (PCT #1 and #4). The Finding includes: Observations on 01/31/2024 for dialysis station #2 revealed PCT #1 at 09:00 AM cleaned the dialysis machine and dialysis station #2 but failed to empty and sanitize the prime waste container and failed to disinfect the shelf behind dialysis station #2 where the patient’s belongings had been stored during the dialysis treatment. At 9:06 AM, observations inside the prime waste container revealed fluid and a plastic needle cap in the container. At 9:16 AM, PCT #4 sets up the dialysis machine in dialysis station #2 for the next patient treatment, but failed to empty and sanitize the prime waste container. At 9:40 AM, the prime waste container still had the plastic needle cap and fluid in the container. Facility policy, entitled, “INFECTION CONTROL FOR DIALYSIS FACILITIES”, revealed, “Priming containers are to be emptied. The interior and exterior should be wiped down with 1:100 (one to one hundred) bleach solution before using on next patient treatment.””

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 22313 Based on observations, interviews, and facility policy, entitled, “Central Venous Catheter (CVC) Care”, one of one Registered Nurses (RN) observed failed to ensure that central line dressings remain clean and dry before/during treatment. (RN#1) The Findings include: Observations on 01/30/2024 at 9:50 AM revealed RN#1 performed a dressing change on Patient #6. The clean dressing was wetted with saline while flushing the Central Venous Catheter (CVC). RN #1 reported, “Oh, well, I have to change it again when (the patient) is finished. At the end of the patient’s dialysis treatment, the wet dressing was removed and a clean dressing was applied. In an interview with the Facility Administrator on 01/30/2024 at 1:25 PM, she/he responded, “Should have changed the wet dressing ....”. Facility policy, entitled, “Central Venous Catheter (CVC) Care”, read,: “3. Keep exit site dressing clean and dry”.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 41743 Based on observations, interviews, and review of manufacture’s guideline, the dialysis staff failed to follow correct procedure when performing Chlorine checks by 1 of 1 Registered Nurses (RN) #1 observed. The finding includes: Observations on 01/30/2024 at 10:20 AM revealed RN #1 obtained 30 ml (milliliters) of quality water, but failed to use a timer of any source for wait time of 30 seconds before checking test strip results. The finding was verified with RN #1 at 10:25 AM. Manufacturer’s instructions, entitled, “ E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips”, revealed, “Rinse standard sample cup provided with water to be tested. Re-fill with approximately 20ml of test water ...Remove strip from water, do not shake. Wait a full 30 seconds. After 30 second wait period, immediately compare the strip to the K100-0106 color chart to determine the Total Chlorine level in the sample.””