Davita Fort Mill Dialysis

“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: 41879 Based on observations and staff interview, the dialysis facility staff failed to follow standard infection control guidelines for cleaning dialysis machines between patients for one of three Patient Care Technicians (PCT’s) observed. (PCT #1) Findings include: On 07/17/2024 at 10:40 AM observations in the treatment area of the facility revealed PCT #1 cleaning dialysis station #6. PCT #1 is observed emptying clear liquid from the priming container at station #6 into the wall box and did not disinfect the priming container after emptying. PCT #1 then brought clean supplies for the next patient to Station #6 and placed on the chair side table with a new patient observed being seated at the station #6. During an interview on 07/17/2024 at 11:20 AM, PCT #1 verified the findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 41879 Based on observations, staff interviews and review of facility policy, “Medication Policy,” the dialysis facility staff failed to ensure 1 of 2 Registered Nurses (RN’s) failed to use aseptic technique when administering medication. (RN #3) Findings include: On 07/17/2024 at 10:45 AM observations in the treatment area revealed RN #3 administering Intravenous (IV) medication to a patient at Station #7. RN #3 did not wipe the saline port prior to administering the IV medication. During an interview on 07/17/2024 at 11:25 AM, RN #3 verified the findings. Facility policy, entitled “Medication Policy,” reads, “Medications are ordered and replaced prior to expiration,” and, “all teammates administering medication must utilize aseptic technique.””

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 41879 Based on observations, staff interview and review of facility policy, “Infection Control for Dialysis Facilities,” the dialysis facility failed to check and removed expired supplies from the patient care areas. The findings include: On 07/15/2024 at 9:30 AM observation of the treatment area revealed (24) vials of Vancomycin 50 mg (milligram) expired 07/01/2024 in a drawer in the patient care area. During an interview on 07/15/2024 at 10:00 AM, the Facility Administrator (FA) verified the findings. During an observation on 07/15/2024 at 9:35 AM of the patient treatment area revealed (8) intravenous (IV) administration sets expired on 02/12/2024. During an interview on 07/15/24 at 9:45 AM, the Facility Administrator verified the findings. Facility policy, entitled “Infection Control for Dialysis Facilities,” reads, “Supplies must be rotated First in -First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 41879 Based on record review, staff interview and review of facility policy, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” the dialysis facility staff failed to ensure the patient signed an IDT care plan and/or document the reason for the delayed patient signature for one of seven patient charts reviewed. (Patient #7) Findings include: Record review on 7/17/2024 at 11:00 AM of Patient #7 revealed Patient #7 was admitted on 10/24/2023. Patient #7 has an IDT (Interdisciplinary Team) meeting dated 03/06/2024 with Patient #7 listed as unstable. Further review of the chart revealed Patient #7 signed the unstable IDT meeting treatment plans and goals on 04/25/2024 which was 49 days past the IDT meeting with no explanation for the late signature. During an interview on 07/17/24 at 1:46 PM, the Facility Administrator (FA) stated, “The IDT meeting and Plan of Care should have been reviewed with the patient and signed by the patient shortly after the meeting.” Facility policy, entitled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” reads, “The patient’s plan of care will be completed by the facility’s IDT, including patient or personal representative and be signed by team members including the patient or patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along wit the reason the signature was not provided.””