Davita Boiling Springs Dialysis

“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: 28883 Based on observations, interviews, and review of the facility’s “Medication Policy”, the dialysis clinic nursing staff failed to ensure expired medication was removed from staff access in the dialysis treatment room. Registered Nurse (RN) #1 failed to ensure a single dose medication vial of Venofer was disposed of after the medication vial was entered. The findings included: Observations on 1/8/24 at 3:00 PM of the medication storage in the dialysis treatment room revealed 7 vials of sterile water for injection, (50 milliliters each), that expired on 1/1/24. Observations of the medication storage drawer in the dialysis treatment room revealed 6 vials of Cefipime 1 gram that expired on 12/2023. The finding was verified by the Clinical Services nurse during an interview on 1/8/24 at 3:05 PM. Observations on 1/10/24 at 9:30 AM revealed an opened single dose vial of Venofer 20 mg/ml (milligrams/milliliter) that was labeled by Registered Nurse (RN) #1 as opened on 1/10/24. During an interview on 1/10/24 at 9:52 AM, RN #1 stated she/he had opened the vial of Venofer earlier and had administered some of the medication to a patient. RN #1 reported he/she was saving the rest of the medication to administer to a patient that would be coming for dialysis treatment. According to RN #1, the facility was out of the Venofer 50 mgs dose vials so were using the 100 mg vials for multiple doses. When informed it was a single dose vial, RN #1 the nurse asked “I can’t use this for another patient?”. Review on 1/10/24 at 12:45 PM of the facility’s “Medication Policy” revealed, “...Single use vials/ampules must be used for only one (1) patient, should not be entered more than once, and if entered, may not be stored for future use...Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory area and disposed of per state/local regulations...”.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 28883 Based on observations, interview, and review of the facility policy, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure”, one of two Registered Nurses (RNs) observed for Central Venous Catheter (CVC) care (RN #1) failed to ensure his/her mask covered the nose during a CVC dressing change and while accessing the catheter for treatment. The findings included: Observations on 1/10/24 at 11:01 AM revealed Registered Nurse #1 performing a dressing change and accessing a central venous catheter (cvc) for a random patient. During the procedures, RN #1 had his/her mask down covering the mouth but not the nares exposing the patient’s cvc exit site and catheter hubs open to potential contamination. During an interview on 1/10/24 at 11:20 AM, the finding was reviewed with RN #1 who did not comment. Review on 1/10/24 at 12:45 PM of the facility policy, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure”, revealed, “...Teammate and patient will wear masks covering the nose and mouth during this procedure. These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as methicillin-resistant Staphylococcus aureus (MRSA)...”.”

“BICARB MIX SYS-STOR/USE TIME/MIN COMBINE CFR(s): 494.40(a) 5.4.4.3 Bicarbonate concentrate mixing systems: storage/use time limits/min combine Once mixed, bicarbonate concentrate should be used within the time specified by the manufacturer of the concentrate. 7 Strategies for bacterial control 7.1 General Storage times for bicarbonate concentrate should be minimized, as well as the mixing of fresh bicarbonate concentrate with unused portions of concentrate from a previous batch. The manufacturer’s instructions should be followed if they are available. This Standard is not met as evidenced by: 28883 Based on observation and interview, the clinic’s Biomedical Technician (BMT) failed to remove Bicarbonate solution from staff access after opening/past the beyond use date. The findings included: Observations on 1/8/24 of the BMT’s work room revealed one opened commercial container of liquid Bicarbonate. The BMT stated she/he did not know when it had been opened and verified it had not been labeled with a date/time. Review on 1/10/24 at 12:45 PM of the facility policy, “Bicarbonate Concentrate System Mixing”, revealed, “...When commercial liquid bicarb solution is used, the manufacturer’s container should be labeled with date, time, and initials of teammate when opened and any unused liquid bicarb is discarded at the end of patient treatment day...”. Review on 1/10/24 of the instructions on the Bicarbonate container revealed the Bicarbonate must be used or discarded within 24 hours of opening.”

“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: 28883 Based on observations and interviews, the dialysis clinic staff failed to ensure expired supplies were removed from staff access in the facility’s in-center storage room and the water treatment room. The findings included: Observations on 1/8/24 at 2:20 PM in the in-center supply storage room revealed 11 suction catheter trays expired on 11/21/22. The finding was verified by the Clinical Services nurse during an interview on 1/8/24 at 2:22 PM. Observations in the water treatment room on 1/8/24 at 2:28 PM revealed 1 box holding 4 bottles of residual Chlorine test strips expired on 11/30/23. The finding was verified by the Clinical Services nurse during an interview on 1/8/24 at 2:30 PM.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 28883 Based on observations, review of the clinic’s emergency plan, documentation of fire extinguisher checks, Daily Water logs, the Mar Cor Purification manufacturer Operations and Maintenance Manual, and interviews, the dialysis clinic biomedical staff failed to ensure monthly checks of the fire extinguishers had been documented for November 2023 and December 2023. Nursing staff failed to ensure they documented checks for chemical residual and chemical consumption after the disinfection of the CWP RO (Continuous Water Purifier Reverse Osmosis) machine. The findings included: Observations on 1/8/24 between 2:40 PM and 2:50 PM revealed 3 fire extinguishers: one in the home therapy department, one in the dialysis treatment room by the exit door, and one near the dialysis treatment room entrance that had tags showing a monthly check of the fire extinguisher last completed on 9/29/23. The documentation of the October 2023, November 2023, and December 2023 checks were not documented on the tags. During an interview on 1/8/24 at 3:45 PM, the biomedical technician provided documentation of a check of the clinic’s fire extinguishers in October 2023. The biomedical technician could not find documentation of checks in November 2023 or December 2023. Review on 1/10/24 at 3:37 PM of the clinic’s emergency plan revealed on page 12, that fire extinguishers would be checked monthly to verify it is fully charged, safety seals are not missing or broken, there is no evidence of physical damage, there is no corrosion, leakage, or a clogged nozzle, and that it is kept in its designated place. Review on 1/9/24 at 11:50 AM of the facility’s Daily Water logs revealed the Continuous Water Purifier (CWP) had been chemically disinfected with Minncare on 12/5/23, 12/27/23 and 1/2/24, but staff had documented, “No” that there was no residual chemical check done the next morning before patient treatment started and had documented “No” for chemical consumption, that the Minncare had not been drawn up by the CWP. During an interview on 1/10/24 at 2:20 PM, Patient Care Technician (PCT) #1 verified the Daily Water log documentation listed above. Review on 1/10/24 at 2:24 PM of the Mar Cor Purification manufacturer Operations and Maintenance Manual revealed under “Start Up of the RO Machine after Chemical Disinfection” revealed that staff are to verify the disinfectant level is lower than the marking from the previous disinfection and staff are to test the water from the drain funnel, if it is positive for disinfectant to continue flushing until testing indicates the absence of disinfectant.”

“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: 28883 Based on observations, interview, and review of the facility policy, “CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”, one of two Registered Nurses (RNs) observed (RN #1) failed to ensure settings in the hemodialysis machine matched the patient’s prescription. The findings included: Observations on 1/9/24 at 10:08 AM revealed Registered Nurse #1 starting a dialysis treatment for a patient at dialysis machine 1 in dialysis station 9. At 10:13 AM, the surveyor reviewed the physician’s orders along with the dialysis machine settings with the nurse and verified that the patient had orders for a 2K (Potassium) 2.5 Ca(Calcium) dialysate, but the dialysis machine had been set for a 2K 3 Ca dialysate. Review on 1/10/24 at 12:45 PM of the facility policy, “CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”, revealed, “...Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment...Prescription components include but are not necessarily limited to: ...Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings...”.”