Davita Morristown Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 40606 Based on facility policy review, observation and interview, the facility failed to ensure adequate infection control measures were taken to ensure preservation of dialysis accesses and patient safety. This resulted in the Condition of Infection Control not met. The findings included: 1. The facility failed to ensure patients, prior to their hemodialysis treatment, performed disinfection of their dialysis access and hands for 4 of 4 observations. Refer to V113 2. The facility failed to ensure the licensed nurses followed appropriate infection control measures when accessing central venous catheters (CVC, a surgically inserted dialysis access) for 4 patients (#18, #15, #17, and #9) of 5 patients observed for discontinuation of dialysis treatment using a CVC catheter. Refer to V147”

“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: 27405 Based on facility policy review, observation and interview, the facility failed to ensure patients, prior to their hemodialysis treatment, performed disinfection of their dialysis access and hands for 4 of 4 observations. The findings include: Review of the facility policy, “Infection Control for Dialysis Facilities,” dated 4/2023, revealed “...Hand Hygiene...2. Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis...” Observations on 4/14/2025, from 10:30 AM to 12:30 PM, revealed the dialysis treatment area had 20 dialysis treatment stations. Further observation revealed 4 patients entered the dialysis treatment area at the appointed time, walked to stations 17, 12, 16, and 13, accompanied by the staff initiating treatment. Observation revealed the patients started the treatment without washing or disinfection of the dialysis access or hands. During an interview on 4/16/2025 at 10:45 AM, the Facility Administrator confirmed patients were expected to adhere to the facility’s access and handwashing policy. Stating “...Yes, most definitely they [patients] should wash their hands prior to initiating treatment...””

“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: 40606 Based on facility policy review, observation and interview, the facility failed to ensure the staff followed appropriate infection control measures when accessing a central venous catheter (CVC, a surgically inserted dialysis access) for 4 patients (#9, #15, #17, and #18) of 5 patients observed for discontinuation of dialysis treatment using a CVC catheter. The findings include: Review of the policy, “Central Venous Catheter (CVC) With...Connectors or CVC End Caps Procedure,” dated 2024 revealed “...aseptic technique used throughout the procedure...perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines...Put on PPE [personal protective equipment] and provide a mask to the patient...Teammate and patient will wear masks covering the nose and mouth during this procedure...set up a clean field with all appropriate supplies on a clean, moisture proof barrier...place a second moisture proof barrier under catheter limbs...” Record review revealed Patient #9 was admitted for hemodialysis on 7/18/2024 for a diagnosis of End Stage Renal Failure Record review revealed Patient #15 was admitted for hemodialysis on 5/23/2023 for a diagnosis of End Stage Renal Disease. Record review revealed Patient #17 was admitted for hemodialysis on 4/9/2025 for a diagnosis of Acute Renal Failure. Record review revealed Patient #18 was admitted to the clinic for hemodialysis on 2/7/2025 with diagnoses including End Stage Renal Disease. During an observation on 4/14/2025 at 11:42-11:48 AM, Registered Nurse (RN) #1 was observed discontinuing a dialysis treatment on Pt #18 in station 8 administered via the patient’s CVC. Observation revealed after RN #1 disconnected the CVC limbs from the bloodlines, RN #1 laid the uncapped CVC limbs down on the treatment barrier pad underneath the CVC and exited the station. Further observation revealed at 11:47 AM, RN #1 re-entered station 8 and discontinued the treatment by scrubbing each CVC end of limbs and capped them with a sterile end cap. Pt #18’s CVC was exposed to the air and surrounding enviroment for 6 minutes before the sterile end caps were placed on each CVC limb. During an observation on 4/14/2025 at 11:50 AM, RN #2 was observed discontinuing a dialysis treatment on Pt #15 administered via the CVC. RN #2 had a mask on, but it was pulled down under her chin. It was not covering her mouth or nose. Continued observation revealed Patient #15 did not have a mask in place. After disconnecting the CVC from the bloodlines, RN #2 was observed laying the open and uncapped end of the CVC down on the treament barrier pad below the CVC. During an observation on 4/14/2025 at 12:10 PM, in the patient care area, RN #3 was observed discontinuing a dialysis treatment for Pt #17 administered via a CVC, without wearing a mask. During an observation on 4/15/2025 at 11:15 AM, in the patient care area, RN #3 was observed discontinuing a dialysis treatment on Pt #9 administered via a CVC. After disconnecting the CVC from the bloodlines and flushing the catheter with a 10 ml (milliliter) syringe, the nurse scrubbed the sides, threads, and end of the hub for 3 seconds instead of the required 15 seconds. During an interview on 4/16/2025 at 10:36 AM, with the Facility Administrator, she revealed it was her expectation during initiation or discontinuation of dialysis administered via a CVC “...the catheter should not be laid down for any amount of time...The hub of the catheter should be scrubbed for at least 15 seconds...All employees are supposed to wear a mask...when connecting or discontinuing a central line.””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 27405 Based on facility policy review, observation and interview, the facility failed to obtain post dialysis weights for 4 patients (#7, #8, #9, & #14) of 8 patients observed exiting the dialysis treatment area. The findings include: Review of the facility policy, “Pre-Intra-Post Treatment Data Collection...,” dated 1/3/2008, revealed “...Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse...Data collection includes but not is not necessarily limited to...Patient weight...” Record review revealed Patient #7 was admitted for hemodialysis on 10/10/2023 with diagnoses including Acute Kidney Failure and Chronic Kidney Disease. Record review revealed Patient #8 was admitted for hemodialysis on 12/12/2023 with diagnoses including Chronic Kidney Disease. Record review revealed Patient #9 was admitted for hemodialysis on 7/18/2024 with diagnoses including Chronic Kidney Disease. Record review revealed Patient #14 was admitted for hemodialysis on 3/18/2024 with diagnosis including Hypertension and Chronic Kidney Disease. During an observation on 4/14/2025 at 11:21 AM, Patient #14 completed their dialysis treatment, walked to the exit door of the treatment room, self-weighed and obtained a post dialysis weight. Patient #14 placed the weight slip on the dialysis treatment door using 1 of many small magnets on the door. Continued observation revealed no patient name or other identifiers were on the weight slip, and no staff were present at the time Patient #14 placed the weight slip on the door. During an observation on 4/15/2025 at 11:22 AM, revealed Patient #9 completed dialysis treatment, walked out of the treatment area and exited the dialysis center without obtaining a post treatment weight. During an observation on 4/15/2025 at 11:40 AM, revealed Patient #7 completed dialysis treatment walked out of the treatment area and exited the dialysis center without obtaining a post treatment weight. During an observation on 4/15/2025 at 11:45 AM, revealed Patient #8 completed dialysis treatment walked out of the treatment area and exited the dialysis center without obtaining a post treatment weight. During an interview on 4/16/2025 at 10:45 AM, the Facility Administrator confirmed she expected the clinic staff to obtain weight slips from patients and not be left on the treatment room door. During a telephone interview on 4/23/2025 at 3:30 PM, with the Facility Administrator, she confirmed the observed practice of allowing patients to weigh themselves after their dialysis treatment unattended did not conform with the facility’s policy and she stated, “...we are working to correct this...””