Davita Memphis Central Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure adequate Infection control measures were followed to ensure patient safety and a clean and sanitary environment. The findings included: 1. The facility failed to ensure hand hygiene was performed per facility policy on the treatment floor. Refer to V113 2. The facility failed to ensure PPE was appropriately utilized to prevent the spread of blood borne pathogens. Refer to V115 3. The facility failed to ensure reusable medical equipment was cleaned between patients to prevent cross-contamination. Refer to V122 4..The facility failed to ensure measures to prevent the spread of Hepatis B were followed. Refer to V128 5. The facility failed to ensure expired medications were disposed of and not readily available for use on the treatment floor. Refer to V143 6. The facility failed to ensure measures to prevent CVC related infections were followed during discontinuation of hemodialysis via CVC. Refer to V147 7. The facility failed to ensure measures to prevent vascular access infections were followed during initiation of dialysis via AVF/AVG. Refer to V550”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure hand hygiene was completed per policy by 2 of 7 (CCHT #1 and RN #1 ) staff observed providing direct patient care. The findings included: 1. Review of the facility’s “Infection Control For Dialysis Facilities” policy revised April 2023 revealed, “...All teammates...will perform hand hygiene prior to gloving and immediately after removal of gloves...” Review of the facility’s “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” policy revised April 2024 revealed, “...Infection Control Measures For Confirmed Positive or Suspected/Unknown Status...PPE will be removed, gloves discarded, and hand hygiene performed immediately when leaving the room or area...” 2. Observations on the treatment floor at Station #21 on 6/10/2025 at 10:30 AM, revealed CCHT #1 cleaning and disinfecting the dialysis station. The CCHT cleaned the dialysis machine, discarded the bleach wipe and removed her gloves. Without performing hand hygiene, CCHT #1 donned new gloves, removed the prime waste container from the machine and emptied its contents into the sink, and removed her gloves. Without performing hand hygiene, CCHT #1 donned new gloves, cleaned the prime waste container, placed it back onto the dialysis machine, and proceeded to clean the chair. CCHT #1 removed her gloves, donned new gloves without performing hand hygiene, then cleaned the area behind the dialysis station. CCHT #1 failed to perform hand hygiene after removing her gloves and before donning new gloves repeatedly. During an interview on 6/11/2025 at 11:50 AM, the FA stated hand hygiene should be performed before and after glove use. 3. Observations on the treatment floor in the Isolation room on 6/10/2025 at 10:55 AM revealed RN #1 removing the dialysis cannula from RP #1’s fistula. After completing the task, RN #1 failed to perform hand hygiene after removing his gown and gloves and before leaving the isolation room. During an interview on 6/11/2025 at 9:18 AM, the FA staff should perform hand hygiene after removing PPE and before leaving the isolation room.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure PPE was utilized appropriately on the treatment floor by 1 of 2 (RN #1) staff members observed providing direct patient care. The findings included: 1. Review of the facility’s “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” policy revised April 2024 revealed, “...Infection Control Measures For Confirmed Positive or Suspected/Unknown Status...When entering the isolation room/area or station for any reason...all teammates will wear long-sleeved fluid resistant/fluid impervious gowns in addition to gloves, face shield, or mask and eye protection. b. The long sleeved gown will be tied in the back. c. PPE will be removed, gloves discarded, and hand hygiene performed immediately when leaving the room or area...” 2. Observations on the treatment floor in the isolation room on 6/10/2025 revealed RN #1 discontinuing a dialysis treatment via an AVF on RP #1. RN #1 was wearing a face shield and face mask when he entered the isolation room. The RN obtained a fluid resistant gown and put his arms through the sleeves, but failed to tie the gown closed while providing care to RP #1, a known Hepatitis B positive patient. After providing patient care, RN #1 removed the gown and gloves and placed them in the garbage can inside the isolation room. While still wearing his face shield and mask, RN #1 exited the isolation room and went back out onto the treatment floor. RN #1 failed to tie the fluid resistant gown while providing care and failed to remove all PPE prior to exiting the isolation room. During an interview on 6/11/2025 at 9:18 AM, the FA stated fluid resistant gowns used in the isolation room should be tied in the back and all PPE including the gown, gloves, face shield and mask should be removed prior to exiting the room.”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure reusable equipment was disinfected between patients by 1 of 7 (RN #1) staff members observed on 2 of 2 (6/9/2025 and 6/10/2025) days of observations on the treatment floor. The findings included: 1. Review of the facility’s “Infection Control For Dialysis Facilities” policy revised April 2023 revealed, “...Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated...Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution...” 2. Observations on the treatment floor on 6/9/2025 revealed the following: At 2:25 PM, RN #1 obtained a stethoscope from the medication preparation area and used it to assess RP #2’s heart and lung sounds at Station #15. The RN hung the stethoscope on the computer cart beside Station #26. At 2:45 PM, RN #1 obtained the stethoscope from the computer cart and used it to assess RP #3’s heart and lung sounds at Station #25. The RN placed the stethoscope back on the computer cart and resumed patient care. RN #1 failed to clean the stethoscope before or after use and when moving from one patient to another. 3. Observations on the treatment floor on 6/10/2025 revealed the following: At 10:20 AM, RN #1 used a stethoscope to assess RP #4’s heart and lung sounds at Station #6. The RN placed the stethoscope between 2 other stethoscopes on the computer cart beside the station. At 10:25 AM, RN #1 picked the stethoscope back up and used it to assess RP #4’s access sites, then placed the stethoscope back on the computer cart beside the station. At 10:45 AM, RN #1 picked the stethoscope back up and used it to assess RP #5’s heart and lung sounds at Station #5. The RN placed the stethoscope back on the computer cart beside the station. RN #1 failed to clean the stethoscope before or after use and when moving from one patient to another. During an interview on 6/11/2025 at 9:18 AM, the FA stated staff should clean the bell of the stethoscope with an alcohol pad between each patient.”

“IC-HBV-ISOLATION (EXISTING FACILITY) CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, designate a separate room for their treatment. For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity. This Standard is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of Hepatitis B were followed by 1 of 2 (RN #1) staff observed providing direct patient care to RP #1, a known Hepatitis B positive patient in the isolation room. The findings included: 1. Review of the facility’s “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” policy revised April 2024 revealed, “...When using a designated isolation room, the walls should be made of a material that allows for visual monitoring of the patient(s) in the room...A door is required to the isolation room and it must be closed during times when blood spurting or spattering is possible, for example at initiation and termination of treatment...” 2. Observations on the treatment floor in the isolation room on 6/10/2025 at 10:55 AM revealed RN #1 discontinuing dialysis treatment via an AVF to RP #1, a known Hepatitis B positive patient. RN #1 failed to close the door during the termination procedure when blood spurting was possible. During an interview on 6/11/2025 at 9:18 AM, the FA was asked if the door to the isolation room should be closed during patient care. The FA stated, “we don’t routinely close it because the patient in there has mental health issues.” The FA was unaware the facility’s policy required the door to be closed during initiation and discontinuation of treatment when the potential for blood spurting was elevated.”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure expired medications were disposed of and not readily available for use in 1 of 3 (medication refrigerator) medication storage areas. The findings included: Review of the facility’s “Medication Policy” revised October 2023 revealed, “...Medications containing a preservative must be discarded 28 days after opening or accessed...Each vial is labeled with the initials of the person opening the vial and the expiration date...All medications are checked monthly for expiration dates...” Observations in the medication refrigerator on 6/9/2025 at 2:12 PM and on 6/11/2025 at 9:30 AM revealed 1 open multidose vial of Purified Protein Derivative with an open date of 8/7/2024. During an interview on 6/11/2025 at 9:30 AM, the FA verified the Purified Protein Derivative was expired and should have been discarded after “30 days.””

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent the spread of infectious bacteria were followed by 1 of 3 (RN #1) nurses observed initiating and/or terminating dialysis treatment via a CVC. The findings included: Review of the facility’s “Central Venous Catheter (CVC) with ClearGuard HD Antimicrobial End Caps Procedure” revised April 2025 revealed, “...Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines...For disconnection process, hub scrub will be completed immediately prior to cap placement...Upon Completion of Dialysis...Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination...Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds...insert the ClearGuard HD rod into the catheter hub...” Observations on the treatment floor at Station #15 on 6/9/2025 at 2:25 PM revealed RN #1 discontinuing dialysis treatment via a CVC on RP #2. RN #1 failed to replace the barrier used during treatment with a new moisture proof barrier under the catheter prior to terminating the treatment. After reinfusing the extracorporeal circuit, the RN disconnected the tubing, and wiped the arterial catheter hub with an alcohol pad then connected the saline syringe. RN #1 repeated the procedure on the venous line, flushed with saline, then removed the saline syringes and connected heparin syringes and instilled the heparin into each port. RN #1 disconnected the heparin syringes and inserted new ClearGuard HD caps into each catheter hub. RN #1 failed to scrub the catheter hubs for 15 seconds with alcohol prior to inserting the ClearGuard HD caps. During an interview on 6/11/2025 at 9:18 AM, the FA stated staff are expected to scrub the CVC hubs with alcohol pads for “30 seconds” at the start or discontinuation of treatment via a CVC.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to ensure staff notified the RN of episodes of elevated blood pressure, and failed to ensure patients leaving treatment greater than 1 kg over target weight was addressed by the RN for 2 of 7 (Patients #4 and 5) sampled patients reviewed. The findings included: 1. Review of the facility’s “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” policy (April 2024) revealed, “...ABNORMAL FINDINGS...the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings...Post-treatment...If patient is above or below 1 kg from the target weight...Blood Pressure-Intradialytic...Systolic greater then 180 mm/Hg or less than 90 mm/Hg...Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” 2. Medical record review for Patient #4 revealed an admisison date of 11/9/2022 with diagnoses which included HTN and ESRD. Review of 4/4/2025 dialysis orders revealed Patient #4’s target weight was 65 kg. Review of the dialysis treatment details report dated 4/3/2025 revealed Patient #4’s post treatment weight was 70 kg, which was 5 kg over the ordered target weight. There was no documentation the RN addressed the post treatment weight. Review of the dialysis treatment details report dated 4/4/2025 revealed Patient #4’s post treatment weight was 68.4 kg, which was 3.4 kg over the ordered target weight. There was no documentation the RN addressed the post treatment weight. Review of the dialysis treatment details report dated 5/12/2025 revealed Patient #4’s post treatment blood pressure was 211/129. There was no documentation the RN addressed the elevated blood pressure. Review of the dialysis treatment details report dated 5/29/2025 revealed Patient #4’s post treatment weight was 67.7 kg, which was 2.4 kg over the ordered target weight. There was no documentation the RN addressed the post treatment weight. 3. Medical record review for Patient #5 revealed an admission date of 2/21/2023 with diagnoses which included HTN and ESRD. Review of 1/5/2025 dialysis orders revealed Patient #5’s target weight was 83 kg. Review of the dialysis treatment details report dated 2/4/2025 revealed Patient #5’s post treatment weight was 85.3 kg, which was 2.3 kg over the ordered target weight. There was no documentation the RN addressed the post treatment weight. Review of the dialysis treatment details report dated 3/13/2025 revealed Patient #5’s post treatment weight was 85.9 kg, which was 2.9 kg over the ordered target weight. There was no documentation the RN addressed the post treatment weight. 4. During an interview on 6/11/2025 at 9:18 AM, the FA stated whenever patient’s blood pressures were elevated, staff should recheck the blood pressure, and if remained elevated, the RN should be informed and assess the patient. During an interview on 6/11/2025 at 9:55 AM, the FA verified a patient going over their target weight greater than one kg post treatment should be addressed and documented in the medical record.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 33763 Based on facility policy review, medical record review and interview, the facility failed to ensure physician’s orders for prescribed BFR were followed for 4 of 7 (Patients #1, 3, 5 and 6) sampled patient reviwed. The findings included: 1. Review of the facility’s “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” policy revealed, “...Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation...Prescription components include...Blood flow rate...Dialysate flow rate...” 2. Medical record review for Patient #1 revealed an admission date of 8/23/2019 with diagnoses which included ESRD and Type 2 Diabetes Mellitus. Review of the physician’s orders dated 2/1/2025 revealed a BFR of 450. Review of the dialysis treatment details report dated 2/10/2025 revealed the BFR was 400 from 11:34 AM until 2:33 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. 3. Medical record review for Patient #3 revealed an admission date of 8/2/2024 with diagnoses which included ESRD and Type 2 Diabetes Mellitus. Review of the physicians’ orders dated 5/1/2025 revealed a BFR of 400. Review of the dialysis treatment details report dated 5/19/2025 revealed the BFR was 350 from 11:02 AM until 2:41 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the dialysis treatment details report dated 5/26/2025 revealed the BFR was 350 from 11:32 AM until 2:32 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified of the deviation from the ordered BFR. 4. Medical record review for Patient #5 revealed an admission date of 2/21/23 with diagnoses which included HTN and ESRD. Review of physician orders dated 1/5/25 revealed a BFR of 450. Review of the Treatment Details Report dated 2/4/25 revealed the BFR was 400 from 10:26 AM until 1:54 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the Treatment Details Report dated 2/18/25 revealed the BFR was 400 from 11:00 AM until 1:43 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the Treatment Details Report dated 3/1/25 revealed the BFR was 400 from 10:12 AM until 1:31 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the Treatment Details Report dated 5/3/25 revealed the BFR was 400 from 9:58 AM until 1:11 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the Treatment Details Report dated 5/24/25 revealed the BFR was 400 from 11:31 AM until 1:01 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the Treatment Details Report dated 5/31/25 revealed the BFR was 400 from 11:12 AM until 2:34 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified of the deviation from the ordered BFR. 5. Medical record review for Patient #6 revealed an admission date of 4/1/2009 with diagnoses which included ESRD and Type 2 Diabetes Mellitus. Review of the physicians’ orders dated 3/27/2025 revealed a BFR of 400. Review of the dialysis treatment details report dated 5/26/2025 revealed the BFR was 350 from 6:32 AM until 9:45 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified of the deviation from the ordered BFR. Review of the dialysis treatment details report dated 5/30/2025 revealed the BFR was 350 from 6:02 AM until 10:14 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified of the deviation from the ordered BFR. 6. During an interview on 6/11/2025 at 9:18 AM, the FA verified staff should notify the physician and document the reason why the BFR is not followed.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 35244 Based on policy review, observation and interview, the facility failed to ensure measures to reduce the risk of infection during cannulation of an AVF and/or AVG were followed by 1 of 2 (CCHT #2) staff members observed initiating hemodialysis via an AVF or AVG. The findings included: 1. Review of the facility’s “ARTERIOVENOUS FISTULA (AVF) AND ARTERIOVENOUS GRAFT (AVG) VASCULAR ACCESS CARE” policy (April 2025) revealed, “...patient care teammate will clean access extremity with skin cleansing agent and pat dry...” 2. Observations on 6/10/25 at 10:00 AM on the treatment floor revealed CCHT #2 performing inititation of hemodialysis via AVF at station #17. CCHT #2 cleaned the AVF sites of RP #6 and immediately cannulated without allowing the skin to dry, or pat dry. During an interview on 6/11/25 at 9:55 AM, the FA stated the AVF sites should be allowed to dry before cannulation needles are inserted.”