Davita Bolivar Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 33763 Based on facility policy review, observation and interview, the facility failed to ensure expired supplies were disposed of and not readily available for use at the nurses’ station on 1 of 1 (2/10/2025) observations days. The findings included: 1. Review of the facility policy titled, “Infection Control for Dialysis Facilities” revised April 2023 revealed, “...Supplies will be stored in a manner that maintains their integrity... Expiration date and package integrity will be verified prior to use... Anytime the integrity of a package with or without an expiration date is in question... the package and its contents must be disposed of and not used...” 2. Observations at the nurses’ station on 2/10/2025 at 11:20 AM, revealed one (1) open bottle of blood leak test strips with an expiration date of 12/31/2024. During an interview on 2/10/2025 at 11:45 AM, RN #2 confirmed the blood test strips were expired.”

“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 performed according to facility policy to prevent the spread of infectious bacteria by 2 of 4 (CCHT #1 and CCHT#2) staff observed providing direct patient care on the treatment floor. The findings included: 1. Review of the facility policy titled, “Infection Control for Dialysis Facilities” revised April 2023, revealed, “...All teammates... will perform hand hygiene... prior to gloving and immediately after removal of gloves... after patient and dialysis delivery system contact... before touching clean areas such as supplies, supply cart and chairside keyboard/mouse... Gloves should be changed when... going from a “dirty” area or task to a “clean” area or task... When moving from a contaminated body site to a clean body site of the same patient...” 2. Observations on the treatment floor at Station #20 on 2/10/2024 at 9:20 AM, revealed CCHT #1 discontinued hemodialysis treatment on RP #1. CCHT donned gloves without performing hand hygiene, used his gloved hand to move the biohazard container closer to the station, and began the rinseback process. After the rinseback was completed, CCHT #1 removed the gloves, performed hand hygiene, and donned new gloves. CCHT #1 removed the venous needle and applied a pressure bandage to the site, then removed the gloves. The CCHT walked to the supply cabinet and obtained additional gauze and returned to the station. Without performing hand hygiene, the CCHT donned new gloves and removed the arterial line and applied a pressure dressing to the site. CCHT #1 failed to perform hand hygiene after removing his gloves and after touching contaminated objects repeatedly. 3. Observations on the treatment floor at Station #9 on 2/10/2025 at 9:32 AM, revealed CCHT #2 discontinuing hemodialysis treatment on RP #2. CCHT #2 performed hand hygiene, donned gloves, then moved the biohazard container closer to the station. Without removing the gloves, performing hand hygiene, and donning new gloves, the CCHT started the rinseback procedure. CCHT #2 repositioned the footrest on the Patient’s chair, then disconnected the venous line while still wearing the contaminated gloves. CCHT #2 failed to remove gloves, perform hand hygiene, and don new gloves when moving from contaminated objects to performing patient care. 4. Observations on the treatment floor at Station #4 on 2/10/2025 at 10:55 AM, revealed CCHT #1 initiating hemodialysis via AVF/AVG on Patient #3. CCHT #1 performed hand hygiene, donned gloves, and assessed Patient #3’s access site with his gloved hand. The CCHT removed the gloves and donned new gloves without performing hand hygiene and proceeded to clean the Patient’s access site with a cleansing cloth. Without changing gloves and performing hand hygiene, the CCHT cleaned the Patient’s access site with an alcohol prep wipe. CCHT #1 removed the gloves, walked over to the supply cabinet and obtained a betadine swab. Without performing hand hygiene, the CCHT donned gloves and cleaned the Patient’s access site with the betadine swab then removed the gloves. CCHT #1 obtained a clip board with paper and pen and wrote information on the paper. Without performing hand hygiene, CCHT #1 donned new gloves and cannulated Patient #3’s access site and removed the gloves and waited for the RN to administer the Patient’s loading dose of heparin. After the heparin was administered, CCHT #1 donned new gloves, completed priming the tubing and connected the dialysis tubing to the Patient and started the treatment. CCHT #1 failed to perform hand hygiene after removing his gloves repeatedly. 5. During an interview on 2/12/2025 at 3:45 PM, the FA verified staff should remove gloves, perform hand hygiene and don new gloves when moving from a dirty to clean task. The FA continued and stated hand hygiene should be performed every time gloves are removed.”

“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 not available for use and/or labeled correctly in 1 of 3 (medication storage area at nurses’ station] medication storage areas observed. The findings included: 1. Review of the facility policy titled, “Medication Policy” revised October 2023 revealed, “If multi-dose vials are used to prepare saline flush syringes, they must be dated upon opening and discarded within 28 days unless the manufacturer specifies a different date for that vial. The beyond-use date should never exceed the manufacturer’s expiration date... Medications are ordered and replaced prior to expiration. Unless an exact expiration date is specified, medications with an expiration date of month/year are considered expired the last day of the stated month... Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulation...” 2. Observations in the medication storage area at the nurses’ station on 2/10/2025 at 11:20 AM, revealed one (1) open, unlabeled multidose vial of heparin and one (1) open bottle of acetaminophen 325 mg tablets with an expiration date of 7/2024. During an interview on 2/10/2025 at 11:45 AM, RN #2 confirmed the multidose vial of heparin should have been labeled and confirmed the acetaminophen was expired. During an interview on 2/12/2025 at 3:45 PM, the FA stated all multi-dose vials should be labeled and dated when opened, and expired medications should be discarded.”

“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 implement measures to address hypertensive episodes for 2 of 7 (Patient #1 and #4) sampled in-center hemodialysis patients. The findings included: 1. Review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” revised April 2024 revealed, “...Intradialytic Data Collection/Assessment... Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse included... Blood pressure... Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary...The licensed nurse notifies the physician (or NNP if applicable) as needed of changes in patient status...All findings, interventions and patient response will be documented in the patient’s medical record...Additional documentation if applicable includes...All medications including time administered...Indication and patient response to PRN medication...”Abnormal Findings...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient specific physician order...Blood pressure: Pre-dialysis...Systolic greater than 180 mm/Hg or less than 90 mm/Hg...Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg... Intradialytic... Systolic greater than 180 mm/Hg or less than 90 mm/HG...Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/HG...Post Treatment...Standing systolic BP greater than 140 mm/Hg or less than 90 mm/HG...diastolic BP greater than 90 mm/Hg or less than 50 mm/HG... Sitting BP for patients that cannot stand...Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/HG...Sitting diastolic BP greater than 90 mm/HG or less than 50 mm/Hg...” 2. Medical record review for Patient #1 revealed an admission date of 12/2/2024 with diagnoses which included Acute Kidney Injury and End Stage Renal Disease. There were no physician’s orders to address Patient #1’s hypertensive episodes during dialysis as verified by the FA via email on 2/13/2025. Review of the Treatment Details Report dated 1/22/2025 revealed a pre-treatment blood pressure of 195/115 at 5:33 AM. the treatment was initiated at 5:47 AM. The Patient’s blood pressures were as follows: 180/108 at 5:47 AM 172/94 at 6:17 AM 204/99 at 6:47 AM “bp noted cn notified” 161/113 at 6:54 AM At 6:57 AM, RN #1 documented, “bp noted; pt alert no distress.” 174/107 at 7:17 AM 177/116 at 7:47 AM 168/115 at 8:17 AM 167/105 at 8:47 AM 174/107 at 9:48 AM The post-treatment blood pressure was 181/111 at 10:10 AM. Facility staff failed to address Patient #1’s blood pressure and failed to notify the physician to obtain orders to treat address the Patient’s blood pressure. During an interview on 2/12/204 at 12:44 PM, the FA stated when patient’s blood pressures are 180/100 or above before treatment, staff should monitor them for the 1st hour. If the patient’s blood pressure didn’t improve, they should consider administering Clonidine (a medication used to treat high blood pressure) and/or call the physician for further orders. During an interview on 2/12/2024 at 12:45 PM, the MCS stated there was no documentation Patient #1’s hypertension was addressed or medications administered. The MCS continued and stated staff should have addressed and treated Patient #1’s hypertension on 1/22/2025. 3. Medical record review for Patient #4 revealed an admission date of 3/18/2023 with diagnoses which included Chronic Hypertensive Kidney Disease and End Stage Renal Disease. Review of a physician’s order dated 7/27/2023 revealed Clonidine 0.1 mg, “Administer one tab PO q hour x 1 for continued hypertension during dialysis. If no improvement at end of treatment, notify physician for further orders. May repeat dose x 1...” Review of the Treatment Details Report dated 1/14/2025 revealed a pre-treatment blood pressure of 178/137 at 10:05 AM. the treatment was initiated at 10:18 AM. The Patient’s blood pressures were as follows: 160/107 at 10:18 AM “BP noted; RN aware” At 10:20 AM, RN #1 documented, “htn noted; no distress” 176/111 at 10:47 AM “BP remains high” 178/113 at 11:17 AM At 11:20 AM, RN #1 documented, “bp noted; no distress” 180/116 at 11:47 AM 178/114 at 12:19 PM 178/112 at 12:47 PM 176/103 at 1:17 PM 192/121 at 1:38 PM The post-treatment blood pressure was 173/117 at 2:00 PM. Facility staff failed to address Patient #4’s blood pressure and did not administer supplemental Clonidine 0.1 mg which was prescribed by the physician. Review of the Treatment Details Report dated 1/212025 revealed a pre-treatment blood pressure of 173/111 at 10:25 AM. the treatment was initiated at 10:31 AM. The Patient’s blood pressures were as follows: 166/102 at 10:31 AM 169/110at 11:01 AM 174/102 at 11:31 AM RN #1 documented, “bp noted; no distress...” 164/102 at 12:01 PM 176/109 at 12:31 PM 167/106 at 1:01 PM 191/122 at 1:31 PM RN #1 documented, “bp noted; no distress; pt taking home bp meds after tx” 150/117 at 2:01 PM The post-treatment blood pressure was 190/116 at 1:13 PM. Facility staff failed to address Patient #4’s blood pressure and did not administer supplemental Clonidine 0.1 mg which was prescribed by the physician. Review of the Treatment Details Report dated 1/23/2025 revealed a pre-treatment blood pressure of 168/105 at 10:37 AM. the treatment was initiated at 10:32 AM. The Patient’s blood pressures were as follows: 168/96at 10:32 AM 166/95 at 11:01 AM 170/101 at 11:31 AM 166/104 at 12:01 PM 178/113 at 12:31 PM 186/109 at 12:32 PM The post-treatment blood pressure was 195/100 at 12:50 PM. Facility staff failed to address Patient #4’s blood pressure and did not administer supplemental Clonidine 0.1 mg which was prescribed by the physician. Review of the Treatment Details Report dated 2/42025 revealed a pre-treatment blood pressure of 194/127 at 6:45 AM. the treatment was initiated at 6:54 AM. The Patient’s blood pressures were as follows: 168/111 at 6:54 AM 172/111 at 7:22 AM RN #1 documented, “bp noted; pt resting no distress will monitor” 173/98 at 7:52 AM 172/108 at 8:52 AM 172/110 at 8:52 AM 180/114 at 9:22 AM 189/107 at 9:52 AM 190/129 at 10:22 AM 196/125 at 10:24 AM The post-treatment blood pressure was 169/112 at 11:00 AM. Facility staff failed to address Patient #4’s blood pressure and did not administer supplemental Clonidine 0.1 mg which was prescribed by the physician. During an interview on 2/12/2025 at 12:58 PM, the MCS verified staff failed to follow physician’s orders to address Patient #4’s blood pressure.”

“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, observation, and interview, the facility failed to ensure physician’s orders for heparin administration were followed for 1 of 7 (Patient #4) sampled in-center hemodialysis patients. The findings included: 1. Review of facility’s “Medication Policy” revised October 2023 revealed, “...Medications are administered as prescribed and then documented in the patient’s medical record...” 2. Medical record review for Patient #4 revealed an admission date of 3/18/2023 with diagnoses which included Chronic Hypertensive Kidney Disease and End Stage Renal Disease. A physician’s order dated 9/18/2023 revealed heparin (medication used to help prevent blood clots) loading dose of 3000 units. A physician’s order dated 8/27/2024, revealed heparin infusion of 500 units per hour for 3 hours with infusion stop 60 minutes prior to termination of treatment. Patient #4 was to receive a total of 4500 units of heparin each treatment. Review of the Treatment Details Report dated 1/18/2025 revealed Patient #4 was administered a heparin loading dose of 3000 units at 9:35 AM. The treatment was initiated at 9:41 AM and ended at 11:41 AM. The report revealed the heparin infusion was not administered due to a “Prescription Change.” There was no further documentation to indicate why the heparin infusion was not administered as ordered. Review of the Treatment Details Report dated 1/23/2025 revealed Patient #4 was administered a heparin loading dose of 3000 units at 10:29 AM. The treatment was initiated at 10:32 AM and ended at 12:32 PM. The report further revealed the heparin infusion was not administered due to a “Prescription Change.” There was no further documentation to indicate why the heparin infusion was not administered as ordered. Review of the Treatment Details Report dated 2/1/2025 revealed Patient #4 was administered a heparin loading dose of 3000 units at 9:15 AM. The treatment was initiated at 9:23 AM and ended at 11:21 AM. The report further revealed the heparin infusion was not administered due to a “Prescription Change.” There was no further documentation to indicate why the heparin infusion was not administered as ordered. Review of the Treatment Details Report dated 2/6/2025 revealed Patient #4 was administered a heparin loading dose of 3000 units at 8:15 AM. The treatment was initiated at 8:17 AM and ended at 10:26 AM. The report further revealed the heparin infusion was not administered due to a “Prescription Change.” There was no further documentation to indicate why the heparin infusion was not administered as ordered. During an interview on 2/12/2025 at 12:48 PM, the MCS stated the heparin infusion wasn’t administered because the Patient informed staff he was going to leave against medical advice after 2 hours of treatment and the heparin infusion would have to be stopped an hour before the treatment ended so there “was no need to give it.” The MCS continued and stated staff should have documented the reason the heparin wasn’t given.”