Davita Tipton County Dialysis

“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: 35244 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of potentially infectious bacteria by 1 of 5 (LPN #1) staff observed during 1 of 2 (3/11/25) observation days on the dialysis treatment floor. The findings included: 1. Review of the facility’s “INFECTION CONTROL FOR DIALYSIS FACILITIES” policy (April 2023) revealed, “...All teammates...will perform hand hygiene...prior to gloving and immediately after removal of gloves...” 2. Observations on 3/11/25 at 10:20 AM on the treatment floor revealed LPN #1 discarded used supplies, removed gloves and donned a new pair of gloves. LPN #1 failed to perform hand hygiene after removing gloves and prior to donning new gloves. In an interview on 3/11/25 at 1:00 PM, the FA verified hand hygiene should have been performed after removing gloves and prior to donning new gloves.”

“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: 35244 Based on policy review, observation and interview, the facility failed to ensure staff utilized PPE appropriately on the treatment floor during 2 of 2 (3/10/25 and 3/11/25) observation days. The findings included: 1. Review of the facility’s “CENTRAL VENOUS CATHETER (CVC) WITH CLEARGUARD HD ANTIMICROBIAL END CAPS PROCEDURE” policy (October 2024) 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 ...UPON COMPLETION OF DIALYSIS ...Teammate and patient will wear masks covering the nose and mouth during this procedure ...” 2. Observations on 3/10/25 at 10:40 AM on the treatment floor at station #13 revealed RN #1 performed CVC site care and CVC initiation for Patient #5. RN #1’s face mask was pulled down below the nose throughout both procedures. Observations on 3/11/25 at 10:42 AM on the treatment floor at station #10 revealed RN #2 performed CVC discontinuation for Random Patient #1 after completion of dialysis treatment. RN #2’s face mask was pulled down below the nose throughout the procedure. In an interview on 3/11/25 at 1:05 PM, the FA verified staff face masks should cover the nose during CVC initiation, site care and discontinuation of treatment.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to ensure physician’s orders for prescribed BFR were followed for 2 of 5 (Patient #1 and #5) sampled patients. The facility also failed to notify the physician of changes to the prescribed dialysis prescription. The findings included: 1. Review of the facility’s “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” policy (April 2024) 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...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” 2. Medical record review for Patient #1 revealed an admission date of 7/13/24 with diagnoses that included HTN and ESRD. Review of 3/10/25 physician orders revealed BFR of 400. Review of the 2/22/25 Treatment Details Report revealed the BFR was 350 from 9:55 AM until 12:50 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 2/26/25 Treatment Details Report revealed the BFR was 350 from 7:58 AM until 11:00 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 3/1/25 Treatment Details Report revealed the BFR was 350 from 10:05 AM until 11:13 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 3. Medical record review for Patient #5 revealed an admission date of 1/7/25 with diagnoses that included DM and ESRD. Review of 2/18/25 physician orders revealed BFR of 300. Review of the 2/14/25 Treatment Details Report revealed the BFR was 350 from 10:49 AM until 1:49 PM. There was no documentation why the BFR was not delivered at the ordered rate of 300. There was no documentation the physician was notified. Review of the 2/19/25 Treatment Details Report revealed the BFR was 350 from 10:26 AM until 1:12 PM. There was no documentation why the BFR was not delivered at the ordered rate of 300. There was no documentation the physician was notified. Review of the 3/3/25 Treatment Details Report revealed the BFR was 350 from 10:41 AM until 1:59 PM. There was no documentation why the BFR was not delivered at the ordered rate of 300. There was no documentation the physician was notified. In an interview on 3/12/25 at 10:00 AM, LPN #2 verified there should be documentation why the ordered BFR was not followed.”