Davita Renal Care of Memphis North

“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: 19001 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed prior to cannulation of a fistula or graft for 1 of 2 (RN #1) staff observed. The findings included: 1. Review of the facility policy “AV FISTULA OR GRAFT CANNULATION WITH NEPRO OR MEDIYSTEMS SAFETY FISTULA NEEDLES ...” revised April 2025, revealed, “Procedure ... Perform hand hygiene ...Perform inspection auscultation ...Locate and palpate the needle cannulation sites prior to skin preparation ...While maintaining aseptic technique, prep each planned needle site by applying 70 % alcohol prep pad to each site using circular rubbing motion ... Do not palpate insertion site once area has been prepped.” 2. Observation on 6/10/2025 at 10:00 AM revealed RN #1 performed hand hygiene and donned clean gloves, listened to Patient #2’s lungs with a stethoscope, touched the dialysis machine, then cleaned Patient #2’s access area and inserted the access needle. RN #1 did not perform hand hygiene and don clean gloves after touching the dialysis machine. RN #1 then touched the second area, previously cleaned with her gloved hands palpating the area before inserting the second access needle. RN #1 failed to perform hand hygiene and don clean gloves before cannulation and re- contaminated the area before cannulating the second access. 3. During an interview on 6/11/2025 at 9:43 AM, the FA verified the nurse should have performed hand hygiene after touching the dialysis machine, before cannulation. The FA also verified the cannulation site should not be touched after cleaning with skin antiseptic.”

“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: 19001 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed for 1 of 2 (Nurse #1) nurses observed during CVC care. The findings included: 1. Review of the facility policy “CENTRAL VENOUS CATHETER (CVC) WITH CLEARGUARD HD AND ANTIMICROBIAL END CAPS PROCEDURE” revealed, “...Perform hand hygiene per procedure. Hand hygiene protects patient and teammate from cross contamination...Set up clean field with all appropriate supplies on a clean moisture proof barrier...Verify the patients clothing is secured away from the exit site/work area...” 2. Observations on 2/27/2024 at 10:20 AM, revealed Nurse #1 performed CVC care to RP #1. Nurse #1 performed hand hygiene and retrieved the clean supplies. Nurse #1 held and folded a large section of RP #1’s shirt and undershirt and taped the shirts down to gain access to the CVC. Nurse #1 then placed a clean field under RP #1’s CVC dressing. Nurse #1 failed to perform hand hygiene and change gloves after touching the patient’s garments and before placing the clean field under RP #1’s CVC. 3. In an interview on 2/28/2024 at 11:15 AM, the FA stated she was unsure if Nurse #1 should have changed her gloves and performed hand hygiene after touching the patients clothing. The FA stated, “I mean, I would have...not sure that our policy states specifically...””

“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: 16579 Based on policy review, medical record review and interview, the facility failed to maintain physician ordered BFR and/or DFR for 2 of 7 (Patient’s #1 and 4) medical records reviewed. The findings included: 1. Review of the facility policy “PRE- INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised in October 2023, revealed, “...Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment...The prescription components include but are not necessarily limited to... Blood flow rate g. Dialysate flow rate... 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 license nurse informed...” 2. Medical record review for Patient #1 revealed an admission date of 2/6/2015 with diagnoses of ESRD and Hypertension. Physician’s orders from his admission, verified by the FA, documented the BFR at 400 mL/min and the DFR at 500 mL/min. Review of the Treatment Details Report dated 2/7/2024 revealed the BFR was started at 200 mL/min beginning at 11:49 AM. The BFR continued at 200 until 12:34 PM. At 2:04 PM the BFR was changed to 300 mL/min with no explanation why it was changed. Review of the Treatment Details Report dated 2/9/2024 revealed the BFR was lowered from 400 mL/min to 300 mL/min at 3:02 PM. It continued at that rate until the treatment was terminated at 3:46 PM with no explanation why it was reduced. In an interview in the FA’s office on 2/27/2024 at 9:15 AM, the FA verified there was no documentation why the BFR’s had been reduced on 2/7/2024 and 2/9/2024. 3. Medical record review for Patient #4 revealed an admission date of 11/16/2021 with diagnoses of ESRD and Diabetes Mellitus. Review of the physician orders for dialysis dated 2/6/2024, revealed Patient #4 received dialysis 3 times per week for 225 minutes with at BFR of 350 mL/min and DFR at 600 mL/min. Review of the Treatment Details Report dated 2/6/2024 at 11:03 AM revealed the BFR was 400 mL/min and remained 400 throughout the treatment. There was no documentation why the BFR was changed. Review of the Treatment Details Report dated 2/13/2024 at 11:32 AM revealed the DFR was 500 mL/min and remained 500 throughout the treatment. There was no documentation why the DFR was changed. Review of the Treatment Details Report dated 2/22/2024 at 11:00 AM, when the treatment was initiated, the DFR was 600 mL/min as ordered. At 1:01 PM, the DFR was changed to 500 mL/min and remained 500 throughout the treatment. There was no documentation why the DFR was changed. In an interview on 2/27/2024 at 11:55 AM, the FA verified any variation in the physician ordered BFR or DFR should be documented on the treatment records.”