Davita Memphis South Dialysis

“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: 46831 Based on facility policy procedure, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed for 2 of 2 (RP #1 and #2) sampled patients with a CVC by 1 of 1 (RN #1) nurses observed on the treatment floor. The findings included: 1. Review of facility procedure “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” revised April 2025, revealed “ ...Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination ...Scrub the sides, threads, and end of hub thoroughly with friction for 15 seconds ...” 2. Observation on the treatment floor at Station #1 on 01/05/2026 at 10:40 AM, revealed RN #1 began to perform discontinuation of treatment of a CVC and did not place a clean barrier beneath RP #2’s catheter. RN #1 did not scrub the hub for 15 seconds per facility policy. Observation on the treatment floor at Station #4 on 01/06/2026 at 10:30 AM, revealed RN #1 began to perform discontinuation of treatment of a CVC and did not place a clean barrier beneath RP #1’s catheter. RN #1 did not scrub the hub for 15 seconds per facility policy. 3. During an interview on 01/06/2026 at 3:00 PM, the FA stated a new barrier should be placed under the CVC before discontinuation.”

“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: 46831 Based on policy review, medical record review and interview, the facility failed to notify the charge nurse of elevated blood pressure and elevated pulse on 1 of 12 sampled treatment days for 1 of 5 (Patient #3) sampled patients. The facility failed to ensure 2 of 5 (Patient #2 and Patient #3) sampled patients received the prescribed dialysis prescription for BFR on 5 of 22 sampled treatment days. The findings included: 1. Review of the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” revised April 2024, revealed... “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately...All findings, interventions and patient response will be documented in the patient’s medical record ...” 2. Medical record review for Patient #2 revealed an admission date of 12/11/2025 with diagnoses that included End Stage Renal Disease. Review of a 12/20/2025 physician’s order revealed BFR of 350. Review of the 12/20/2025 Treatment Details Report revealed the BFR was 300 from 11:33 AM until 1:58 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation of physician being notified. Review of the 12/27/2025 Treatment Details Report revealed the BFR was 300 from 10:32 AM until 1:40 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation of physician being notified. Review of the 12/30/2025 Treatment Details Report revealed the BFR was 200 from 9:33 AM until 9:36 AM, then 250 from 10:03AM until 10:33 AM and then 300 from 11:03 AM until 1:04 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation of physician being notified. 3. Medical record review for Patient #3 revealed an admission date of 6/30/2023 with diagnoses that included End Stage Renal Disease. Review of the 11/28/2025 Treatment Details Report revealed a BFR of 300 and a BP of 93/67 at 8:02 AM, a BFR of 300 and a BP of 94/71 at 8:32 AM, a BFR of 300 at 9:02 AM, a BFR of 300 at 9:05 AM, a BFR of 300 at 9:32 AM and a BFR of 300 at 9:42 AM. There was no documentation of the charge nurse being notified. Review of the 12/1/2025 Treatment Details Report revealed a pulse of 100 at 7:33 AM, a pulse of 102 at 8:02 AM, a pulse of 105 at 9:03 AM, a pulse of 104 at 9:38 AM, a pulse of 104 at 10:00 AM and a pulse of 105 at 10:02 AM. There was no documentation of the charge nurse being notified. Review of the 12/3/2025 Treatment Details Report revealed a pulse of 103 at 5:56 AM, a pulse of 102 at 6:02 AM, a pulse of 100 at 7:02 AM, a pulse of 101 at 7:32 AM, a pulse of 100 at 8:02 AM, a pulse of 102 at 8:32 AM, a pulse of 102 at 9:02 AM, a pulse of 106 at 9:32 AM, and a pulse of 104 at 9:42 AM. There was no documentation of the charge nurse being notified. Review of the 12/10/2025 Treatment Details Report revealed a pulse of 118 at 6:12 AM, a pulse of 120 at 6:32 AM, a pulse of 116 at 7:02 AM, a pulse of 117 at 7:32 AM, a pulse of 114 with a BFR of 375 at 8:02 AM, a pulse of 117 with a BFR of 300 at 8:32 AM, a pulse of 115 with a BFR of 300 at 9:02 AM, a pulse of 117 with BFR of 300 at 9:32 AM, a pulse of 114 with a BFR of 300 at 10:02 AM and a pulse of 116 with a BFR of 300 at 10:03 AM. There was no documentation of the charge nurse being notified. Review of the 12/17/2025 Treatment Details Report revealed a BP of 88/59 with a pulse of 108 at 6:13 AM, a BP of 84/56 with a pulse of 109 at 6:14 AM, a pulse of 109 at 6:16 AM, a pulse of 108 at 6:32 AM, a pulse of 108 at 7:02 AM, a pulse of 108 at 7:33 AM, a BP of 89/60 with a pulse of 112 at 8:03 AM, a BP of 97/59 with a pulse of 111 at 8:07 AM, a pulse of 113 at 8:32 AM, a BP of 93/67 with a pulse of 115 at 9:02 AM, a BP of 96/57 with a pulse of 115 at 9:32 AM and a pulse of 119 at 10:02 AM. There was no documentation of the charge nurse being notified. During an interview on 1/6/2026 at 2:45 PM the FA stated CCHT’s should notify the RN with any abnormal readings, and the RN should document on the Treatment Details Report they were notified and the reason for any change or adjustment.”

“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: 46831 Based on review of facility policy, observation, and interview, the facility failed to ensure measures were taken to prevent the potential spread of infection by 2 of 2 (CCHT #1 and #2) staff members before cannulation of an AVF and/or AVG prior to initiation of hemodialysis on 1 of 1 (01/05/2026) observation days. The findings included: 1. Review of facility policy “Infection Control for Dialysis Facilities” revised 04/2023, revealed “ ...Patients and caregivers will be encouraged to ...Wash their hands and access extremity upon entering the treatment area and prior to the initiation of dialysis ...” 2. Observation on the treatment floor on 01/05/2026 at 8:47 AM, revealed a half full, dark drink in a plastic cup, sitting inside the cabinet below the supply drawer. Observations on the treatment floor on 01/05/2026 at 9:47 AM, revealed CCHT #2 initiated hemodialysis on RP #3 via an AVF/AVG. CCHT #2 failed to ensure the access site was cleaned with soap and water before proceeding with skin antisepsis. Observations on the treatment floor on 01/05/2026 at 10:10 AM, revealed CCHT #1 initiated hemodialysis on RP #4 via an AVF/AVG. CCHT #1 failed to ensure the access site was cleaned with soap and water before proceeding with skin antisepsis. 3. During an interview on 01/06/2026 at 3:00 PM, the FA stated that staff should ensure the AVF/AVG is cleaned prior to initiating hemodialysis.”