Davita Wolfchase 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: 19001 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 infectious bacteria by 2 of 5 (PCT #1 and PCT #2) staff observed during 1 of 2 (12/3/2024) observation days on the dialysis treatment floor. The findings included: 1. Review of the facility’s “Hand Hygiene” policy (revised 8/2020) revealed, “...HAND HYGIENE will be performed...6. Before clean/aseptic procedure...8. After touching patient surroundings (e.g. [for example], dialysis machine, any items in the dialysis area or chairside computers)...9. After gloves are removed...” 2. Observations on the treatment floor on 12/3/2024 beginning at 9:45 AM revealed PCT #2 wearing gloves, removed AV fistula needles from Patient #3 during discontinuation of dialysis treatment. PCT #2 removed gloves then donned a new pair of gloves without first performing hand hygiene. Observations on 12/4/2024 beginning at 10:10 AM revealed PCT #1 wearing clean gloves touched the dialysis machine and keyboard at Station #3. PCT #1 then opened the clean supplies to initiate the dialysis treatment for RP #1, without first performing hand hygiene. 3. During an interview on 12/5/2024 at 9:25 AM, the FA verified hand hygiene should be performed after gloves are removed. During an interview on 12/5/2024 at 11:15 AM, the FA verified hand hygiene should be performed before opening clean supplies to initiate a treatment.”

“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 staff followed facility infection prevention protocols during 1 of 2 (LPN #1) CVC dressing changes observed. The findings included: 1. Review of the facility policy “Dialysis Catheter Dressing Change Procedures” last revised 2/2023 revealed, “PURPOSE: To provide guidance on performing dialysis catheter dressing changes to prevent infection which includes...assessment of insertion site and procedure...PROCEDURE: 1. Don PPE (face shield or goggles, mask, gown) perform hand hygiene and don clean gloves. 2. Place mask on patient...4. Remove gloves, perform hand hygiene and don clean gloves 5. Remove and discard old exit site dressing. Remove gloves, perform hand hygiene, and don clean gloves.6 Observe catheter site for redness, swelling...8. Use aseptic technique, cleanse skin surrounding the exit site...” 2. Observations on 12/3/2024 beginning at 10:10 AM, revealed Patient #4 was wearing a mask covering her mouth, but her nose was exposed. LPN #1 did not ask Patient #4 to cover her nose with the mask. LPN #1 removed the dirty dressing from Patient #4’s CVC, discarded the dirty dressing, then cleaned the CVC site. LPN #1 did not remove his gloves, perform hand hygiene, and don clean gloves before cleaning the CVC site. 3. During an interview on 12/5/2024 at 11:14 AM, the FA verified patients should be instructed by staff to cover their nose and mouth, with a mask, during CVC care. The FA also verified the expectation was for nurses to perform hand hygiene and don clean gloves after removing the dirty CVC dressing, during CVC care.”

“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: 19001 Based on facility protocol review, medical record review and interview, the facility failed to ensure staff notified the RN of patient’s elevated blood pressure for 1 of 5 (Patient #3) sampled in-center hemodialysis patients. The findings included: 1. Review of the facility’s “PCT/CCHT/LPN: Report to Charge Nurse INTRA-DIALYSIS” protocol (no date documented) revealed, “...B/P...Systolic >180 or <90...Diastolic >110...” 2. Medical record review for Patient #3 revealed an admission date of 4/5/2023 with diagnoses that included HTN and ESRD. Review of the dialysis treatment flowsheet dated 11/9/2024 revealed Patient #3’s blood pressure readings were as follows: at 10:16 AM the blood pressure was 200/95. There was no documentation the charge nurse was notified of the elevated blood pressure reading. Review of the dialysis treatment flowsheet dated 11/21/2024 revealed Patient #3’s blood pressure readings were as follows: at 6:33 AM the blood pressure was 217/88. There was no documentation the charge nurse was notified of the elevated blood pressure reading. Review of the dialysis treatment flowsheet dated 11/25/2024 revealed Patient #3’s blood pressure readings were as follows: at 6:33 AM the blood pressure was 218/103. at 8:33 AM the blood pressure was 194/85. at 9:03 AM the blood pressure was 206/114. at 9:33 AM the blood pressure was 190/91. at 10:00 AM the blood pressure was 202/87. at 10:03 AM the blood pressure was 201/86. at 10:14 AM the blood pressure was 191/84. There was no documentation the charge nurse was notified of the elevated blood pressure readings. 3. During an interview on 12/5/2024 at 9:25 AM, the FA verified the charge nurse (RN) should have been notified of the elevated blood pressure readings.”

“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: 19001 Based on medical record review and interview, the facility failed to ensure 1 of 1 (Patient #7) sampled patients performing home hemodialysis documented their Heparin medications during home dialysis treatments. The findings included: 1. Medical record review for Patient #7 revealed an admission dated of 2/4/2022 with diagnoses that included ESRD, HTN, DM and Anemia. Review of physician orders for home dialysis dated 4/10/2024 revealed dialysis with a Tablo machine 4 times per week. Review of a physician order dated 4/18/2024 revealed Patient #7 was to administer Heparin 300 units intravenous during each home dialysis treatment. Review of 8 home treatment records from 11/3/2024 through 11/27/2024 revealed no documentation regarding the Heparin administration during home dialysis treatments. 2. During an interview on 12/4/2024 at 1:50 PM, the Home Training Nurse verified Patient #7 was not recording the Heparin on his home treatment flowsheets. She further stated she expected the medications to be documented. The Home Training Nurse stated Patient #7 reported during clinic visits he was giving himself the Heparin, but was not documenting. 3. During an interview on 12/4/2024 at 1:55PM and 12/5/2024 at 9:20 AM, the surveyor requested the facility policy regarding home medication administration for patients on home hemodialysis. On 12/5/2024 at 11:15 AM, the Clinical Specialist stated there was not a policy, but the patients were expected to document their medications administered during dialysis on their home treatment flowsheets.”