Davita South Jackson Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 46831 Based on facility policy review, observation, and interview, the facility failed to ensure dialysis machines were properly cleaned and disinfected between patients, which included the priming containers by 3 of 4 (PCT #2, #3, and #4) staff members observed on the treatment floor. The findings included: 1. Review of the “INFECTION CONTROL FOR DIALYSIS MACHINES” policy revised 4/2023, revealed, “...Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces...At the end of each treatment, the dialysis station will be cleaned and disinfected...Priming containers are to be emptied prior to disinfection...” 2. Observation on the treatment floor at Station #8 on 03/03/2025 at 11:20 AM, revealed PCT #2 was cleaning Machine #16 in preparation for the next patient. PCT #2 failed to disinfect the priming container before placing it back on the dialysis machine. Observation on the treatment floor at Station #8, on 03/04/2025 at 10:45 AM, revealed PCT #4 was cleaning Machine #16 in preparation for the next patient. PCT #4 failed to disinfect the priming container before placing it back on the dialysis machine. Observation on the treatment floor at Station #14, on 03/04/2025 at 10:50 AM, revealed PCT #3 was cleaning Machine #10 in preparation for the next patient. PCT #3 failed to disinfect the priming container before placing it back on the dialysis machine. 3. During an interview on 03/04/2025 at 11:15 AM, PCT #2, #3, and #4 were asked to explain the process of cleaning the dialysis machine after treatment. PCT #2, #3, and #4 stated the dialysis machine was to be disinfected with 1:100 bleach solution (1 part water to 100 parts bleach), including the priming container, before being placed back on the dialysis machine. When asked if they always cleaned the priming container before placing it back on the dialysis machine, PCT #2 and #4 stated “Yes” and PCT #3 stated, “Oops.” When asked what the “Oops” was for, PCT #3 stated, “She got us.” During an interview on 03/04/2025 at 1:35 PM, the FA was asked her expectations for cleaning a dialysis machine after treatment. She stated, “The entire dialysis machine should be cleaned, including the blood pressure cuff and the prime bucket. The water should be dumped out of the prime bucket and then cleaned with 1:100 bleach solution inside and out.””

“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: 49570 Based on facility policy review, medical record review, and interview, the Medical Director failed to ensure staff followed facility policies by not ensuring the RN was notified of abnormal patient findings before, during, or after hemodialysis treatment for 4 of 7 (Patient #1, #2, #4, and #7) medical records reviewed. The findings included: 1. Review of 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 ...Abnormal Parameters: ...Blood Pressure-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 ...” 2. Medical record review for Patient #1 revealed an admission date of 01/10/2018 with diagnoses which included Type 2 Diabetes Mellitus with ESRD. A physician’s order dated 02/03/2025 revealed Patient #1 was to receive hemodialysis treatments three times a week for three hours duration with each treatment. Review of the Treatment Details Report dated 02/07/2025 revealed Patient #1 started hemodialysis treatment at the facility at 7:17 AM. At 8:17 AM the Patient’s BP was 178/167 and CCHT #1 documented, “Rechecking bp; face visible.” At 8:20 AM the Patient’s BP was 164/135 and CCHT #1 documented, “Patient blood pressure is elevated; Patient awake; alert; and states no complaints at this time.” At 8:50 AM the Patient’s BP was 168/102 and CCHT #1 documented “bp rechecked.” AT 8:51 AM the Patient’s BP was 133/105 and CCHT #1 documented, “Patient awake; alert; and states no complaints at this time.” At 9:49 AM the Patient’s BP was 184/26 and CCHT #1 documented, “BP rechecked.” AT 9:50 AM the Patient’s BP was 205/172 and CCHT #1 documented, “Cuff adjusted.” There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Details Report dated 02/17/2025 revealed Patient #1 started hemodialysis treatment at the facility at 6:20 AM. At 8:20 AM the Patient’s BP was 155/126 and CCHT #1 documented, “Elevated bp noted; pt asymptomatic; recheck bp.” At 8:20 AM the Patient’s BP was 164/135 and CCHT #1 documented, “Patient blood pressure is elevated; Patient awake; alert; and states no complaints at this time.” At 8:50 AM the Patient’s BP was 168/102 and CCHT #1 documented “bp rechecked.” At 8:51 AM the Patient’s BP was 133/105 and CCHT #1 documented, “Patient awake; alert; and states no complaints at this time.” At 9:49 AM the Patient’s BP was 184/26 and CCHT #1 documented, “BP rechecked.” At 9:50 AM the Patient’s BP was 205/172 and CCHT #1 documented, “Cuff adjusted.” There was no documentation the RN was notified of the Intradialytic abnormal findings. 2. Medical record review for Patient #2 revealed an admission date of 04/15/2016 with diagnoses which included Hypertension with ESRD. A physician’s order dated 02/03/2025 revealed Patient #2 was to receive hemodialysis treatments three times a week for four hours and thirty minutes duration with each treatment. Review of the Treatment Details Report dated 02/05/2025 revealed Patient #2 started hemodialysis treatment at the facility at 7:06 AM. At 8:06 AM the Patient’s BP was 155/106 and PCT #2 documented, “Patient appears to be tolerating treatment well at this time; bp elevated.” At 9:36 AM the Patient’s BP was 169/108 and PCT #2 documented, “Patient appears to be tolerating treatment well at this time; bp elevated.” At 10:07 AM the Patient’s BP was 186/82 and PCT #2 documented, “Recheck.” At 10:37 AM the Patient’s BP was 188/124 and PCT #2 documented, “Recheck.” At 10:38 AM the Patient’s BP was 181/92 and PCT #2 documented, “Patient appears to be tolerating treatment well at this time; bp elevated.” There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Details Report dated 02/07/2025 revealed Patient #2 started hemodialysis treatment at the facility at 7:39 AM. At 10:05 AM the Patient’s BP was 171/105 and PCT #2 documented, “Patient appears to be tolerating treatment well at this time.” At 11:05 AM the Patient’s BP was 194/112 and PCT #2 documented “Patient appears to be tolerating treatment well at this time.” There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Details Report dated 02/12/2025 revealed Patient #2 started hemodialysis treatment at the facility at 7:20 AM. At 9:13 AM the Patient’s BP was 183/115 and PCT #1 documented, “Patient appears to be tolerating treatment well at this time; bp elevated.” At 9:43 AM the Patient’s BP was 168/107 and PCT #1 documented, “Recheck.” At 10:14 AM the Patient’s BP was 171/105 and PCT #1 documented “Patient appears to be tolerating treatment well at this time; bp elevated.” There was no documentation the RN was notified of the Intradialytic abnormal findings. 3. Medical record review for Patient #4 revealed an admission date of 02/04/2025 with diagnoses which included Acute Kidney Injury. A physician’s order dated 02/03/2025 revealed Patient #4 was to receive hemodialysis treatments three times a week for three hours and thirty minutes duration with each treatment. Review of the Treatment Details Report dated 02/20/2025 revealed Patient #4 started hemodialysis treatment at the facility at 12:25 PM. At 1:25 PM the Patient’s BP was 199/149 and CCHT #1 documented, “Bp trending down, lines secure. Nurse informed of HTN; face visible.” CCHT #1 did not designate which “nurse” was notified, the LPN or the RN. At 1:55 PM the Patient’s BP was 214/135 and LPN #1 documented, “Recheck b/p.” At 2:20 PM the Patient’s BP was 221/146 and LPN #1 documented, “Recheck b/p & hr.” There was no documentation the RN was made aware of the Intradialytic abnormal findings until 2:30 PM; however, no BP for Patient #4 was documented by the RN until 2:55 PM. 4. Medical record review for Patient #7 revealed an admission date of 11/02/2023 with diagnoses which included Acute Kidney Failure and Chronic Kidney Disease with ESRD. A physician’s order dated 02/01/2025 revealed Patient #7 was to receive hemodialysis treatments three times a week for four hour duration with each treatment. Review of the Treatment Details Report dated 02/07/2025 revealed Patient #7 started hemodialysis treatment at the facility at 11:31 AM. At 12:01 PM, the Patient’s BP was 184/107 and CCHT #1 documented, “HTN noted; lines secure. Face visible.” At 12:31 PM the Patient’s BP was 169/100 and CCHT #1 documented, “Bp trending down; lines secure. Face visible.” There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Detail Report dated 02/08/2025 revealed Patient #7 started hemodialysis treatment at the facility at 12:11 PM. At 1:40 PM, the Patient’s BP was 196/110 and PCT #3 documented, “htn noted; pt alert; lines secure.” At 1:42 PM the Patient’s BP was 184/103 and PCT #3 documented, “htn noted; pt alert; no complaints.” There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Detail Report dated 02/13/2025 revealed Patient #7 started hemodialysis treatment at the facility at 10:01 AM. At 12:57 PM, the Patient’s BP was 193/112 and PCT #3 documented, “htn noted; pt alert; no complaints. There was no documentation the RN was notified of the Intradialytic abnormal findings. Review of the Treatment Detail Report dated 02/27/2025 revealed Patient #7 started hemodialysis treatment at the facility at 9:51 AM. At 12:51 PM, the Patient’s BP was 169/102 and LPN #1 documented, “Patient awake; alert; and states no complaints at this time.” There was no documentation the RN was notified of the Intradialytic abnormal findings. 5. During an interview on 03/04/2025 at 1:33 PM, the FA confirmed staff were expected to notify the RN anytime there were abnormal findings with a patient either before, during, or after hemodialysis treatment. She stated that the notification should always be documented in the patient’s medical record, and that the RN should always be notified even if an LPN is on the treatment floor.”

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure appropriate measures were taken by 1 of 2 (CCHT #1) staff members to reduce the risk of infection during cannulation of an AVF and/or AVG prior to initiation of hemodialysis. The findings included: 1. Review of the facility policy, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised October 2022 revealed, “ ...While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to the table above). [TABLE: Skin Antiseptic: Povidone Iodine - Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site. - Effective Contact Time: 30 seconds - Air Drying Time: 2 minutes] ...All skin antiseptics work to kill bacteria on the skin and require specific air-dry times ...” 2. Observations on 03/03/2025 at 9:48 AM on the treatment floor revealed CCHT #1 initiating hemodialysis on Random Patient #1 via an AVF/AVG. CCHT #1 failed to clean the access site per facility policy by scrubbing with Povidone Iodine/Betadine for 8 seconds instead of 30 seconds and failed to allow the Povidone Iodine/Betadine to dry per facility policy by only allowing 1 minute and 15 seconds dry time instead of 2 minutes per facility policy. 3. During an interview on 03/04/2025 at 1:33 PM, the FA confirmed staff were expected to follow the facility policy for initiation of dialysis with an AVG/AVF. She stated the Povidone Iodine/Betadine should come into contact with the skin for at least 30 seconds for appropriate cleansing and then be allowed to dry for at least two minutes before cannulation is attempted.”