Davita Quince Road Dialysis

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 33763 Based on policy review, observation, and interview, the facility failed to ensure reusable medical equipment was cleaned and disinfected after each use by 2 of 2 (RN #1 and RN #2) nurses observed on the treatment floor. The findings included: 1. Review of the facility policy titled, “Environmental Cleaning” dated 10/1/2019 revealed, “...All external work surfaces will be thoroughly cleaned, and disinfected immediately, or as soon as feasible...between patients...Clean and disinfect all items used for patient care including...Stethoscopes...” 2. Observations on the treatment floor at Station #13 on 4/30/2024 beginning at 9:22 AM revealed RN #1 assessed Random Patient #8’s breath sounds using a stethoscope. After assessing the patient’s breath sounds, the RN placed the stethoscope around her neck and walked to Station #12, where Patient #3’s hemodialysis treatment had just ended. RN #1 terminated the patient’s treatment via a CVC, then removed the stethoscope from around her neck and assessed Patient #3’s breath sounds. RN #1 failed to clean the stethoscope before and after use and in-between each patient. 3. Observations on the treatment floor at Station #19 on 4/30/2024 at 2:05 PM revealed RN #2 assessed Random Patient #12’s breath sounds using a stethoscope. After assessing the patient’s breath sounds, the RN placed the stethoscope around her neck and left the station. The RN went to the nurses’ station and entered data into the computer. RN #2 left the nurses’ station while still wearing the uncleaned stethoscope around her neck, walked to Station #25, terminated Random Patient #13’s treatment via a CVC, then used the stethoscope to assess the patient’s breath sounds. RN #2 failed to clean the stethoscope before and after use and in-between each patient. 4. In an interview on 5/1/2024 at 10:37 AM, the CM stated stethoscopes should be cleaned with alcohol before and after using.”

“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: 33763 Based on policy review, observation and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed by 1 of 2 (RN #1) nurses observed discontinuing hemodialysis treatments via a CVC. The findings included: 1. Review of the facility policy titled, “CVC Connections & Disconnection (Scrub The Hub)” dated 8/10/2023 revealed, “...Care will be taken to prevent contamination of the CVC, using aseptic technique...CVC attached to a syringe may be set down on the clean drape...” 2. Observations on the treatment floor at Station #13 on 4/30/2024 beginning at 9:22 AM revealed RN #1 was preparing to discontinue the patient’s HD treatment via a CVC. The RN performed hand hygiene, donned gloves and stopped the dialysis treatment. Without placing a clean barrier under the CVC hubs, RN #1 disconnected the venous line, scrubbed the hub with an alcohol swab, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. The RN disconnected the arterial line, scrubbed the hub with alcohol, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. RN #1 disconnected the saline syringe from the venous line, attached a syringe of heparin and flushed the line, removed the syringe, and placed a new cap on the limb. RN #1 repeated the procedure on the arterial line. RN #1 failed to place a clean barrier under the CVC limbs prior to discontinuing the treatment. Observations on the treatment floor at Station #12 on 4/30/2024 beginning at 9:28 AM revealed RN #1 was preparing to discontinue the patient’s HD treatment via a CVC. The RN performed hand hygiene, donned gloves and stopped the dialysis treatment. Without placing a clean barrier under the CVC hubs, RN #1 disconnected the venous line, scrubbed the hub with an alcohol swab, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. The RN disconnected the arterial line, scrubbed the hub with alcohol, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. RN #1 disconnected the saline syringe from the venous line, attached a syringe of heparin and flushed the line, removed the syringe, and placed a new cap on the limb. RN #1 repeated the procedure on the arterial line. RN #1 failed to place a clean barrier under the CVC limbs prior to discontinuing the treatment. Observations on the treatment floor at Station #13 on 4/30/2024 beginning at 9:36 AM revealed RN #1 was preparing to discontinue the patient’s HD treatment via a CVC. The RN performed hand hygiene, donned gloves and stopped the dialysis treatment. Without placing a clean barrier under the CVC hubs, RN #1 disconnected the venous line, scrubbed the hub with an alcohol swab, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. The RN disconnected the arterial line, scrubbed the hub with alcohol, then attached a syringe of normal saline and flushed the line. The RN laid the CVC limb and syringe onto the old barrier. RN #1 disconnected the saline syringe from the venous line, attached a syringe of heparin and flushed the line, removed the syringe, and placed a new cap on the limb. RN #1 repeated the procedure on the arterial line. RN #1 failed to place a clean barrier under the CVC limbs prior to discontinuing the treatment. In an interview on 5/1/2024 at 10:37 AM, the CM verified a clean barrier should be placed under the CVC limbs prior to discontinuing treatment.”

“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: 33763 Based on policy review, medical record review, and interview, the facility failed to ensure physician’s orders for prescribed BFR and DFR were followed for 2 of 3 (Patient #1, and #3) sampled hemodialysis patients, and failed to obtain standing blood pressures to assess for orthostatic hypotension for 2 of 3 (Patient #2 and #3) sampled ambulatory hemodialysis patients. The findings included: 1. Review of the facility policy titled, “Initiation of Dialysis Treatment” dated 1/2020 revealed, “...Assess patient using subjective and objective assessment skills...Ensure the following...Blood flow rate is a prescribed rate...” Review of the facility policy titled, “Intradialytic Monitoring of Patient” dated 9/2020 revealed, “...Direct patient care staff will monitor the following parameters during each dialysis treatment...Blood flow rate...” Review of the facility policy titled, “Initiation of Hemodialysis Treatment...” dated 6/2/2023 revealed, “...Start blood pump...increase BFR to ordered flow rate...If unable to achieve prescribed blood flow rate, document interventions and notification to RN...” 2. Medical record review for Patient #1 revealed an admission date of 5/18/2023 with diagnoses which included Calculus of Kidney, Type 2 Diabetes Mellitus and Hypertensive Chronic Kidney Disease. The physician’s orders dated 11/9/2023, 12/19/2023 and 1/2/2024 revealed a BFR of 400 mL/min and a DFR of 800 mL/min. Review of the Hemo Treatment Log Summary dated 12/14/2023 revealed the BFR was 300 mL/min from 6:01 AM until 8:57 AM. There was no documentation why the prescribed BFR was not followed. Review of the Hemo Treatment Log Summary dated 12/19/2023 revealed the BFR was 425 mL/min from 5:30 AM until 8:57 AM. There was no documentation why the prescribed BFR was not followed. Review of the Hemo Treatment Log Summary dated 12/26/2023 revealed the BFR was 425 mL/min from 5:30 AM until 9:04 AM. There was no documentation why the prescribed BFR was not followed. 3. Medical record review for Patient #2 revealed an admission date of 3/11/2024 with diagnoses which included Hypertensive Chronic Kidney Disease. The physician’s orders dated 2/29/2023 revealed a BFR of 350 mL/min and DFR of 525 mL/min. Review of the Hemodialysis Flowsheet dated 3/11/2024 at 2:18 PM revealed “...TX started...Increased blood flow to ordered rate without difficulty...” Further review revealed the BFR was 200 mL/min from 2:18 PM until 2:31 PM, and 250 from 3:01 PM until 5:01 PM. There was no documentation why the prescribed BFR was not followed. The physician’s orders dated 3/25/2024 revealed a BFR of 300 mL/min and DFR of 600 mL/min. Review of the Hemodialysis Flowsheet dated 4/3/2024 revealed the BFR was 235 mL/min through 260 mL/min from 2:02 PM until 5:02 PM. Further review revealed the DFR was 500 mL/min from 2:02 until 5:02 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/5/2024 revealed the BFR was 250 mL/min at 2:22 PM, O mL/min at 2:37 PM, and 200 mL/min from 5:01 PM through 5:31 PM. Further review revealed the DFR was 400 mL/min from 3:01 PM until 5:31 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/8/2024 revealed the BFR was 200 mL/min from 2:32 PM until 6:06 PM. There was no documentation why the prescribed BFR was not followed. Review of the Hemodialysis Flowsheet dated 4/10/2024 revealed the BFR was 245 mL/min at 3:31 PM, O mL/min at 4:01 PM, 250 mL/min at 4:31 PM and 205 mL/min from 5:01 PM until 5:59 PM. Further review revealed the DFR was 400 mL/min from 5:01 PM until 5:59 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/12/2024 revealed the BFR was 200 mL/min from 2:02 PM until 3:02 PM, and 245 mL/min from 3:32 PM until 5:32 PM. Further review revealed the DFR was 400 mL/min from 2:02 PM until 3:02 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/15/2024 revealed the BFR was 240 mL/min from 1:31 PM until 5:01 PM. There was no documentation why the prescribed BFR was not followed. Review of the Hemodialysis Flowsheet dated 4/17/2024 revealed the BFR was 200 mL/min and the DFR was 400 from 3:01 PM until 5:41 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/19/2024 revealed the BFR was 250 mL/min from 3:02 PM until 6:32 PM. There was no documentation why the prescribed BFR was not followed. Review of the Hemodialysis Flowsheet dated 4/22/2024 revealed the BFR was 200 mL/min at 2:02 PM, 225 mL/min from 2:32 PM until 3:02 PM, and 195 mL/min from 3:32 PM until 4:32 PM. Further review revealed the DFR was 400 mL/min from 3:32 PM until 4:32 PM. There was no documentation why the prescribed BFR and DFR were not followed. Review of the Hemodialysis Flowsheet dated 4/26/2024 revealed the BFR was 250 mL/min from 2:31 PM until 3:01 PM, 225 mL/min at 3:31 PM, 250 ml/min from 4:01 PM until 5:01 PM, and 150 mL/min from 5:31 PM until 5:59 PM. There was no documentation why the prescribed BFR was not followed. 4. Medical record review for Patient #3 revealed an admission date of 10/26/2023 with diagnoses which included Type 2 Diabetes Mellitus with Chronic Kidney Disease. The physician’s orders dated 3/9/2024 revealed a BFR of 400 mL/min and a DFR of 600 mL/min. Review of the Hemodialysis Flowsheet dated 4/19/2024 revealed the BFR was 350 mL/min from 11:31 AM until 2:31 PM. There was no documentation why the prescribed BFR was not followed. 5. In an interview on 5/1/2024 at 10:37 AM, the CM verified staff should document the reason the prescribed BFR and/or DFR was not followed during a hemodialysis treatment. 6. Review of the facility policy titled, “Initiation of Hemodialysis Treatment...” dated 6/2/2023 revealed, “...Obtain the following vitals: a. Blood pressure standing, (if patient able) and sitting...” Review of the facility policy titled, “Termination of Hemodialysis Treatment” dated 4/1/2021 revealed, “...Take patient’s standing blood pressure prior to disconnecting lines. If unable to stand, take a sitting blood pressure. Document in the treatment record if the patient refuses or unable to stand for blood pressure...” 7. Medical record review for Patient #2, an ambulatory patient, revealed an admission date of 3/11/2024 with diagnoses which included Hypertensive Chronic Kidney Disease. Review of the Hemodialysis Flowsheet dated 4/3/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/5/2024 revealed no documentation a standing blood pressure was obtained after the treatment ended. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/17/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/22/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/26/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. 8. Medical record review for Patient #3, an ambulatory patient, revealed an admission date of 10/26/2023 with diagnoses which included Type 2 Diabetes Mellitus with Chronic Kidney Disease. Review of the Hemodialysis Flowsheet dated 4/6/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/9/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/19/2024 revealed no documentation a standing blood pressure was obtained after the treatment ended. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/25/2024 revealed no documentation a standing blood pressure was obtained after the treatment ended. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/27/2024 revealed no documentation a standing blood pressure was obtained after the treatment ended. There was no documentation the patient refused or was unable to stand. Review of the Hemodialysis Flowsheet dated 4/30/2024 revealed no documentation a standing blood pressure was obtained prior the initiation of the treatment. There was no documentation the patient refused or was unable to stand. 9. In an interview on 5/1/2024 at 10:37 AM, the CM verified standing blood pressures should be obtained before the initiation of treatment and prior to disconnecting the lines for all ambulatory hemodialysis patients unless they are unable to stand or refuse. The CM stated staff should document the reason why a standing blood pressure was not assessed.”