Davita Lone Star Dialysis

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on record review and interview the facility’s Medical Director failed to ensure nursing staff followed the facility’s policy and procedures to prevent or reduce complications pre, during or post treatment in that the nursing staff did not complete the initial nursing assessment within the first hour of treatment in 4 of10 records reviewed. (Patient ID #s 6, 7, 9, 11). The facility currently has a census of 107 hemodialysis patients that could be affected by the nursing staff failing to complete the initial nursing assessment within the first hour of hemodialysis treatment. Policy Reviewed: Review on 8/06/2024 of the facility’s current policy titled: “Pre-Inter-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08; Latest Revision: April 2024. Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. Records Reviewed: Review on 08/06/2024 along the Facility Administrator, staff ID #A of selected patient records identified the following: Patient ID # 6 hemodialysis treatment sheet: 07/26/2024 treatment initiated 10:40 AM, pre-nursing assessment 12:38 PM. Patient ID # 7 hemodialysis treatment sheet: 08/02/2024 treatment initiated 10:06 AM, pre-nursing assessment 16:09 PM. Patient ID # 9 hemodialysis treatment sheet: 07/03/2024 treatment initiated 11:37 AM, pre-nursing assessment 16:28 PM. 07/10/2024 treatment initiated 12:11 PM, pre-nursing assessment 15:50 PM. Patient ID # 10 hemodialysis treatment sheet: 07/24/2024 treatment initiated 05:17 AM, pre-nursing assessment 09:17 AM. 07/29/2024 treatment initiated 05:13 AM, pre-nursing assessment 07:07 AM. Interview with the facility administration, staff ID # confirmed the above findings and stated the initial assessment should be completed with the first hour of hemodialysis.”

“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: 30124 Based on observation, interview and record review the facility failed to follow their current infection control policy and procedures and failed to maintain a sanitary environment in that dialysis equipment was not properly cleaned and disinfected after use. Policy Reviewed: Review of the facilities current policy titled: Infection Control for Dialysis Facilities; Policy: 1-05-01; Last revision April 2023. Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Disinfection: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood. i. For visible blood or gross blood spills, a 1:10 bleach solution must be utilized. ii. After all visible blood is cleaned with the 1:10 bleach solution, teammates are to use a new disposable towel soaked with 1:10 bleach solution and clean a second time. iii. Cleaning of visible blood should be performed when first observed. b. Use an appropriate disinfectant such as 1:100 bleach solution for routine disinfection of environmental services. i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfection should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant time contact. iv. Items disinfected via submersion will be fully submerged. c. Spray bottles containing cleaning solutions are single use and cannot be reused or refilled. This practice does not include contracted housekeeping services. 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. A. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chairs, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel. Findings: Observation of the patient treatment are on the morning of 02/07/2024 along with the Manager of Clinical Services, staff ID #C the following was observed: 02/07/2024 at 1056 AM Station #46, was identified to have been cleaned and disinfected and was set up and ready for the next hemodialysis patient. Surveyor and staff ID #C observed two areas of reddish-brown splatter droplets on the left lateral side panel adjacent to the hemodialysis machine. Surveyor ask staff ID #C if the hemodialysis station # 46 had been cleaned and disinfected and if the station was ready for the next patient. Staff ID #C confirmed the station was set up and prepared for the next patient. Surveyor pointed out the reddish-brown splatter on the hemodialysis chair. Staff ID #C confirmed the reddish-brown splatter. Staff ID #C when observed the splatter on the above chair immediately obtained a bleach towel and was able to wipe the reddish-brown splattered droplets off the equipment. Staff ID #C confirmed the above finding and stated the equipment had not been properly cleaned and disinfected.”