South Oak Cliff Dialysis Center

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility staff failed to ensure that the sink, available for patients to wash their access sites prior to treatment and their hands after treatment, located near the scale, had a supply of paper towels available for use and was protected from contamination. During the tour of the facility’s in-center treatment area with the Facility Administrator (Staff #1) on the morning of 08/18/2025, the surveyor observed there being no paper towels available at the sink located near the scale used for patients to wash their hands and access sites. During the tour of the facility on 08/18/2025, the above findings were confirmed and acknowledged by the Facility Administrator (Staff #1).”

“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: 30377 Based on direct observation the staff failed to ensure that direct patient care staff changed gloves between tasks. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by increasing the potential of cross-contamination between patients. Findings: During observation of care of the facility’s in-center treatment area on 06/25/2024 the following was observed: At 09:25am: The patient care technician staff member # 4 was observed gloved removing the patient’s cover from the patient’s lower body, documenting on the dialysis machine keyboard, repositioning the blood pressure cuff on the patient’s leg, initiating rinse-back by gently squeezing the saline bag, and finally disconnecting the dialysis lines from the patient’s needles. The patient care technician did not change his gloves and or hand sanitize between the above tasks. In an interview conducted, with the Clinical Coordinator, on 6/25/24 at 09:35am confirmed that staff were required to wash or sanitize hands between glove changes, when moving from tasks, and after touching patients to prevent cross contamination.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 50181 Based on observation and staff interview during a facility tour on 06/25/2024 the facility failed to ensure expired vaccinations were discarded on or before the expiration date and not available for patient use in the facility. Findings included: During a tour of the facility treatment floor on the morning of 06/25/2024 one box of Pneumoccocal Vaccine Polyvalent with an expiration date of 2024May06 printed on the box was found in the medication refrigerator. During the tour and interview with Staff #1 she confirmed the vaccine was expired and still available for patient use and immediately discarded the vaccine.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 50181 Based on observation and staff interview, the facility’s direct patient care (DPC) staff failed to ensure the vascular access was visible at all times during treatment on 4 out of 10 patient observations. Ensuring proper visualization of the arteriovenous fistula access is important for the early recognition and prevention of bleeding from the patient’s access site. During a tour of the facility’s in-center treatment area on 06/25/2024 at 9:20 AM with Staff # 1, the surveyor observed patients receiving dialysis treatment at the following stations with their access covered: Station #23, #31, #24 and #9. The surveyor observed the patient’s access covered for more than 10 minutes without any intervention from the direct care staff. This was reported to Staff #1 and above observations were confirmed. Staff #1 discussed findings with each DPC staff caring for the patients and the access was uncovered after findings noted.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 50181 Based on medical record review, policy review and staff interview the facility failed to ensure the direct patient care (DPC) staff reported patient status changes during treatment to the Registered Nurse (RN) to ensure a reassessment was performed and documented with appropriate interventions and/or physician notification, if required. Findings included: A review of facility’s protocol titled, “Patient Evaluations/Reportable by DPC to CN,” indicates the following is to be reported to the RN: Blood Pressure: Systolic >200 or <100, Diastolic >100Pulse: >100 or <60 The following were noted during treatment record review: Patient #7 treatment record dated 06/19/2024 reveals the following: 16:39: Blood Pressure (BP) 180/105 There is no documentation acknowledging the diastolic BP was a reportable finding and was reported to the RN by the DPC staff. 17:30: Blood Pressure 198/109 There is no documentation acknowledging the diastolic BP was a reportable finding and was reported to the RN by the DPC staff. 18:00: Blood Pressure 225/120 There is no documentation acknowledging the BP was a reportable finding and was reported to the RN by the DPC staff. 18:32: Blood Pressure 231/124 There is no documentation acknowledging the BP was a reportable finding and was reported to the RN by the DPC staff. Patient #7 treatment record dated 06/21/2024 reveals the following: 19:02: Blood Pressure (BP) 148/105 There is no documentation acknowledging the diastolic BP was a reportable finding and was reported to the RN by the DPC staff. Patient #4 treatment record dated 06/17/2024 reveals the following: 16:20: Pulse 5916:42: Pulse 5917:01: Pulse 59 There is no documentation acknowledging the low pulse was a reportable finding and was reported to the RN by the DPC staff. Patient #4 treatment record dated 06/19/2024 reveals the following: 16:34: Pulse 55 17:00: Pulse 56 17:31: Pulse 58 There is no documentation acknowledging the low pulse was a reportable finding and was reported to the RN by the DPC staff. Patient #6 treatment record dated 06/19/2024 reveals the following: 18:27: Blood Pressure (BP) 229/12418:33: Blood Pressure: 249/124 There is no documentation acknowledging the elevated BP was a reportable finding and was reported to the RN by the DPC staff. On 06/26/2024, an interview with the Staff #1 confirmed the facility’s reportable parameters and documentation required for out of parameter findings pre/intra/post dialysis treatment by the DPC staff to the registered nurse.”

“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: 50181 Based on record review, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The specific BFR is needed to ensure that the blood pump is at constant speed to push the patient’s blood through the dialyzer and back into the patient’s body and is a part the patient’s dialysis prescription. Review of Patient #10 treatment record for 06/21/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 350mL/min from 13:02 until the end of treatment at 16:22 with no documentation reporting the change to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 06/17/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 350mL/min for the duration of the four hour treatment with no documentation reporting the change to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 06/19/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 350mL/min for the duration of the four hour treatment with no documentation reporting the change to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 06/21/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 350mL/min for the duration of the four hour treatment with no documentation reporting the change to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment.”