Davita Katy Dialysis Grand Parkway

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 The facility failed to ensure that oxygen tanks were stored and identified according to Federal and State laws that regulated medical gases. 1. Six oxygen tank cylinders observed on the treatment floor were not properly identified as full or empty. 2. Five oxygen tanks were observed to be opened for use with regulators attached to the oxygen cylinders. 3. One oxygen tanks observed on the treatment floor with seal intact and not identified as full or empty. The facility failed to safely store oxygen in accordance with National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Record Reviewed: Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified as full or empty and stored separately. NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. “ A cylinder is considered “full” provided it still has its seal from the supplier. Once the seal has been removed, the cylinder is no longer considered full and cannot be stored with full cylinders. “ NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. Review of the facility’s policy titled, “Incenter hemodialysis (ICHD), Peritoneal Dialysis (PD), Home Hemodialysis (HHD), DaVita Skilled Nursing Facility Dialysis (DSD) Clinic Administration Vol * DaVita Inc.”, Policy: 8-04-01; revision April 2018. Policy: 10. The dialysis facility will store supplies in a manner that is consistent with fire safety and other appropriate regulations. Supplies will not obstruct any fire exits or hallways. Refer to: Monthly OSHA and Safety Checklist for further guidance or as required by local jurisdiction requirements. Supplies are stored as to minimize deterioration, contamination or breakage. Finings: Observation of the patient care area on 03/28/2024 at 12:40 PM along with the facility administrator, staff ID # A, six oxygen tanks observed in the patient treatment area were found. Five oxygen tanks were observed to have been opened for use with regulators attached to the cylinders and were not labeled as full or empty, and oxygen cylinders observed with the seal intact and not labeled as full or empty. Interview with staff # A on 03/028/2024 at 12:50 PM confirmed the oxygen tanks were not able to be identified if they were full or empty and oxygen cylinders were not stored and separated to identify full or empty oxygen cylinders.”

“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: 30124 Based on observation and interview, the facility staff failed to monitor patients’ vascular accesses to ensure patient safety, citing 2 of 10 stations (stations #12, 13)), during patients’ dialysis treatment were not visible to staff. Allowing patients to cover access sites and line connections with blankets provides an opportunity for accidental needle dislodgement or disconnection to go undetected. This practice placed patients of the facility at risk for potential needle dislodgement and/or disconnection which could result in exsanguination and harm. Policy Reviewed of the facility’s current policy Title: Pre-Intra-post Treatment Data Collection, Monitoring and Nursing assessment; Policy: 1-01-08; Revision date October 2023. 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. Intradialytic Date Collection/Assessment: 9. C. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. Findings included: During a tour of the facility on 3/28/2024 at 12:20 PM along with staff #A the surveyor observed: Patient ID #7 at station #12 was observed to be receiving his dialysis treatment with a blood flow of 450 ml/minute through a left upper arm vascular access. Patient #7 had his vascular access covered with blankets and not visible during their dialysis treatment. Patient ID # 9 at station # 13 was observed to be receiving his dialysis treatment with a blood flow of 350 ml/minute through a left upper arm vascular access. Patient # 8 had his vascular access covered with a blanket and not visible during the dialysis treatment. This finding was confirmed in an interview with the staff member #A on 03/28/2024 at 13:00 PM. Staff was seen immediately uncovering the patient’s access and reminding the patients to keep their access uncovered.”