Davita Southcross Dialysis Center

“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: 35561 Based on observation, interview, and review of the facility’s policies and procedures, the facility failed to ensure two of two Licensed Vocational Nurses (Licensed Vocational Nurse (LVN)1, LVN2) and seven of seven Patient Care Technicians (Patient Care Technician (PCT)1, PCT2, PCT3, PCT4, PCT5, PCT6, and PCT7) who were observed during care delivery, implemented proper infection control measures after discontinuation of dialysis by failing to encourage hand hygiene for patients holding pressure on access needle sites which presents a risk for blood exposure. Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients, staff, and others to blood-borne pathogens. This deficient practice had the potential to affect all 85 patients receiving treatment in the dialysis unit. Findings include: During an observation on 02/21/24 at 11:25 AM, PCT1 was observed discharging an unidentified patient at Station 5. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT1 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT1 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. During an observation on 02/21/24 at 3:00 PM, PCT3 was observed discharging an unidentified patient at Station 5. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT3 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT3 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. During an observation on 02/21/24 at 3:40 PM, PCT5 was observed discharging an unidentified patient at Station 16. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT5 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT5 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. During an observation 02/22/24 at 9:10 AM, PCT2 was observed discharging an unidentified patient at Station 3. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT2 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT2 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. During an observation on 02/22/24 at 1:50 PM, PCT4 was observed discharging an unidentified patient at Station 5. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT4 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT4 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. During an observation and interview on 02/23/24 at 9:15 AM, PCT7 was observed discharging an unidentified patient at Station 7. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT7 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. PCT7 failed to offer, remind, or encourage hand hygiene at the dialysis station, or at the weigh scale station upon discharge. When questioned about encouraging patients to wash hands post dialysis, PCT7 stated “We are supposed to.” During multiple observations on the dialysis treatment floor on 02/21/24 from the hours of 10:00 AM to 1:00 PM, and 2:30 PM to 4:00 PM, on 02/22/24 from the hours of 9:00 AM to 11:00 AM, and, 1:00 PM to 2:30 PM, and on 02/23/24 from the hours of 9:00 AM to 11:00 AM, it was noted that each staff member (LVN1, LVN2, PCT1, PCT2, PCT3, PCT4, PCT5, PCT6, and PCT 7) who were observed during care delivery, failed to encourage, offer, or provide hand hygiene opportunities for patients when leaving the treatment area. Collectively, during the above observation times on the treatment floor a total of 13 unsampled patients were observed leaving the treatment area after holding access needle sites, touching multiple surface areas such as the weigh scale, and counter tops without performing hand hygiene. During an interview on 02/23/24 at 2:30 PM, these findings were discussed with the Facility Administrator who responded, “These observations do not meet the requirements of our infection control policy.” The Facility Administrator acknowledged that this practice presented a risk for cross contamination and stated, “we all need to do better with that.” Review of the facility’s policy titled “Infection Control for Dialysis Facilities,” last revised date April 2023, indicated “Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis and perform hand hygiene after treatment before leaving treatment area.””

“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: 35561 Based on observation, interview, review of the facility’s teaching tool, and review of the facility’s policies and procedures, the facility failed to ensure one of two Registered Nurses (Registered Nurse (RN)1) who were observed during the administration of intravenous medications, implemented proper safe work practices while administering those medications. This deficient practice had the potential to affect all 85 patients receiving treatment in the dialysis unit. Findings include: During an observation on 02/21/24 at 11:45 AM, RN1 was observed administering intravenous (IV) medications to an unidentified patient at Station 15 who was undergoing a dialysis treatment. RN1 was observed cleansing, then inserting the needle into the medication injection port of the saline line connected to the extracorporeal hemodialysis system. After injecting the medication, RN1 removed the needle and syringe from the infusion port and while holding the needle cap in between two fingers, recapped the contaminated needle prior to discarding the syringe and needle in a sharp’s container. During an observation on 02/21/24 at 12:15 PM, RN1 was observed administering IV medications to an unidentified patient at Station 9 who was undergoing a dialysis treatment. RN1 was observed cleansing, then inserting the needle into the medication injection port of the saline line connected to the extracorporeal hemodialysis system. After injecting the medication, RN1 removed the needle and syringe from the infusion port and while holding the needle cap in between two fingers, recapped the contaminated needle prior to discarding the syringe and needle in a sharp’s container. During an interview on 02/23/24 at 10:50 AM, RN1 stated “I think I knew that recapping those needles was a bad idea but said, “that was the way I was taught.” During an interview on 02/23/24 at 2:40 PM, these findings were discussed with the Facility Administrator who responded, “These observations do not meet the requirements of our workplace safety policy.” The Facility Administrator acknowledged that this practice presented a risk for needlestick injury and stated, “our policy is to never recap used needles.” Review of the facility’s policy titled “Preparation and Administration of Parenteral Medications,” last revised October 2023, indicated “If using saline infusion line medication injection port open lower saline infusion line clamp. Aseptically remove protective cap from needle. Insert and advance the needle into the mediation injection port. Inject the medication. Remove needle and syringe from injection port and discard in a sharp’s container.” Review of the facility’s teaching tool titled “Medications - RN; Quick Observation Tool,” dated 2021, stated “Used syringes are not recapped and promptly discarded in sharps container.””

“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: 35561 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure two of two Licensed Vocational Nurses (Licensed Vocational Nurse (LVN)1, LVN2) observed caring for Central Venous Catheters (CVC - a large plastic tube placed in a vein in the neck for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment), implemented proper infection control measures during initiation of dialysis through a CVC. Failure to use recommended infection control practices increased the relative risk for bacteremia in patients with dialysis catheters. This deficient practice had the potential to affect all current and future facility patients that dialyzed with CVC accesses. Findings include: During an observation on 02/21/24 at 2:45 PM, LVN1 was observed initiating hemodialysis for an unidentified patient with a CVC access at Station 10. When removing the dressing covering the CVC insertion site, LVN1 touched the catheter insertion site multiple times with a gloved hand. LVN1 then cleansed the area surrounding the catheter insertion site starting from the very top of the area moving down to the catheter insertion site. After cleaning the catheter limbs for approximately five seconds each with an alcohol wipe, LVN1 removed the protective end caps from the arterial and venous limbs and dropped both open lumens of the CVC on a non-sterile surface. During an observation on 02/21/24 at 3:30 PM, LVN1 was observed initiating hemodialysis for an unidentified patient with a CVC access at Station 12. After removing the dressing covering the CVC insertion site, LVN1 cleansed the area surrounding the catheter insertion site starting from the very top of the area moving down to the catheter insertion site. After cleaning the catheter limbs for approximately five seconds each with an alcohol pad, LVN1 removed the protective end caps from the arterial and venous limbs and dropped both open lumens of the CVC on a non-sterile surface. LVN1 then opened two sterile 10-millimeter syringes and placed them on a clean under pad chairside with multiple other supplies. As LVN1 scrubbed each limb with alcohol wipes, LVN1 discarded the used wipes on the under pad, inadvertently, and without recognizing it, touching, and contaminating the sterile tip of the open, yet to be used 10-millimeter syringes. LVN1 then proceeded to connect these syringes, which had been contaminated, to the limbs of the catheter. During an observation on 02/22/24 at 09:25 AM, LVN2 was observed initiating hemodialysis for an unidentified patient with a CVC access at Station 17. After removing the dressing covering the CVC insertion site, LVN2 cleansed the area surrounding the catheter insertion site starting from the very top of the area moving down to the catheter insertion site. Next, LVN2 opened two sterile 10-millimeter syringes and placed them on a clean under pad with multiple other supplies. As LVN2 prepared the CVC for connection, LVN2 discarded used supplies on the clean underpad, inadvertently and without recognizing it, contaminating the sterile tips of the open, yet to be used 10-millimeter syringes. LVN2 then proceeded to connect these syringes, which had been contaminated, to the limbs of the catheter. During an interview on 02/23/24 at 2:40 PM, these findings were discussed with the Facility Administrator Manager and the Clinical Nurse Manager at which time the Facility Administrator responded, “These observations do not meet the requirements of our infection control policy, sterile technique is essential when accessing any CVC in order to prevent infection.” Review of the facility’s policy titled, “Central Venous Catheter (CVC) Procedure,” last revised October 2023, indicated, “Holding catheter with non-dominant had and using aseptic technique, clean exit site for a minimum of 30 seconds using gentle friction progressing from the insertion site to the periphery using both sides of the swab.” The policy further stated “Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction. Hold limbs until the antiseptic has dried.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 35561 Based on observation, staff interview, review of policies and procedures, and review of manufacturer’s instructions for use, the facility failed to ensure one of two Licensed Vocational Nurses (Licensed Vocational Nurse (LVN)1, and two of six Patient Care Technicians (Patient Care Technicians (PCT)4, PCT6) who were observed during care delivery, prepared the dialyzers (artificial kidney) by discarding the saline prime in accordance with the manufacturer’s instructions for use prior to initiating the dialysis treatment. Failure to ensure that all equipment is operated in accordance with the manufacturer’s recommendations had the potential to adversely affect safe in center dialysis treatments for all patients. This deficient practice had the potential to affect all 85 current patients receiving hemodialysis treatments. Findings include: During observation on the dialysis treatment floor on 02/21/24 at 10:45 AM, LVN1 was observed at Station 14 initiating a dialysis treatment for an unsampled patient. It was noted LVN1 failed to refresh the normal saline (0.9% salt solution) contained within the extracorporeal circuit (circuit consisting of the artificial kidney and bloodlines) as required. Instead, when initiating the dialysis treatment, LVN1 was observed infusing the recirculated normal saline into the patient. During an observation on 02/21/24 at 2:45 PM, at Station 10, LVN1 was observed initiating a dialysis treatment for an unsampled patient. It was noted LVN1 failed to refresh the normal saline contained within the extracorporeal circuit as required. Instead, when initiating the dialysis treatment, LVN1 was noted to infuse the recirculated normal saline into the patient. During an observation on 02/23/24 at 9:40 AM, at Station 16, PCT4 was observed initiating a dialysis treatment for an unsampled patient. It was noted PCT4 failed to refresh the normal saline contained within the extracorporeal circuit fully as required. Instead, when initiating the dialysis treatment, PCT4 was observed discarding a small amount of saline from the arterial and venous bloodlines prior to initiation of dialysis. At the start of dialysis, PCT4 infused the remaining recirculated normal saline into the patient. During an observation and interview on 02/23/24 at 10:10 AM, at Station 12, PCT6 was observed initiating a dialysis treatment for an unsampled patient. It was noted PCT6 failed to refresh the normal saline contained within the extracorporeal circuit fully as required. Instead, when initiating the dialysis treatment, PCT6 was observed discarding a small amount of saline from the arterial and venous bloodlines prior to initiation of dialysis. At the start of dialysis, PCT6 infused the remaining recirculated normal saline into the patient. When asked how much saline needs to be discarded prior to connecting the patient to the machine, PCT6 stated “just a small amount from each line.” Review of the Optiflux dialyzer manufacturer’s instructions titled, “Instructions for Use,” dated 07/23, revealed, “Do not infuse the recirculated saline prime into the patient. Discard the recirculated saline and fill the entire extracorporeal circuit with fresh saline prior to connecting to the patient. The volume of fresh saline used to fill the extracorporeal circuit should be equal to the volume of the dialyzer and blood tubing set in use.” An interview with the Facility Administrator on 02/23/24 at 2:35 PM verified that the staff were expected to discard the existing recirculated saline prime and to fill the entire extracorporeal circuit with fresh saline prior to connecting to the patient. Review of the facility’s policy titled, “Treatment using the Fresenius 2008 Series Dialysis Delivery Systems,” last revised October 2021, indicated “Open the clamp on the arterial line and flush for 25 seconds (approximately 50 ml (milliliters) of saline) through the arterial line ...unclamp venous line, turn blood pump on and flush 250 ml of normal saline into priming container ... this flushes the dialyzer and blood lines with fresh saline prior to treatment initiation.””

“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: 39425 Based on interview, review of the Incident report for P#1 and record review, facility’s Patient care technician failed to report changes and /or the registered nurse failed to conduct intradialytic assessment on patient with elevated blood pressure during hemodialysis treatment. Findings: review of the patients treatment sheets revealed the Patient care technician ( PCT ) and or LVN did not report changes to the registered nurse and did not follow the dialysis prescription. Patient #1 05:17 BP 133/64 HR 73 BFR 400 DFR 800 AP-200 PCT documented “ treatment started without complications” 05:30 BP 102/58 HR 73 BFR 400 DFR 800 AP -266 PCT documented “bp decrease readjust cuff retake BP”. 05:32 BP 112/56 HR 71 BFR 400 DFR 800 AP-276 PCT documented “ bp retake wnl feet elevated tolerating tx well at this time” 05:59 BP 126/64 HR 66 BFR 350 DFR 800 AP -206 PCT documented “ Pt monitored eyes closed patient resting” 06:33 PCT documented “ BFR reduced to 350 due to high AP” 06:30 BP 117/57 HR 70 BFR 300 DFR 800 AP-193 PCT documented “patient awake alert states no complaints at this time Patients appears to be tolerating treatment well at this time BFR 300 due to high AP”. 06:39 BP 107/49 HR 70 BFR 200 DFR 800 AP-58 PCT documented bp decrease readjust bp cuff retake BP” 06:52 BP 120/54 HR 69 PCT documented “ capture time changed to 06:40” Review of the facility reportable parameter states “Report to RN if Blood pressure diastolic < 55 and pulse <55 Review of the patients treatment orders states “ Blood flow rate 400 ml/min” Patient#2 06:03 BP 205/98 LVN documented “ Treatment started without complications” 06:16 BP 208/96 LVN documented “ bp increased vs q 15 min temp increased pt alert asymptomatic cn notified cont to monitor” 06:31 BP 202/101 PCT documented “ bp remains high legs down pt asymp uf prof 2 will inform RN continue to monitor. 06:46 BP 198/80 PCT documented “ bp check pt resting w/legs down cont to monitor”. 07:01 BP 195/92 PCT documented “ bp cont to improve pt resting w/legs down no apparent distress” 07:16 BP 188/92 LVN documented “ bp decrease pt sitting with feet down eyes closed cont to monitor vs q 15” 07:31 BP 178/80 LVN documented “ patient monitored eyes closed patient restingbp trending down” 07:46 BP 182/84 LVN documented “ patient monitored eyes closed patient resting” 08:01 BP 170/78 LVN documented “ bp decreased pt sitting with feet down eyes closed cont to monitor” 08:16 BP 193/86 LVN documented “ bp increased pt alert sitting with feet down cont to monitor vs q 15” 08:31 BP 184/66 PCT documented “ bp improved pt resting tolerating tx well” 08:46 BP 215/96 LVN documented “ bp cuff readjusted” 08:47 204/76 LVN documented “ bp cuff readjusted” 08:48 183/71 LVN documented “ pt alert sitting w feet down cont to monitor” 09:01 BP 177/68 LVN documented “Treatment terminated” Review of the facility reportable parameters states Report to RN if Blood pressure systolic >190 and diastolic > 100 <55. Interview with Staff#3 at 13: 22 in the facility conference room confirmed the above findings and stated PCTs and LVNs do not have the authority to change a patients RX.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 34839 Based on interview and record review facility’s Registered Nurse failed to ensure patient’s hemodialysis treatment was administered based on the physician’s order in 1 out of 1 patients. Findings: Facility policy and procedure reads in part: Dialysis Regulatory and Ancillary Policies & Procedures Policy: 3-02-03 Title: Physician Orders For Patient Care Revision Date October 2023 9. The licensed nurse teammate and Registered Dietitian have the right to refuse to carry out orders, which in his/her judgement may be harmful or damaging to the patient. In such and event, he/she must notify the involved physician and Administrator/designee immediately. The Administrator/designee will in turn notify the Medical Director, and the Regional Operations Director. The licensed nurse teammate or Registered Dietitian refusing to carry out the order must document (including signature and date) the reason they have refused to carry out the order in the patient’s medical record. Resoluation to the licensed nurse teammate or Registered Dietitian’s refusal to carry out the order must also be documented (including signature and date) by an appropriately licensed or registered Administrator/designee or Regional Operations Director and signed/dated by the involved physician or Medical Director. Complainant alleges that on 10/23/23 patient arrived late for treatment. Facility staff presented a paper to patient and asked the patient to sign. Patient is visually impaired and refused to sign the paper due to not knowing what the patient is signing. Facility staff then discontinued patient treatment 40 minutes prior to prescribed treatment time end. Patient #1 Treatment Details Report 10/23/23 Dialysis Prescription Treatment Time: 3 Hours 0 Minutes (180 Minutes) Post-Treatment Vitals Treatment Duration: 141 Minutes (2Hours 21Minutes) Comments Post: Goal not met due to late arrival to treatment. 1.9 kilograms fluid removed. Blood pressure fluctuated throughout treatment, patient asymptomatic during treatment, monitored every 15 minutes. No signs of distress during treatment, remained on 2 Liters oxygen nasal cannula throughout treatment. Blood pressure slightly elveated post treatment, within clinic parameters. Patient stable. Leaving greater than 5 kilograms above tare weight post treatment. Encouraged to continue limiting fluid intake to 1 liter per day. During interview on 12/6/23 with the Facility Administrator revealed at 1119 “She signed off early that day.” Surveyors discussed with Facility Administrator that complainant said that Patient #1 arrived late for the patient treatment scheduled treatment time and that facility staff presented a paper and asked the Patient #1 to sign it. Patient #1 did not sign it and Patient #1 was taken off 40 minutes prior to prescribed treatment time end. Regarding the complaint the Facility Administrator stated at 1134 “They took her off at her scheduled off time, if she would have arrived at her regular time, that’s the time they took her off.” Surveyors discussed that the last patient taken off of treatment that day was at 1940 and that Patient #1 was taken off at 1830, the Facility Administrator stated at 1157 “She could have run her treatment time.””