Davita Lancaster Dialysis

“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: 30377 Based on review of hemodialysis flow sheets and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment. The findings included: Review of hemodialysis flow sheets dated 7/26/24 and 7/27/24 in the facility conference room revealed the following discrepancies: Patient # 1 Flow Sheet Dated: 7/26/24 - Pre Vitals: 185/78 heart rate 69. Blood pressure ranged from 167/64 to 195/83 with heart rate from 59-68 during treatment. Post Vitals: 184/78 heart rate 69. No documentation was found that the registered nurse addressed the hypertension before, during, or post treatment. The registered nurse documented post assessment findings as followed: Vitals signs stable at the time of discharge home. Patient # 2 Flow Sheet Dated: 7/27/24 - Blood pressure ranged on treatment from 189/111 to 198/102 with heart rate from 85-89. No documentation by the direct patient care staff that the registered nurse was notified of the hypertension during treatment. No documentation was found that the registered nurse addressed the hypertension during treatment. The registered nurse documented post assessment findings as followed: ...Teammate did not inform charge nurse that patient still has a high blood pressure during treatment. An interview conducted with (Staff #1) on 7/29/24 following her own review of the findings revealed she was unaware of the discrepancies found in the flow sheets.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 50181 Based on observation and staff interview during a facility tour on 05/02/2024 the facility failed to ensure expired supplies were discarded on or before the expiration date and not available for patient and staff use in the facility. Also, the facility failed to ensure blood splatter is cleaned timely and appropriately. Findings included: During a tour of the facility treatment floor on the morning of 05/02/2024, the following expired supplies were found and available for patient and staff use: 4 Hand Sanitizer stations on the treatment floor had expired hand sanitizer available for patient and staff use with the following expiration dates: 08/2023, 06/2023 and 05/2023 Blood splatter noted on two dialysis machines in use on the treatment floor Blood splatter noted on two sharps containers in use on the treatment floor In an interview with the Facility Administrator (Staff #1) on 05/02/2024 she confirmed the supplies were expired and still available for patient and staff use.”

“BICARB CONC DIST-COLOR CODED BLUE & SEALED CFR(s): 494.40(a) 5.5.4 Bicarbonate concentrate distribution systems: color coded blue & sealed Bicarbonate concentrate delivery piping should be color-coded blue at the point of use (at the jug filling station or dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility failed to ensure that the wall boxes (dispensing outlets) at the dialysis stations were properly disinfected between each patient treatment. This deficient practice had the likelihood to cause bacterial grow in the wall boxes and infect the patients that were receiving in-center hemodialysis at the facility. Findings included: During a tour of the facility treatment floor on the morning of 05/02/2024 the wall boxes were noted to have a crusted, white and brown sediment and build-up around the connectors of the wall box.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility failed to monitor and provide a safe sanitary environment to minimize the transmission of infectious agents. During a tour of the facility on 05/02/2024 the following physical plant related infection control issues and safety issues were noted: Leaves and dirt noted under the storage flats in the store room, near the door exiting the building, containing unopened shipping boxes with supplies Stained ceiling tiles throughout the building dust and dead bugs noted in a shelf in the hallway holding hand sanitizer, a thermometer and masksRust and dirt noted on the rolling sharps containers being used on the treatment floor An interview with the Facility Administrator (Staff #1) on 05/02/2024 confirmed the above findings.”