Davita Carrollton Dialysis

“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: 43999 Based on observation, record review, and staff interview, the staff failed to furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements.The staff did not notify the nurse to assess the patient when significant changes occurred during treatment and report significant patient changes for intervention. This deficient practice had the likelihood to cause harm to the patients at the facility. Findings: Facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient ’ s medical record.” Additional facility guidelines: “Data Collection Patient Assessment Reporting Protocol- Carrollton Purpose: To provide guidelines for the PCT, LVN, and RN in identifying and reporting patient assessment data that is outside the usual outcome for the patient... Vascular Access-Positive for bruit and thrill (AVG & AVF), patient (CVC), without Signs/Symptoms of infection, ... any change from baseline, infiltration, difficulty cannulation, inability to achieve BFR, bleeding around CVC or needles, variance in VP/AP readings from baseline. Report to CN for evaluation of needle placement, lines/dialyzer clotting, bleeding around needles, ability to recannulate and continue treatment. Notify MD if unable to dialyze.” Review of the following patient treatment sheet 12/29/24 revealed facility staff did not report to the CN the patient’s vascular access pressure changes after initiation of treatment and before recannulation of access. Staff documented the following 02/29/24 on the treatment sheets, no REM (report event monitoring) was found, no documentation the CN was notified regarding the recannulation or high Venous Pressures (VP) prior to recannulation nor after recannulation. Patient # 1 “ 06:32am Initial Entry VENOUS PRESSURE GOES UP; VENOUS RECANNULATED ABOVE;NOW VENOUS VP PRESSURE OK” An interview conducted with Staff #1 and #2 on 03/11/24 confirmed the flow sheet findings did not provide documentation by the PCTs to the nurse for interventions or follow-up.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 43999 Based on observation and staff interview the facility failed to ensure the environment was maintained to minimize the transmission of infectious agents within the facility and adjacent areas. Findings: During a tour of the facility on the afternoon of 3/11/24 the following was observed: * Clean supplies in the storage/supply room behind the nursing station were stored under and beside shipping boxes., Four shipping boxes with dialyzers were open. * Clean supplies ( boxes of gloves), stethoscopes and patient personal belongings were stored on countertops behind patients’ treatment areas. * Under the sink labeled dirty, closest to chair 12, the cabinet was damaged by water with cracked laminate pulled apart exposing the fiberboard under the laminate, visible mold, rusty loose hinges. Cabinet drawers were damaged and unable to properly close, these drawers contained supplies . Under the second sink labeled dirty, the cabinet was damaged by water with brown and white residual on laminate. This practice can lead to cross contamination due to inefficient cleaning of the non-intact surfaces. * Storage/supply room away from the treatment area : patient supplies stored in large plastic bins within the supply room with no top on them, allowing them to be exposed to dust and dirt. There were shipping boxes stored by clean supplies. In an interview with staff #1 & #2 on 3/11/24, it was confirmed the above findings.”