Davita Wharton Dialysis

“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: 10802 Based on observation, interview and record review, facility’s direct care staff failed to wash sanitize hands after direct contact with contaminated equipment. In 2 of 3 staff observed; Licensed Vocation Nurse (B) and Patient Care Technician (C) Findings: Licensed Vocational Nurse (B) On 11/01/2023 at 9:50 a.m. Licensed Vocational Nurse (B) was observed terminally cleaning hemodialysis station # 2, hemodialysis machine # 5, post hemodialysis treatment of a patient. After terminally cleaning the unit, Licensed Vocational Nurse (B) removed her contaminated gloves but she did not wash / sanitize her contaminated hands. After removing the contaminated gloves, she walked over the clean supply area of the cupboard and picked up a clean red bag for the cupboard drawers. Patient Care Technician (C ) On 11/01/ 2023 at 12:07 p.m. Patient Care Technician (C) was observed at station #16. The patient’s hemodialysis machine alarmed indicating high arterial pressure. Patient care Technician (C) donned a pair of clean gloves and reset the panel on the patient’s hemodialysis machine and repositioned the patient’s external blood lines. After completing the task, Patient Care Technician ( C) removed her contaminated gloves, picked up clean gloves from the box of gloves stored on the computer station. Patient Care Technician ( C) did not wash/ sanitize her hands after removing the contaminated gloves. The Surveyor immediately notified her that she did not wash/ sanitize her hands after removing the contaminated gloves. Patient Care Technician (C) states “ yes man you are correct.” Review of facility’s current Policy and Procedure on Infection Control Policy #1-05-01 revised April 2023 directs staff as follows: Hand hygiene All teammates, Physicians and Non-Physicians (NPP0 will perform hand hygiene. (a) Upon entering a exiting the patient treatment area (b) Prior to gloving and immediately after removal of gloves (c) After contamination with blood or other infectious material (d) After patient and dialysis delivery system contact (e) After interacting with wall boxes (i.e., plugging /unplugging acid/ bicarb lines from dialysis machine, changing acid types when exchanging a dialysis machine) (f) Between patients even if contact is casual (g) Before touching clean areas such as supplies, supply cart and chairside keyboard/ mouse.””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, Facility’s direct care staff failed to clean/ disinfect Hansen Connectors, chase, water/ wall box, back of hemodialysis machines and hoses during terminal cleaning of the unit in 2 of 3 staff observed terminally cleaning hemodialysis units Licensed Vocational Nurse (B) and Patient Care Technician (D) Findings: Licensed vocational Nurse (B) On 11/01/2023 at 9:50 a.m. Licensed Vocational Nurse (B) was observed terminally cleaning hemodialysis station # 2, hemodialysis machine # 5, post hemodialysis treatment of a patient. Observation revealed during terminal cleaning of the unit Licensed Vocational Nurse (B) did not clean and disinfect the Hansen connectors, chase, water/ wall box , back of hemodialysis machines and hoses during terminal cleaning of the unit. On 11/01/23 at 9:53 a.m. Licensed Vocational Nurse (B) was observed setting up clean external blood lines and dialyzer in preparation for an on- coming patient. Patient Care Technician (D) On 11/01/2023 at 10:30 a.m. Patient Care Technician (D) was observed terminally cleaning hemodialysis station # 6, hemodialysis machine # 15, post hemodialysis treatment of a patient. Observation revealed during terminal cleaning of the unit Patient Care Technician (D) did not clean and disinfect the Hansen connectors, chase, water/ wall box, back of hemodialysis machines and hoses during terminal cleaning of the unit. On 11/01/23 at 10:37 a.m. Patient Care Technician (D) was observed setting up clean external blood lines and dialyzer in preparation for an on- coming patient. On 11/01/2023 at 10:40 a.m. The Surveyor notified Facility’s Medical Clinical Support personnel that stations #2 and 6 Hansen connectors, chase, water/ wall box , back of hemodialysis machines and hoses were not cleaned/ disinfected during terminal cleaning of the unit. The Facility’s Medical Clinical Support personnel notified both staff that they did not clean all of the unit. Patient Care Technician (D) states “someone was cleaning it before that’s why I did not clean all of it.” Review of facility’s current Policy and Procedure on Infection Control Policy #1-05-01 revised April 2023, directs staff as follows: “At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. Pressurized washers, spray bottles, or sprayers for cleaning purposes will not be used on wall boxes or the adjoining area Teammates will monitor and address wall box residue/build up and patency issues. ii. Priming containers are to be emptied prior to disinfection. Drain line and water supply line should not be placed with ends in prime containers or in a position where they can drip into or contaminate the prime bucket. b. Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient. i. All dialysis patients must be clinically stabilized.””

“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: 10802 Based on observation, interview and record review, facility’s registered nurse failed to ensure patient’s hemodialysis treatments are administered based on the patient’s physician’s prescription in 1 of 6 sampled patients; Patient #3 Findings: Patient #3 On 11/01/2023 Patient #12:36 a.m. Patient #3 was observed at #16. The patient was receiving hemodialysis treatment at a blood flow rate 350 mls/ minute and dialysate flow rate of 600 mls/ minute via a right double lumen central venous catheter. The patient was observed vomiting yellow exudate in a red bag. Review of the patient’s physician’s order located in the chairside computer revealed an order dated 09/29/2023 for blood flow rate of 350 mls/ minute and dialysate flow rate of 600 mls/ minute. Treatment sheet dated 10/30/2023 Review of the Patient’s treatment sheet dated 10/30/2023 revealed the following documentation: The record revealed the patient’s hemodialysis treatment was initiated by Licensed Vocational Nurse (B) at 14 35 p.m. at a blood flow rate of 250 mls/ minute. 15:02 p.m. Patient’s blood flow rate increased to 350 mls/ minute. 15:30 p.m. Patient’s blood flow rate decreased to 300 mls/ minute and maintained at 300 mls/ minute until 18:32. Registered Nurse (G) assigned to the patient documented the following entries at 17:02 p.m., 17:32 p.m., 18:02 p.m.: “Patient appears to be to be tolerating treatment well.” Documentation indicated the patient’s hemodialysis treatment was terminated at 18:38 p.m. There was no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/ minute. Treatment Sheet dated 10/18/2023 The record revealed the patient’s hemodialysis treatment was initiated by Licensed Vocational Nurse (B) at 10:20 a.m. at a blood flow rate of 350 mls/ minute. 10:32 a.m. Patient’s blood flow rate decreased to 323 mls/ minute. The Licensed Vocational Nurse documented “Patient blood pressure low; UF off. Will continue to monitor” Documented blood pressure 89/54. 11:32 a.m. Documented blood pressure 82/49. Patient’s blood flow rate decreased to 300 mls/ minute and maintained at 300 mls/ minute until 14:24 when the patient’s hemodialysis treatment was discontinued. There was no intradialytic assessment documented by the registered nurse. Documentation indicated the registered nurse conducted a pre- treatment assessment on the patient at 13:02 p.m. and post treatment assessment at 15:38. There was no documentation by the registered nurse of the decreased blood flow rate and the patient’s low blood pressure. Treatment Sheet Dated 10/13/2023 The record revealed the patient’s hemodialysis treatment was initiated by the registered nurse at 14:18 p.m. at a blood flow rate of 300 mls/ minute and maintained at 300 mls until 17:03 p.m. At 17:33 p.m. the blood flow rate was increased to 315 mls/ minute and at 18:03 p.m. decreased to 300 mls/ minute. Documentation indicated the patient’s hemodialysis treatment ended at 18:33. Documentation by the Registered Nurse at 15:03 p.m. and 17:03 p.m. “Patient appears to be tolerating treatment well at this time.” There was no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/ minute.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the Facility’s Medical Director failed to ensure facility’s registered nurse implement facility’s policy to conduct assessment on patients when there is a change in condition in 2 of 6 sampled patient; Patient #4 and 3 Findings: Patient #4 On 11/01/2023 at 2:23 p.m. Patient #4 was observed on the treatment floor of the facility at station #13. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysate rate of 600 mls/ minute via a left upper arm vascular access. Patient’s recorded blood pressure on the hemodialysis machine 98/51, pulse 75 beats per minute. The patient complained of difficulty breathing and chest pain. The Surveyor informed the Licensed Vocational Nurse (B) of the patient’s complaint. The Licensed Vocational Nurse (B) who was present on the unit states “I will give him some oxygen.” The patient states “my head is spinning like crazy.” Patient complained of sharp pain in chest. The Licensed Vocational Nurse then directed Patient Care Technician (C) to call the registered nurse. There was no registered nurse present on the unit during the observation. Interview with Patient Care Technician (C) during the observation revealed she said one registered nurse was on break. The patient Care Technician paged for a Registered nurse but there was no response. The Patient Care Technician then opened the door and called Registered Nurse (G) who responded and inquired of the patient how he was feeling. “The patient states “I am having chest pain and I can’t breathe”. Registered Nurse (G) told the patient “Blow it out.” The registered nurse then took the patient blood pressure and then administered Nitroglycerin sublingually to the patient. Review of the patient’s treatment sheet for the following dated revealed the following findings: Treatment Sheet dated 11/01/2023 13:38: the Patient Care Technician documented “UF off dt low BP and pt not feeling good.” Documented blood pressure 77/35. There is no registered nurse assessment documented, 13: 40: The Patient Care Technician documented “Nurse notified pt c/o chest pain. 100 cc of NS given.” There is no documented assessment by the registered nurse. 13:45: Documented blood pressure 98/51, the Patient Care Technician documented “UF remains off.” 14:02: Documented blood pressure 99/51. The Patient Care Technician documented “PT still in pain. UF remains off.” 14:26: The Licensed Vocational Nurse documented “Treatment terminated; O2 2 L via nasal cannula “ Post treatment documentation by Registered Nurse (G) was as follows: “Pt complained to PCT, and nurse was alerted. Assessment done. Pt complaining of chest pain, rubbing across his chest with right hand., denies any heaviness or tightness to his chest or pain radiating to his left arm. Pt placed on oxygen 3 L/NC. Pt also states he feels dizzy. 1433 BP 114/63 P 83. 14:38 Nitro 0.4 mg tab sublingual administered. 14:50 DR D-- called and gave order to send Pt to the ER via EMS. 14:53. Family called and notified. 14:55: Wharton EMS .” Review of Hospital emergency room record dated 11/01/2023 revealed the following: “Chief complaint Chest pain, Clinical impression Chest pain, elevated d dimer Chronic anemia hypotension.” The record revealed from 13:38 p.m. when the patient initially complained of chest pain there was no documented intervention by the registered nurse. The Licensed Vocational Nurse intervened after the Surveyor’s observation at 2:26 p.m. Reviewed patient’s treatment sheet dated 10/25/2023. 13.01: Documented blood pressure 125/75 pulse rate 92 beats per minute. The registered nurse documented “Patient appeared to be tolerating treatment well at this time. “ 13:33 documented blood pressure 117/58 pulse 81 beats per minute 14:01: documented blood pressure 113/61 14:31: documented blood pressure 89/49, pulse rate 80 beats per minute 14:40: documented blood pressure 92/31, pulse rate 79 beats per minute. There is no registered nurse assessment documented, The Patient Care Technician documented “BP low checking.” 14:53: blood pressure 126/67 pulse rate 84 beats per minute. Reviewed patient’s treatment sheet dated 10/23/2023. 13:31: Documented blood pressure 107/57 pulse rate 70 beats per minute, the patient care technician documented “UF off d/t pt c/o cramping; nurse notified.” 13:43: Documented blood pressure 127/74. Pulse rate 93 beats per minute. The patient care technician documented “pt still cramping. uf still off “ 14:01: Documented blood pressure 92/48 pulse rate 72 beats per minute. The record indicated the patient’s hemodialysis treatment ended at 14:31 p.m. The record (treatment sheet revealed a documented post treatment assessment by the licensed vocational nurse at 14:52 and documented post treatment assessment by the registered nurse at 18:24 after the patient’ treatment ended at 14:31 p.m. Interview with Registered Nurse G on 11/01/ 2023 at 14:30 revealed she said “I was on break and was not aware that the patient was having chest pain.” Reviewed patient’s treatment sheet dated 10/23/2023. 13:31: Documented blood pressure 107/57 pulse rate 70 beats per minute, the patient care technician documented “UF off d/t pt c/o cramping; nurse notified.” 13:43: Documented blood pressure 127/74. Pulse rate 93 beats per minute. The patient care technician documented “pt still cramping. uf still off “ 14:01: Documented blood pressure 92/48 pulse rate 72 beats per minute. The record indicated the patient’s hemodialysis treatment ended at 14:31 p.m. The record (treatment sheet revealed a documented post treatment assessment by the licensed vocational nurse at 14:52 and documented post treatment assessment by the registered nurse at 18:24 after the patient’ treatment ended at 14:31 p.m. Interview with Registered Nurse G on 11/01/ 2023 at 14:30 revealed she said “I was on break and was not aware that the patient was having chest pain.” Patient #3 Treatment Sheet dated 10/18/2023 Review of the patient’s clinical record revealed the patient’s hemodialysis treatment was initiated by Licensed Vocational Nurse (B) at 10:20 a.m. at a blood flow rate of 350 mls/ minute. 10:32 a.m. Patient’s blood flow rate decreased to 323 mls/ minute. The Licensed Vocational Nurse documented “Patient blood pressure low; UF off. Will continue to monitor” Documented blood pressure 89/54. 11:32 a.m. Documented blood pressure 82/49. Patient’s blood flow rate decreased to 300 mls/ minute and maintained at 300 mls/ minute until 14:24 when the patient’s hemodialysis treatment was discontinued. There was no intradialytic assessment documented by the registered nurse. Documentation indicated the registered nurse conducted a pre- treatment assessment on the patient at 13:02 p.m. and post treatment assessment at 15:38. There was no documentation by the registered nurse of the decreased blood flow rate and the patient’s low blood pressure. Review of the Facility’s Policy and Procedure on intradialytic Data Collection Policy #1-03-08, revised October 2023. directs staff as follows: “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 license nurse will use his /her clinical judgement based on individual patient needs to determine if clinical interventions are necessary.” (13) All findings, interventions and patient response will be documented in the patient’s medical record.” Pre/intra/ Post Patient Report/ Complaints and /or teammate observation of pain chest pain.””