Davita Cedar Park Dialysis Center

“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 record review and interview, the facility staff failed to comply with applicable State laws and regulations pertaining to licensure and any other relevant health and safety requirements. Findings : A. “(c) Dialysate. (3) Prior to each patient treatment, staff shall verify the dialysate conductivity and pH of each machine with an independent device. Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. Facility staff did not verify treatment conductivity using an independent meter “. B. “A review of ESRD rules Chapter 117_07_2010, Texas Department of State Health Services Regulatory Licensing Unit-Facility Licensing Group, read in part, “...Incident Reports. 117.48 (a) (1). (a) A facility shall report the following incident(s) to the department within ten working days: (1) death of a dialysis patient, which occurs in the facility, at home, or in a hospital.” A. During observation on the patient treatment floor 4/10/24, the staff did not check the conductivity of four of four machines using an independent meter prior to initiation of the patient’s treatment. The findings confirmed 4/10/24 during the observation with the Charge Nurse and the CCHT providing patient care. Staff #2 stated, “We got rid of all our Phoenix meters. The manufacturer’s recommendations say conductivity is not needed to be manually checked. We manually check pH with test strips.” B. Based on record review and interview, the facility failed to report patient death at the facility, citing two of two patient (patient #7 & #8) that there was no documented evidence of the facility’s Texas Department of State Health Services Regulatory Licensing Unit-Facility Licensing Group Incident Report. Findings: Review of the mortality reports from August 2023 to present, there was two deaths that did not have a TDH Incident report to review. On 4/10/24, when the CN (staff # 2)& CC (staff #5) was asked for the facility’s written report to the State for patient death. it was stated they do not have an incident report to the State as required.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 43999 Based on observation, interview and record review, the facility’s nursing staff failed to wear gowns and disinfect contaminated equipment in between patient usage in 3 of 3 observations. These findings have a potential to cause harm by increasing the risk of infection to all patients receiving care at the facility. Findings: Facility based policy , “Title: Infection Control for Dialysis Facilities stated in part, 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area. DISINFECTION 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient.” During observation of the treatment room, 4 of 4 patients were transferred from wheelchair to treatment chair using the SNF hoyer lift with no disinfection performed between patients. During an interview with the SNF staff #8, it was shared they use the hospital disinfection wipes, but there were unavailable and she would need to locate some. It was also asked how the gown is to be worn for proper protection and it was shared it should be closed. The SNF staff #8 confirmed both were not being followed during the interview. These findings have a potential to cause harm by increasing the risk of infection to all patients receiving care at the facility. Staff # 5 confirmed the above findings 4/10/23.”

“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: 43999 Based on observation and interview, the facility failed to provide and actively monitor a safe, functional, comfortable, and sanitary environment which minimizes or prevents transmission of infectious diseases for all patients and visitors, and the public. Findings: Observation 4/10/24 of the facility’s treatment room, revealed the following findings: The treatment flooring had peeling paint on the floor and three different areas with uneven concrete needing repair. The ceiling exhaust vent above the crash cart was not proper sealed . There is a hole in the ceiling above the clean sink. The flooring in the treatment room had an accumulation of bicarbonate solution and dirt observed under and around the water and dialysis machines at all 6 stations. The sink labeled :dirty” had white cloudy buildup in the sink and around the water handles. The locked cabinets at the medication area had brownish orange droplets. The cabinet under the dirty sink had accumulation of white and brown buildup. The trash can outside the treatment floor entrance had gowns from the hooks blocking the top of the trash can. The eye wash station was labeled out of order. Staff #1 and Staff #5 confirmed the above findings.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 43999 Based on review of employee files and interview on 4/10/24 it was determined that the Medical Director did not verify competency of dialysis technician (CCHT) members to cannulate a hemodialysis access, administer normal saline, heparin, lidocaine and oxygen. Findings : Review of employee files for 1 of 1 dialysis technician (CCHT) did not have delegation of duties signed by the Medical Director that allows Dialysis technicians to provide specific care to patients. Staff # 2 dialysis technicians (CCHT) had no designation/certification by the Medical Director.. In an interview with the ROM and CC 4/10/24, the lack of the delegation of duties by the Dialysis technicians by the Medical Director was acknowledged in the above employee file.”

“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, interviews and documentation reviewed, the facility is not in compliance with applicable State regulatory licensing requirements. The Charge Nurse(CN) provided direct patient care duties contrary to Texas ESRD Rules and Regulations. Findings include: During an interview with staff on 12/5/23, it was shared, often there was only one RN/CN (registered Nurse/Charge Nurse) assigned with eight or more patients and this nurse provides direct patient care as well as charge nurse duties. Review of the staff/patient daily assignments for 11/22/23-12/6/2023 , documentation revealed the RN who was also the CN and CC (Clinical Coordinator) was assigned all nursing responsibilities for all patients that included initiation and termination of patient that have a central venous catheter (CVC) as well as administration of all patient ordered medications, assessments, and other CN duties. Review of patient/staff assignments identified one CN, 3 PCTs (patient care technicians) assigned to provide direct patient care on the following dates: 11/22, 29, and 30/2023 12/2 and 4/2023 Direct patient care includes initiation, termination of all patients with a CVC, administration of medications and charge nurse duties. Documentation of patient treatments have the CN signatures for patient care. In an interview with staff #1 (Facility Administrator) on 12/5/23, it was acknowledged the RN/CN does provide direct patient care.”

“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, interview and policy review the facility failed to monitor and provide a sanitary environment which minimized risk of transmission of infectious agents within the unit and with any adjacent or public areas. Findings included: Upon entrance into the facility on 12/5/23, the lobby floors were visibly dirty. The front lobby had six containers stacked just to the right of the door and another five containers stacked by the reception window, additional wheelchair parts were stacked on a wheelchair in the lobby. The front of the building had layers of dirt in the windows and on the door that included a large sign taped to the bottom part of the door that was torn and caked with dirt and grime. The building had stained, cracked tiles throughout the facility with buildup of what appeared to be scum on the floors in all areas. Floor wall bases have visible dirt and debris build-up. The janitor room was not locked (allowing access to chemical cleaners) and was dirty with debris and dust, mops, and buckets were soiled. Overall appearance of the janitor room was dirty and unmonitered. On 12/5/23 the above findings were acknowledged by Regional Operation Director.”