Davita Horizon 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: 48020 Based on observation, interview and record review, the facility’s direct care staff: failed to perform hand hygiene after removal of contaminated gloves in 1 of 3 staff observed: Registered Nurse (A) B) failed to encourage patients to perform hand hygiene after removal of contaminated gloves in 2 of 3 staff observed: Patient Care Technician (C) and Registered Nurse (A) and Patient #s 1, 10 Findings: Review of facility’s current policy and procedure: Infection Control For Dialysis Facilities, Policy: 1-05-01, Revision Date: April 2023 directs staff as follows: “HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and 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 form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.” Staff Hand Hygiene: Registered Nurse (A) Observation on 12/08/2025 at 9:47 AM, revealed Registered Nurse (A) located at station #13 discontinuing the hemodialysis treatment on Patient #10. Registered Nurse (A) attached a syringe to the patient’s vascular access needle, removed his gloves, walked to the chairside cart located between station #s 15 and 16, reached into a glove box his contaminated hand. Registered Nurse (A) failed to perform hand hygiene after removing the contaminated gloves. The Surveyor notified Registered Nurse (A) at 10:05 AM that he failed to perform hand hygiene after removal of the contaminated gloves. Registered Nurse (A) said, “Okay.” Patient Hand Hygiene: Patient Care Technician (C) Patient #1 Observation on 12/08/2025 at 9:40 AM, revealed Patient #1 holding his vascular access with a gloved hand at station #2. After the bleeding ceased, Patient Care Technician (C) taped the patient’s vascular access site. The patient removed his glove, picked up his personal items, was weighed, and left the treatment area without performing hand hygiene. The Surveyor notified Patient Care Technician (C) at 10:10 AM that Patient #1 failed to perform hand hygiene after removal of the contaminated glove used to hold his vascular access. Patient Care Technician (C) said, “Okay.” Registered Nurse (A) Patient #10 Observation on 12/08/2025 at 9:47 AM, revealed Patient #10 holding his vascular access with a gloved hand at station #13. After the bleeding ceased, Registered Nurse (A) taped the patient’s vascular access site. The patient removed his glove, picked up his personal items, without performing hand hygiene. The Surveyor notified Registered Nurse (A) at 10:05 AM that Patient #10 failed to perform hand hygiene after removal of the contaminated glove used to hold his vascular access. Registered Nurse (A) said, “Okay, I will tell him next time.””

“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: 48020 Based on observation, record review and interview, the facility’s licensed nurses and direct care staff failed to administer patients’ hemodialysis treatments at the prescribed Heparin rate in 1 of 10 sampled patients: Patient #s 4. Findings: Review of the facility’s current policy and procedure on Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, Policy 1-03-08, directs staff as follows: “POLICY 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting)” Heparin Administration Patient #4 Observation on 12/08/2025 at 12:57 PM revealed Patient #4 was seated at station #13 machine #2 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and an ultrafiltration rate of 686 mL/min via a right upper arm vascular access. The patient was utilizing an Elisio-17H non reuse dialyzer. A syringe was engaged in the heparin pump for administering heparin. During the observation with Patient Care Technician (J) at the chairside, the Surveyor asked Patient Care Technician (J) to reveal how much Heparin was being administered. Patient Care Technician (J) tapped the Heparin button on the hemodialysis machine which revealed a flow rate of 0.5 mL/h of Heparin had been administered. Review of the patient’s heparin prescription in the chairside computer with Patient Care Technician (J) revealed a physician’s order for Heparin maintenance 600 units/hour instead of the 500 units/hour observed on the patient’s hemodialysis machine. Patient Care Technician (J) stated “I must have put in the wrong number by mistake. I will change it.” Review of the patient’s Treatment Details Report dated 12/08/2025 revealed the following documentation: 11:03 AM- patient’s hemodialysis treatment was initiated, Heparin Pump- Y (yes) 11:34 AM- Nurse Prescription Verification was completed by the registered nurse The patient did not receive the prescribed Heparin administration from 11:03 AM (treatment initiation) - 1:00 PM (Surveyor observed the Heparin setting on the hemodialysis machine).”

“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: 30124 Based on observation, interview and record review the facility’s medical director failed to ensure staff followed the facility’s policy and procedures in labeling medications. Review of the facility’s current policy titled, “Medication Policy”, Policy: 1-06-01, Revision date October 2023. Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of medication. Policy: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory. 19. Medications administered via infusion are to be prepared and administration started within four (4) hours. In the States of New Jersey and South Carolina, medications administered via infusion must be prepared and administration started within one (1) hour of preparation. 20. If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of the medication, date, time prepared, dose and initials of the teammate preparing the medication. Observation on 12/08/2025 at 10:14 AM Patient ID #8 was observed receiving hemodialysis treatment at station #5, machine #15. Surveyor observed an empty 250 ml bag of normal saline with a label identifying the patient along with the medication Cefepime HCL 2 Gram. The label did not include the date, time prepared or the initials of the teammate preparing the mediation as required. Interview on 12/08/2025 at 10:29 AM with the Facility Administrator (H) confirmed the above findings.”