Davita Clear Creek Dialysis

“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: 37322 Based on observation and interview the facility did not follow their policy regarding infection control. On 08/13/2024 at 1125, it was observed the seats of four (4) chairs and three (3) stools were noted to be peeling, with cloth exposed, and could not be disinfected. Finding Include: Facility policy, updated April 2023, Infection Control for Dialysis facilities 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. On 08/13/2024 at 1125, it was observed the seats of three (3) chairs and three (3) stools on the dialysis floor and one chair in the biomed area were peeling with cloth exposed. Interview with staff (ID#8) who validated the findings.”

“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 record review and interview the Medical Director failed to ensure nursing staff followed the facility’s policy and procedures to prevent or reduce complications pre, during or post treatment in that the nursing staff did not complete the initial nursing assessment within the first hour of treatment in 2 of5 records reviewed. (Patient ID #s 1, 7). The facility currently has a census of 43 hemodialysis patients that could be affected by the nursing staff failing to complete the initial nursing assessment within the first hour of hemodialysis treatment. Policy Reviewed: Review on 8/13/2024 of the facility’s current policy titled: “Pre-Inter-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08; Latest Revision: April 2024. Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. Records Reviewed: Review on 08/13/2024 along the Facility Administrator, staff ID #A of selected patient records identified the following: Patient ID #1 hemodialysis treatment sheet: 08/07/2024 treatment initiated 13:16 PM, pre-nursing assessment 18:08 PM. Patient ID #7 hemodialysis treatment sheet: 08/08/2024 treatment initiated 07:46 AM, pre-nursing assessment 08:57 AM. 07/30/2024 treatment initiated 07:32 AM, pre-nursing assessment 08:50 AM. Interview on 08/13/2024 at 14:30 PM with the Facility Administration, staff ID #A confirmed the above findings and stated the initial assessment should be completed with the first hour of hemodialysis.”