Davita Montana Vista 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: 28421 Based on review of documentation and interview, it was determined that Charge Nurses preformed patient care duties contrary Texas ESRD Rules and Regulations. Findings were: Tour of the patient treatment area on 8/20/24 revealed 24 dialysis patients, 2 RNs and 1 LVN and 4 techs. Review of two weeks of treatment sheets for 20 randomly selected patients, revealed documented evidence that the Charge Nurse provided patient care including catheter care and medication administration. Patients # 18 and 20 had treatment records that substantiated that the Charge Nurse provided patient care on 8/18/24, 8/10/24 and 8/20/24. On 8/5/24, patient #9 received care from the Charge Nurse as did patient # 21 on 8/4/24. In an interview with the Facility Administrator on 8/21/24, it was admitted that the Charge Nurses, at times, preformed patient care duties.”

“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: 31690 Based on observation, review of documentation and interviews it was determined that the facility failed to ensure that there was adequate oversight in the area of infection control and as a result patient safety and quality of patient care was compromised. Findings were: Tour of the storage area and water room on 8/20/24 revealed a lack of weather stripping on the double doors leading outside. This space under the doors could allow entry of vectors into the facility. Tiles were observed to be damaged at chairs 19 and 21 preventing adequate cleaning and potentially allowing bacteria to grow. Review of the Facility QAPI minutes reflected this was identified in February of 2024 and has not been repaired. Review of the Facility QAPI minutes reflected that patients have been observed not washing their hands and access before and after their dialysis treatment. The problem was identified in February of 2024 and is still ongoing. The above findings were confirmed in an interview with staff #1.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 31690 Based on interview and record review, the facility failed to develop and implement a Quality Assessment Performance Improvement Program which analyzed infection prevention, developed a root cause analysis and implemented a plan to address identified areas of concern. Findings: Review of the Facility’s Quality Assessment Performance Improvement Program (QAPI) meeting minutes and data, dated 2/28/24, 4/24/24, 5/22/24, 6/19/24, and 7/24/24. QAPI Meeting, Dated 2/28/24, 4/24/24, 5/22/24, 6/19/24, and 7/24/24. “IP Start Date 2/28/24. Issue Statement: Patients are not washing their hands and access before or after treatment ... Process Improvement Goals: For 95% of patients to wash their hands and access before and after treatment. Process Deep Dive: Facility teammates are not asking patients to wash their hands and access before treatment. Actions and Interventions: 1. FA to hold in-service with facility teammates to reinforce importance of patients washing their hands and access before and after treatment. Expectations will be set. 2. Facility teammates to remind patients to wash their hands and access before and after treatment. 3. FA to visually audit effectiveness of plan during change of shift. QAPI Meeting, Dated 5/22/24, 6/19/24, and 7/24/24. IP Start Date: 3/27/24. Issue Statement: Floor tiles in treatment area are cracked and discolored. Process Deep Dive: Damage caused by drain and machine leaks. Actions and Interventions: Created a work order with CBRE on 2/22/24 work order #515455. IP Evaluation: Continue to follow up with CBRE and with BOM. 4/2/24 ... Continue to follow up with no progress. During an interview, on the afternoon of 8/20/24, Staff #1 reported that she had no documentation of visually auditing the effectiveness of the plan. She verified that the QAPI action plan and interventions are not updated when the previous plan does not work. The above findings were confirmed in an interview with staff member #1.”