Davita Winchester 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: 49355 Based on observations, interviews and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene and glove changing. Specifically, hand hygiene (HH) was not performed and gloves were not changed, per policy, in one (1) out of two (2) observations of discontinuation of dialysis with a central venous catheter (CVC) and in one (1) out of three (3) observations of discontinuation of dialysis with an arteriovenous (AV) fistula. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: “Hand Hygiene 1. All teammates...will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... d. after patient and dialysis delivery system contact, ... g. before touching clean areas such as supplies, supply car and chairside keyboard/mouse ... PPE ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.... a. Gloves should be changed when: ... ii. When going from a ‘dirty’ area or take to a ‘clean’ area or task.” A review of the facility’s procedure entitled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” procedure: 1-04-02B, revision date April 2025, reads, in part: ... “Upon Completion of Dialysis 26. Perform hand hygiene per procedure. Put on PPE.... Hand hygiene helps prevent cross contamination. PPE is worm to protect teammate. ... 29. Remove gloves and discard, perform hand hygiene per procedure and re-glove. ... 31. Remove gloves and discard, perform hand hygiene per procedure and re-glove.” A review of the facility’s procedure entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure: 1-04-01B, revision date April 2023, reads, in part: ... “1. Perform hand hygiene. Put on PPE. Hand hygiene protects patient and teammate from cross contamination. PPE is worn to protect teammate.” On May 20, 2025, at 1:22 P.M., while discontinuing dialysis on MR24 at station #11, EMP6 did not remove gloves, perform HH or don clean gloves before disinfecting the CVC connections. On May 20, 2025, at 8:56 A.M., while discontinuing dialysis on MR20 at station #12, EMP10 did not remove gloves, perform HH or don clean gloves before aseptically removing the access needles from an AV fistula. On May 20, 2025, at 9:07 A.M., while discontinuing dialysis on MR22 at station #3, EMP6 placed item’s in the patient’s duffle bag, touching the bag. EMP6 then used the computer, touching the screen, picked trash off the floor and then proceeded to flush the lines and remove the access needles from MR22’s AV fistula. MR22 never removed gloves, performed HH or donned clean gloves during this process. During separate interviews with MR1 and MR2 on May 20, 2025, both employees agreed that glove changes and HH should have occurred in these instances.”

“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: 49355 Based on observations, interviews and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients in three (3) out of four (4) observations. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: ... “Disinfection ... 13. 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...).... ... ii. Priming containers are to be emptied prior to disinfection.” On May 20, 2025, at 9:18 A.M., EMP10 failed to disinfect the inside of the prime waste container at station #11. EMP10 also failed to disinfect the outside of the dialysis chair, underneath each side tray. On May 21, 2025, at 9:58 A.M., EMP6 failed to disinfect the inside of the prime waste container at station #16. EMP6 also failed to disinfect the outside of the dialysis chair, underneath each side tray. On May 21, 2025, at 10:39 A.M., EMP19 failed to disinfect the outside of the dialysis chair, underneath each side tray. During separate interviews with EMP1 and EMP2, both agreed that the outsides of the dialysis chairs, underneath the side trays, should be disinfected and the inside of the prime waste container should be disinfected as well.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49355 Based on observation, interview and document review, it was determined the facility failed to have a mechanism in place to ensure all expired medications are not available for patient use in the dialysis facility. The findings: The facility’s policy entitled, “Medication Policy,” policy 1-06-01, revision date October 2023, reads, in part: ... “Policy: ... 30. All medications in the facility are checked monthly. All medications are checked monthly for expiration dates. ... 32. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations.” On May 19, 2025, at 4:20 P.M., twenty-five (25) single dose vials of Tazicef 1 gram/vial for injection, NDC #00409-5082-16, with an expiration date of February, 2025, were discovered in one of the facility’s medication storage drawers on the treatment floor. EMP9 witnessed and agreed the medication had expired. EMP9 indicated that medications are checked monthly for expiration dates and the Tazicef was obviously overlooked.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in three (3) out of three (3) observations, facility staff touched the cannulation sites of arteriovenous (AV) fistulas after the areas were prepped with antiseptic. The findings include: The facility’s procedure entitled, “AV Fistula or Graft Cannulation with JMS Sysloc (R) Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” procedure 1-04-01D, revision date April 2025, reads, in part: ... “Procedure: ... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possible allow for the introduction of bacteria during contamination.” On May 21, 2025, at 10:15 A.M., EMP6 palpated MR25’s AV fistula cannulation site at station #14 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On May 21, 2025, at 10:24 A.M., EMP8 palpated MR26’s AV fistula cannulation site at station #12 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On May 21, 2025, at 10:31 A.M., EMP18 palpated MR27’s AV fistula cannulation site at station #5 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. EMP1 and EMP2 indicated during separate interviews that the site should be recleansed after palpating and before cannulating and not touched again.”

“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: 40084 Based on interview and document review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues related to the use of vascular clamps. The findings include: The Current survey: Based on observations, interviews and document review, it was determined that the facility failed to follow policy related to the use of clamps in two (2) in-center hemodialysis patients and failed to have an order for the usage of clamps in one (1) in-center hemodialysis patient. The Prior Recertification Survey Ending November 3, 2021 Based on observations, interview, and facility document review, it was determined that the facility’s staff 1.) failed to follow facility policy when using vascular access clamps for two (2) of two (2) patients and 2.) failed to ensure a physician’s order was present to use vascular access clamps for one (1) of two (2) patients.”

“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: 49355 Based on observations, interviews and document review, it was determined that the facility failed to follow policy related to the use of clamps in two (2) in-center hemodialysis patients and failed to have an order for the usage of clamps in one (1) in-center hemodialysis patient. The Findings: The facility’s policy entitled, “Utilizing Vascular Access Clamps,” policy 1-04-08, revision date April 2019, reads, in part: ... “Policy: ... 3. Vascular access clamps should not be used routinely. However, if a patient is unable to hold his/her own sites, it is recommended that only one (!) clamp is used at a time and should not be left on longer than 20 minutes.” On May 19, 2025, at 3:36 P.M., MR16 was observed at station #15 with two (2) vascular clamps placed by EMP20. A review of the medical record for MR16 revealed there were no orders for clamp usage in the record. On May 20, 2025, at 9:28 A.M., MR28 was observed at station #6 with two (2) vascular clamps placed by EMP17. A review of the medical record for MR28 revealed there was an order for the usage of clamps in the record, but the order was for two (2) clamps, which is contradictory to facility policy. During an interview on May 21, 2025, at 10:20 A.M., EMP16 agreed the facility policy stated only one (1) clamp should be used at a time. During an interview on May 21, 2025, at 10:48 A.M., EMP1 agreed the facility policy stated only one (1) clamp should be used at a time.”