Davita Meherrin Dialysis Center

“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 three (3) infection control observations, interview, and document review, it was determined the facility staff failed to conduct hand hygiene to reduce the risk of spreading infectious disease. Findings: On 03/25/2024 between the times of 10:47 and 11:13 a.m. during observations on the treatment floor, the surveyor observed Staff Member #16 change gloves several times, all without performing hand hygiene before donning a new pair of gloves. On 03/25/2024 between the times of 12:06 and 1:34 p.m. during observations on the treatment floor, the surveyor observed, on numerous occasions, Staff Members #16 and #15, use ungloved hands to enter data on the keyboard of dialysis machines, then did not perform hand hygiene when moving on to the next patient’s station to enter data on that station’s keyboard. On 03/25/2024 at 3:15 p.m. during observations on the treatment floor, the surveyor observed a gloved Staff Member #21 adjusting the blood pressure (BP) cuff on the patient at station #13. Once the staff member was finished fixing the BP cuff, Staff Member #21 starting removing the tape from the patient’s fistula site and proceeded to pull the access needles, all without ever removing their gloves, performing hand hygiene and donning a new pair of gloves. A discussion with Staff Members # 1, 2 and 5 at 4:30 p.m. on 03/25/2024, confirmed that staff members should be performing hand hygiene and/or changing gloves before donning a new pair of gloves, moving on to another dialysis station to enter data on the computer, and before touching an access site. A review of the policy titled: “Infection Control for Dialysis Facilities,” Policy 1-05-01, last revision date October 2021, states in part: Teammate Hygiene 1. “Hand Hygiene is to be performed... prior to gloving, after removal of gloves... after patient and dialysis delivery system contact, between patients even if the contact is casual.... all teammates are to follow these requirements for glove use and hand hygiene.” ... Chair Side Terminal and Cart ... 76. “Gloves are to be removed and hands washed or alcohol based hand rubs used before and after touching the keyboard.” The above concerns were discussed 11 a.m. with Staff Members #1 and 2.”

“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, interview and document review, it was determined the facility staff failed to ensure that dialysis stations were appropriately disinfected between patients in two (2) out of five (5) observations. The findings include: On 03/25/2024 at 11:13 a.m., the surveyor observed Staff Member #14 cleaning a dialysis station. The staff member cleaned the blood pressure cuff and then placed it on the dirty dialysis chair. When the staff member started cleaning the chair, Staff Member #14 folded the “cleaned” cuff up and put it on top of the dirty dialysis machine. On 03/25/2024 at 11:31 a.m., this surveyor witnessed Staff Member #15 cleaning treatment station #8. The staff member cleaned the machine, emptied the prime waste container and then placed the dirty container on top of the cleaned machine, without wiping down the exterior of the container first. These observations were shared with Staff Members #1, 2 and 5 at 4:30 p.m. on 03/25/2024. All staff members agreed that these actions did not follow facility policy. A review of the facility’s policy, entitled, “Infection Control for Dialysis Facilities,” Policy 1-05-01, with a revision date of October 2021, reads in part: ... Facility Hygiene ... 46. Equipment including the dialysis delivery system, the interior and exterior of the prime container, the dialysis chair and side tables...blood pressure equipment... wiped clean with a bleach solution of the appropriate strength after completion of procedures, before being used on another patient,... and after each treatment. ... Dialysis Station Management ... 66. Teammates will thoroughly wipe down all non-disposable items and equipment such as the blood pressure cuff, the inside and outside of the prime container... and the dialysis delivery systems, with an appropriate disinfectant after every treatment. ... 67. Priming containers are to be emptied. The interior and exterior should be wiped down with 1:100 (one to one hundred) bleach solution before using on next patient treatment. The above findings were discussed at the exit conference on 03/26/2024 at 11:00 a.m. with Staff Members #1 and 2.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on observations, interview, and document review, it was determined the facility staff failed to maintain aseptic technique when providing care to a central venous catheter (CVC) exit site for one (1) out of two (2) observations The findings include: On 03/25/2024 at 10:50 a.m., the surveyor observed Staff Member #12 cleaning a CVC exit site on Patient #9 at station #13. The staff member cleansed around the CVC exit site with antiseptic. Once finished, the staff member allowed the patient’s t-shirt to touch the site. The shirt was allowed to stay on the site until the staff member allowed the area to dry and then applied a sterile dressing. A discussion with Staff Members #1, 2 and 5 on 03/25/2024 at 4:30 p.m. confirmed this practice did not follow the facility’s policy for CVC exit site care. A review of the facility’s procedure, entitled “Central Venous Catheter (CVC) With Tego Connectors or CVC End Caps Procedure,” Procedure 1-04-02A, revision date October 2023, reads, in part: ... Procedure ...3. ... Verify patient’s clothing is secured away from the exit site/work area. ... Rationale ... 3. ... Securing the patient’s clothing away from the work area minimizes the risk of cross contamination. The above concern was discussed at the exit conference on 03/26/2024 at 11:00 a.m. with Staff Members #1 and 2.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 42042 Based on document review and interview, it was determined the facility staff failed to notify the licensed nurse and physician of post-treatment weight exceeded +-1 kg of the target weight for seven (7) of eight patients (8). The findings include: The surveyor initiated medical record review of Patient # (1-8) on 03/25/24 at 2:00 pm and again on 03/26/24 at 10:06 am. For Patient # (1-7), the surveyor identified discrepancies between the post treatment weights and ordered target weights--exceeding one (1) kilogram (kg)--without corresponding documentation for nurse and/or provider notification. The following are excerpts from the treatment flowsheet documentation surrounding each occurrence: Patient #1 03/11/24: Prescribed target weight: 63.5 kg. Post treatment weight: 66.1 kg (Difference of 2.6 kg). Patient #2 03/12/24: Prescribed target weight: 60.5 kg. Post treatment weight: 63.4 kg (Difference of 2.9 kg). 03/19/24: Prescribed target weight: 60.5 kg. Post treatment weight: 62.5 kg (Difference of 2.0 kg). 03/23/24: Prescribed target weight: 60.5 kg. Post treatment weight: 62.3 kg (Difference of 1.8 kg). Patient #3 03/12/24: Prescribed target weight: 137.0 kg. Post treatment weight: 138.9 kg (Difference of 1.9 kg). 03/14/24: Prescribed target weight: 137.0 kg. Post treatment weight: 138.1 kg (Difference of 1.1 kg). 03/16/24: Prescribed target weight: 137.0 kg. Post treatment weight: 139.1 kg (Difference of 2.1 kg). 03/19/24: Prescribed target weight: 137.0 kg. Post treatment weight: 139.2 kg (Difference of 2.2 kg). Patient #4 03/12/24: Prescribed target weight: 71.0 kg. Post treatment weight: 74.5 kg (Difference of 3.5 kg). 03/14/24: Prescribed target weight: 71.0 kg. Post treatment weight: 74.5 kg (Difference of 3.5 kg). 03/16/24: Prescribed target weight: 71.0 kg. Post treatment weight: 74.5 kg (Difference of 3.5 kg). 03/19/24: Prescribed target weight: 71.0 kg. Post treatment weight: 75.9 kg (Difference of 4.9 kg). 03/21/24: Prescribed target weight: 71.0 kg. Post treatment weight: 75.8 kg (Difference of 4.8 kg). 03/23/24: Prescribed target weight: 71.0 kg. Post treatment weight: 76.4 kg (Difference of 5.4 kg). Patient #5 03/14/24: Prescribed target weight: 81.5 kg. Post treatment weight: 83.7 kg (Difference of 2.2 kg). 03/19/24: Prescribed target weight: 81.5 kg. Post treatment weight: 82.8 kg (Difference of 1.3 kg). 03/21/24: Prescribed target weight: 81.5 kg. Post treatment weight: 83.6 kg (Difference of 2.1 kg). Patient #6 07/15/23: Prescribed target weight 70.5 kg. Post treatment weight: 78.8 kg (Difference of 8.3 kg). 03/18/24: Prescribed target weight: 70.5 kg. Post treatment weight: 79.1 kg (Difference of 8.6 kg). 03/22/24: Prescribed target weight: 70.5 kg. Post treatment weight: 71.8 kg (Difference of 1.3 kg). Patient #7 03/18/24: Prescribed target weight: 59.0 kg. Post treatment weight: 60.7 kg (Difference of 1.7 kg). The surveyor met with both Staff Member #1 and Staff Member #2 for interview in the evening of 03/26/24. Following dissemination of the medical record review findings, Staff Member #2 verbally confirmed that any variation of post treatment weight beyond one (1) kg from target weight should have corresponding documentation in medical record, including notification of the nurse and/or physician. The surveyor reviewed the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (with last revision date of 10/2023) received from Staff Member #1 in the evening of 03/25/24. Under “ABNORMAL FINDINGS” section of page five (5), the policy stated, in part, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time”. Under “Fluid Status” header, the same policy read, “Post-treatment: If patient is above or below 1 kg from the target weight”.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 40084 Based on document review and interview, it was determined the facility staff failed to report intradialytic blood pressure differences of 20 mm Hg or greater for five (5) of eight (8) patients and heart rate of less than sixty (60) beats per minute (BPM) for one (1) of eight (8) patients to the licensed nurse. The findings include: The surveyor initiated medical record review of Patient # (1-8) on 03/25/24 at 2:00 pm and again on 03/26/24 at 10:06 am. The surveyor identified the following from the treatment flowsheet documentation during record review: Patient #1 03/15/24: Dialysis treatment was initiated at 9:47 am and was terminated at 2:01 pm. Blood pressure documented: “123/65” at 11:32 am, “140/75” at 12:02 pm, “106/54” at 12:32 pm. 03/20/24: 03/15/24: Dialysis treatment was initiated at 9:50 am and was terminated at 1:47 pm. Blood pressure documented: “143/74” at 12:01 pm, “119/63” at 12:31 pm. Patient #2 03/12/24: Dialysis treatment was initiated at 5:53 am and was terminated at 9:29 am. Blood pressure documented: “137/55” at 6:34 am, “160/52” at 7:04 am, and “176/81” at 8:34 am, “136/69” at 9:05 am. 03/19/24: Dialysis treatment was initiated at 6:25 am and was terminated at 9:34 am. Blood pressure documented: “141/69” at 6:34 am, “172/65” at 7:07 am. 03/21/24: Dialysis treatment was initiated at 6:02 am and was terminated at 9:35 am. Blood pressure documented: “171/32” at 6:05 am, “144/67” at 6:35 am, “179/27” at 7:35 am, “157/75” at 8:05 am, and “121/70” at 8:35 am, “145/68” at 9:05 am. Patient #4 03/23/24: Dialysis treatment was initiated at 10:02 am and was terminated at 1:02 pm. Blood pressure documented: “92/39” at 11:08 am, “114/56” at 11:10 am. Patient #6 03/11/24: Dialysis treatment was initiated at 6:44 am and was terminated at 10:02 am. Blood pressure documented: “155/67” at 9:02 am, “185/86” at 9:32 am. 03/13/24: Dialysis treatment was initiated at 7:05 am and was terminated at 9:03 am. Blood pressure documented: “163/73” at 8:35 am, “191/87” at 9:03 am. 03/15/24: Dialysis treatment was initiated at 6:00 am and was terminated at 9:33 am. Blood pressure documented: “125/60” at 6:00 am, “156/74” at 6:32 am. Patient #8 03/12/24: Dialysis treatment was initiated at 6:21 am and was terminated at 9:21 am. Blood pressure documented: “171/85” at 7:04 am, “145/70” at 7:34 am, “139/69” at 8:04 am, “114/58” at 8:34 am. 03/15/24: Dialysis treatment was initiated at 2:11 pm and was terminated at 5:11 pm. Blood pressure documented: “120/61” at 2:11 pm, “153/76” at 2:32 pm. 03/19/24: Dialysis treatment was initiated at 6:20 am and was terminated at 9:20 am. Blood pressure documented: “147/73” at 7:04 am, “121/60” at 7:34 am. Patient #1 03/11/24: Dialysis treatment was initiated at 9:44 am and was terminated at 1:45 pm. Heart rate/pulse documented: “55” at 9:44 am, “54” at 10:05 am, “57” at 10:35 am, “59” at 11:05 am. 03/15/24: Dialysis treatment was initiated at 9:47 am and was terminated at 2:00 pm. Heart rate/pulse documented: “56” at 9:47 am, “53” at 10:02 am, “54” at 10:32 am and at 11:02 am, “55” at 11:32 am. 03/18/24: Dialysis treatment was initiated at 9:19 am and was terminated at 1:21 pm. Heart rate/pulse documented: “58” at 9:31 am, “59” at 10:01 am. 03/20/24: Dialysis treatment was initiated at 9:50 am and was terminated at 1:47 pm. Heart rate/pulse documented: “56” at 10:01 am and 10:31 am. 03/22/24: Dialysis treatment was initiated at 9:27 am and was terminated at 1:29 pm. Heart rate/pulse documented: “59” at 9:27 am and 9:31 am, “56” at 10:01 am, “59” at 11:01 am. On 03/25/2024 at 4:15 pm, Staff Member #13 advised during interview that they expect to be notified by the dialysis technician promptly. Staff Member #13 added that both the dialysis technician and licensed nurse should make a notation on the flow sheet, acknowledging the variation, and which interventions, if applicable, were taken. The surveyor reviewed the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (with last revision date of 10/2023) received from Staff Member #1 in the evening of 03/25/24. Under “ABNORMAL FINDINGS” section, the policy stated, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time”. The same policy continued to read, in part, “Blood Pressure-Intradialytic: Difference of 20 mm Hg increase or decrease from patient’s last intradialytic treatment BP [blood pressure] reading ...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat” [sic]. At the time of exit conference on 03/26/24 at 11:10 am, the surveyor had not received any evidence regarding nurse or physician notification of the abnormal pulse and blood pressure variations.”

“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: 42042 Based on document review and interview, it was determined the facility staff failed to adhere to the policies and procedures of the facility for verification of dialysis prescriptions by a licensed nurse within one (1) hour of treatment initiation for seven (7) of eight (8) patients reviewed. The findings include: The surveyor initiated medical record review of Patient # (1-8) on 03/25/24 at 2:00 pm and again on 03/26/24 at 10:06 am. The surveyor identified the following from the treatment flowsheet documentation during record review: Patient #1 03/13/24: Dialysis treatment was initiated at 9:38 am with documentation of the treatment prescription being verified by the nurse on 11:00 am. 03/22/24: Dialysis treatment was initiated at 9:27 am with documentation of the treatment prescription being verified by the nurse on 1:10 pm. Patient #2 03/12/24: Dialysis treatment was initiated at 5:53 am with documentation of the treatment prescription being verified by the nurse on 7:11 am. Patient #3 03/12/24: Dialysis treatment was initiated at 11:22 am with documentation of the treatment prescription being verified by the nurse on 1:05 pm. 03/16/24: Dialysis treatment was initiated at 8:10 am with documentation of the treatment prescription being verified by the nurse on 9:12 am. Patient #4 03/14/24: Dialysis treatment was initiated at 10:42 am with documentation of the treatment prescription being verified by the nurse on 12:13 pm. Patient #5 03/16/24: Dialysis treatment was initiated at 10:42 am with documentation of the treatment prescription being verified by the nurse on 1:27 pm. 03/19/24: Dialysis treatment was initiated at 10:47 am with documentation of the treatment prescription being verified by the nurse on 12:36 pm. 03/23/24: Dialysis treatment was initiated at 10:15 am with documentation of the treatment prescription being verified by the nurse on 11:57 am. Patient #6 03/13/24: Dialysis treatment was initiated at 7:05 am with documentation of the treatment prescription being verified by the nurse on 8:43 am. Patient #7 03/15/24: Dialysis treatment was initiated at 10:43 am with documentation of the treatment prescription being verified by the nurse on 1:12 pm. The surveyor reviewed the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (with last revision date of 10/2023) received from Staff Member #1 in the evening of 03/25/24. On page two (2), the policy stated, in part, the following, “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation 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” [sic].”