Davita Hioaks 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 two (2) infection control observations and facility policy review, it was determined that the facility failed to follow required infection control and prevention practices related to hand hygiene and glove changes. The findings included: On 07/15/2024 at 10:08 a.m., Staff Member #15 was treating the patient at station #6. The machine alarm sounded at station #7. Staff Member #15 walked to the machine at station #7 and, using a gloved hand, silenced the alarm. The Staff Member then returned to the patient at station #6 and proceeded to continue treating them. Staff Member #15 never changed gloves during the entire course of events. On 07/16/2024 at 10:03 a.m., Staff Member #20 was cleaning the treatment area at station #19. The patient’s machine alarmed at station #18. The Staff Member removed the right hand glove and walked over to the patient’s machine at station #18. Staff Member #20 stuck their right hand up under their gown and silenced the alarm. The Staff Member then returned to station #19, donned a new glove on their right hand and continued disinfecting the station. The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy # 1-05-01, with a revision date of April 2023, reads, in part: ... “1. ... Hand Hygiene ... f. between patients even if the contact is casual ... 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: ... iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” The above concerns were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49355 Based on two (2) infection control observations and document review, it was determined the facility failed to clean and disinfect a thermometer after use and before being taken to a common clean area or used on another patient. The findings include: On 07/15/2024 at 10:06 a.m., Staff Member #17 took a thermometer from station #14 to use on the patient at station #12. Once finished, the Staff Member returned the thermometer to station #14. The Staff Member did not disinfect the instrument before or after using it. On 07/16/2024 at 9:45 a.m., Staff Member #20 took a thermometer from station #14 to use on the patient at station #12. Once finished, the Staff Member returned the thermometer to station #14, never disinfecting it before or after use. The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy # 1-05-01, with a revision date April 2023, reads, in part: ... “Supplies ... 11. Measures will be taken to prevent cross contamination between patients. ... b. Electronic thermometers...should not be placed on potentially contaminated equipment such as the dialysis delivery system. ... Disinfection ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station....” The above observations were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“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 and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients in four (4) out of four (4) observations. The findings include: On 07/15/2024 at 2:41 p.m., Staff Member #18 failed to disinfect the outside of the dialysis chair, underneath the side trays. At 2:50 p.m., Staff Member #17 did not disinfect the inside of the prime waste container at station #3 after emptying the contents. The Staff Member also failed to disinfect the outside of the dialysis chair, underneath the side trays. On 07/16/2024 at 10:01 a.m., Staff Member #19 did not disinfect the inside of the prime waste container at station #3 after emptying the contents. The Staff Member also failed to disinfect the outside of the dialysis chair, underneath the side trays. At 10:33 a.m., Staff Member #20 failed to disinfect the outside of the dialysis chair, underneath the side trays. A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy #1-05-01, with a revision date of April 2023 reveals: ... “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: ... ii. Priming containers are to be emptied prior to disinfection.” The above concerns were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“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 observations, interviews and document review, it was determined the facility failed to include the necessary label components on opened multidose vials of medication and failed to remove expired medications from the active stock on the treatment floor. The findings include: This facility consists of two separate buildings. One houses the in-center hemodialysis program, the other building houses the home treatment programs, hemodialysis and peritoneal dialysis. On 07/15/2024 at 11:27 a.m., a surveyor touring the home program building, inspected refrigerators #1 and #2. In refrigerator #1, an opened multidose vial (MDV) of Epogen 20,000 units/ml was discovered. The label of the vial did not contain any information as to the date when the vial was opened, the time or by whom. A MDV of Tuberculin 1 mg was also discovered, again without the proper documentation on the vial’s label. In refrigerator #2, the surveyor found #26 prefilled syringes of influenza vaccine that had expired on 06/23/2024. On 07/15/2024 at 10:03 a.m. while touring the in-center hemodialysis building, this surveyor discovered #26 vials of Vancomycin 500 mg were expired as of 07/01/24. The medication vials were removed from the active stock and given to Staff Member #10. At a meeting on the afternoon of 07/15/2024 with Staff Members #1 and #4, the findings were discussed and there was agreement that the information noted above should have been added to the MDVs once the vials were opened and entered. In reviewing the facility’s policy entitled, “Medication Policy,” policy #1-06-01, with a revision date of October 2023, it was revealed that: ... “Policy: ... 29. Medications containing a preservative must be discarded 28 days after opening or accessed (e.g. needle punctured), unless the manufacturer specifies a different ... date or as directed by the manufacturer.... Each vial is labeled with the initials of the person opening the vial and the expiration date. ... 30. All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. All medications are checked monthly for expiration dates. ... 31. Medications are ordered and replaced prior to expiration. ... 32. Disposal of expired medications...are removed from the treatment and inventory areas....” The above concerns were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 49355 Based on observation and document review, it was determined that the facility failed to remove expired pH test strips that were available for staff use. The findings include: On 07/16/2024 at 10:02 a.m., this surveyor discovered a container of pH test strips on the counter of the nursing station with an expiration date of 03/31/24. The contents of this container were being used to check the pH of the dialysate before beginning a patient’s treatment. The numeric value obtained from correctly using these strips is entered into the dialysis machine and that value must fall within specific parameters. The container of strips was removed from the counter and given to Staff Member #13. A review of the facility’s policy entitled, “Testing pH and Conductivity of Proportioned Dialysate and Verification of Temperature of Proportioned Dialysate,” policy #1-03-02, with a revision date of April 2020, revealed the following: ... “Policy: ... 1. Trained teammates will test pH ... utilizing appropriate test strips.... ... 3. Document results in the electronic treatment record or dialysis delivery system log, as applicable. ... 6. Independent pH is required to be performed prior to each treatment. ... 7. The acceptable range for final dialysate pH is 6.9-7.6. Check independent pH with approved test method for final dialysate.” The above concern was discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“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: 49355 Based on medical record reviews, interview and document review, it was determined the facility failed to document deviations of +/- 1 kg in target weight (TW) versus post treatment weight (PTW) in three (3) out of nine (9) in-center hemodialysis patient records reviewed. The findings include: The six (6) most recent flow sheets for nine (9) in-center hemodialysis patients were reviewed on 07/15/2024 by this surveyor. Patient #1: Treatment date 07/05/2024: TW was 77.5 kg, PTW was 80.9 kg, a discrepancy of 3.4 kg. There was no documentation on the flowsheet that this disparity was noted. Patient #3: Treatment date 07/01/2024: TW was 96.0 kg, PTW was 94.8 kg, a 1.2 kg discrepancy. Treatment date 07/10/2024: TW 95.0 kg, PTW 93.5 kg, a 1.5 kg discrepancy. There was no documentation on the flowsheets for either treatment date indicating that the disparity was noted. Patient #9: Treatment date 07/04/2024: TW was 98.0 kg, pre-treatment weight was 98.2 kg, PTW was 100.0 kg. Treatment date 07/06/2024: TW 98.0 kg, pre-treatment weight 98.7 kg, PTW 99.5 kg. Treatment date 07/11/2024: TW 98.0 kg, pre-treatment weight 98.2 kg, PTW 99.5 kg. There was no documentation on any of the above flowsheets indicating that the disparities in pre-treatment versus PTW was noted. During a interview with Staff Member #10 at 9:15 a.m. on 07/16/2024, the lack of documentation addressing disparities in TW, PTW and, in the case of Patient #9. pre-treatment weight, were discussed. The Staff Member stated that Patient #9 wears a medical device that weighs 2.0 kg. Since the patient wears the device while the pre-treatment & post-treatment weights are measured, that 2.0 kg would not affect the weight disparity. The Staff Member did agree that any weight disparities should be relayed to the charge nurse by the technician and addressed in the post treatment assessment notes by the charge nurse. In reviewing the facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy #1-03-08, with a revision date of April 2024, it was noted that: ... “Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Post-treatment: ... If the patient is above or below 1 kg from the target weight.” The above concerns were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49355 Based on medical record review, interview and policy review, it was determined the facility failed to follow the dialysis treatment orders, specifically blood flow rate (BFR), dialysate flow rate (DFR) and/or treatment time, for four (4) out of nine (9) patient records reviewed. The findings include: The six (6) most recent flowsheets for nine (9) in-center hemodialysis patients were reviewed on 07/15/2024. Patient #3: Treatment date 07/01/2024: DFR was run at 500 ml/min for the first two (2) hours of a four (4) hour treatment cycle when the prescribed rate was 800 ml/min. There was no documentation in the flowsheet as to why this decrease was made or that the charge nurse had been notified. Patient #4: Treatment date 07/08/2024: the prescribed treatment time was 4 hours while the actual treatment time was documented as 3 hours 43 minutes, a 17 minute discrepancy. There was no notation on the flowsheet as to why this occurred and no documentation under “discharge status” that the patient was AMA. The note states, “Discharge to Home (routine discharge)” 07/12/2024: DFR was run at 500 ml/min for the entirety of the 4 hour treatment instead of the prescribed rate of 800 ml/min. There was no documentation in the flowsheet as to why this decrease was made or that the charge nurse had been notified. Patient #7: Treatment date 07/01/2024: BFR was run at 350 ml/min, the prescribed rate, for the first 30 minutes and then decreased to 325 ml/min for the remainder of the 3 hour 30 minute treatment cycle. There was no documentation in the flowsheet as to why this decrease was made or that the charge nurse had been notified. 07/08/2024: DFR was prescribed at 800 ml/min. For two (2) one-hour periods during the 3 hour 30 minute treatment cycle, the DFR was recorded as “0,” with no documentation in the flowsheet as to why this decrease was made or that the charge nurse had been notified. Patient #9: Treatment date 07/06/2024: the prescribed treatment time was 4 hours while the actual treatment time was documented as 3 hours 51 minutes. There was no notation on the flowsheet as to why this occurred and no documentation under “discharge status” that the patient was AMA. The note states, “Discharge to Home (routine discharge).” 07/11/2024: BFR was run at 449 ml/min versus the prescribed rate of 400 ml/min. There was no documentation in the flowsheet as to why this increase was made or that the charge nurse had been notified. The prescribed treatment time was 4 hours while the actual treatment time was 3 hours 37 minutes. There was no notation on the flowsheet as to why this occurred and no documentation under “discharge status” that the patient was AMA. The note states, “Discharge to Home (routine discharge).” 07/13/2024: The prescribed treatment time was 4 hours while the actual treatment time was 3 hours 50 minutes. There was no notation on the flowsheet as to why this occurred and no documentation under “discharge status” that the patient was AMA. The note states, “Discharge to Home (routine discharge).” In interviews with Staff Members #10 and #19 on 07/16/2024, both Staff Members revealed any shortened treatment time, of any length, should be noted as “AMA” on the flowsheet and the charge nurse should be notified. A review of the facility’s policy entitled, “Prescribed Treatment Time Not Met,” policy #1-01-09, with a revision date of April 2024, reveals that: ... “Policy: ... 1. ...any time time the patient requests to terminate their treatment earlier than the prescribed run time. ... 6. This applies only to shortened treatments. ... B. Prescribed Treatment Time Not Met ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, if appropriate: ... The amount of time by which the treatment was shortened ... A description of why the treatment was shortened ... A description of all other interventions planned to address the shortened treatment, including recommendations to the patient. ... The Facility Administrator (FA)/Designee will verify that all shortened treatments are recorded and trended....” The above concerns were discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“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 an arteriovenous (AV) graft/fistula in one (1) out of four (4) observations. The findings include: At 10:58 a.m. on 07/15/2024, this surveyor observed Staff Member #15 disinfect the AV graft/fistula site of Patient # 2 at station #6. The Staff Member palpated the cannulation site after antisepsis and then accessed the site with the cannulation needle, without disinfecting the area again. In discussions with Staff Members #1 and #4 during the afternoon of 07/15/2024, both Staff Members agreed that the site should have been cleansed again before needle insertion. A review of the facility’s policy entitled, “AV Fistula or Graft Cannulation With Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” policy #1-04-01E, with a revision date of October 2022, reads, in part: ... “Procedure ... 13. Do not palpate insertion site once area has been prepped ... Rationale ... 13. Once the access site has been prepped, touching will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” The above observation was discussed at the exit conference on 07/16/2024 at 3:45 p.m.”

“H-PT CONSULTATION WITH IDT MEMBERS PRN CFR(s): 494.100(c)(1)(iv) Services include, but are not limited to, the following: (iv) Patient consultation with members of the interdisciplinary team, as needed. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to ensure that one (1) of seven (7) home peritoneal dialysis patients received necessary referral and consultation with the provider as needed to address the non-compliance with intradialytic blood pressure and weight monitoring. The findings include: On July 16, 2024, at 9:15 AM, the surveyor met Staff Member #2 at the home program location for medical record review. The surveyor selected a total of nine (9) home patients for record review to include seven (7) patients with peritoneal dialysis (PD). While reviewing the most recent two (2) weeks’ worth of treatment flowsheet records for Patient #17, the surveyor observed that there were no blood pressure or weights recorded. The surveyor confirmed with Staff Member #2 that the patient had orders for daily home PD, and that weight and blood pressure monitoring was indicated with treatment. The surveyor inquired with Staff Member #2 regarding the omitted data, who indicated that the patient was non-compliant with the documentation of blood pressure and weights during daily PD treatments. The surveyor questioned the staff member whether the Attending Physician was made aware of the abnormal/absent treatment findings. Both Staff Member #2 and Staff Member #6 were unable to locate any documentation from the medical record indicating that the physician was ever made aware of the lack of blood pressure and weight monitoring during home PD treatments. In the afternoon of July 16, 2024, the surveyor was provided the facility policy titled, “Daily Home Treatment Record (Flowsheet)” Policy: 5-01-29 (with last revision date of September 2023). The policy referenced that the patient should be assessed for various clinical indicators, to include blood pressure and fluid status-as determined by weight-and that appropriate notification to other members of the care team should be made when necessary. In the evening of July 16, 2024, the surveyor reviewed the facility policy titled, “Medical Records Documentation Guidance” [sic] Policy 3-02-02 (with last revision date of October 2023) which stated that documentation should be made for any time in which a physician (or NPP) is notified regarding patient treatment or status.”