Davita Midlothian

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 49355 Based on observation, facility staff (EMP) interview, and document review, it was determined the facility failed to secure patients protected health information (PHI) and medications in the evacuation kit with a breakaway lock, as per the facility’s policy. The findings: A review of the facility’s policy titled “Facility Emergency Management Plan (ICHD, Home)” policy 4-07-01, revision October 2024, reads in part: ... “Emergency Evacuation Kit ... 8. Evacuation kit will be sealed with a breakaway lock....” The evacuation kit had a broken breakaway lock and printed PHI stacked on top of the kit when inspected on August 18, 20251:11 A.M. During an interview on August 19, 2025, EMP1 was aware the kit should be locked and PHI should be within the locked kit.”

“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, facility staff (EMP) interview and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. The findings: 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, Physicians and Non-Physician (NPP) 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 cart 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. ... Disinfection ... 15. The chair side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas.” On August 18, 2025, at 10:05 AM., EMP11 was removing the fistula needles from patient (MR)5 at station #1. After removing the first contaminated needle, EMP11 touched the tv screen and then proceeded to removing the second fistula needle from MR5. EMP11 did not change gloves and did not perform HH. On August 18, 2025, at 1:58 P.M., EMP11 uncapped a syringe at station #12 using gloved hands. EMP11 reached over, silenced the dialysis machine alarm and then attached the syringe to MR9’s central venous catheter (CVC) hub, without changing gloves and performing HH. On August 18, 2025, at 2:19 P.M., EMP10 touched the the bloodlines of the patient receiving treatment at station #1 without wearing gloves. EMP10 retrieved a clean clamp from a drawer, never using HH prior and then returned to the patient’s station. EMP10 donned gloves, not performing HH first, and used the retrieved clamp to hold the blood lines to the patient’s t-shirt. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated that gloves should have been worn when touching the patient and HH should have be performed prior to donning gloves.”

“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 observations, facility staff (EMP) interview and document review, it was determined the facility failed to clean and disinfect non-disposable equipment and failed to keep clean and dirty areas separate, per policy. The findings: The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revision date April 2023, reads, in part: ... “Disinfection ... 12. ... b. ... iv. Items disinfected via submersion will be fully submerged. ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. ... b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution. For disinfection of vascular access clamps, please refer to policy: ‘Utilizing Vascular Access Clamps.’ ... Facility Hygiene 16. Clean areas should be clearly designated for...unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” The facility’s policy entitled, “Utilizing Vascular Access Clamps,” policy 1-04-08, revision date April 2019, reads, in part: ... “Policy: ... 7. Non-occluding spring loaded vascular access clamps are reusable and disinfected between each use with a 1:100 (one to one hundred) bleach solution. A 1:10 (one to ten) bleach solution is used to clean vascular access clamps visibly contaminated with blood or body fluids. Bleach solution used for disinfection of vascular access clamps should be placed in a designated dirty area. 8. Vascular access clamps are disinfected for a minimum of two (2) minutes.” On August 18, 2025, at 10:35 A.M., a dirty clamp was observed in a sink marked “clean.” Later that same day at 2:10 P.M., the clamp was still there. At 1:34 P.M. on August 19, 2025, the dirty clamp was still in the clean sink. On August 18, 2025, at 2:12 P.M., this surveyor observed a container with a 1:10 bleach solution and contaminated clamps. Many of the clamps were not fully submerged in the disinfectant. At 2:18 P.M., EMP11 added more dirty clamps to the container and “stirred” the contents around with a hand. Clamps were still not fully submerged. At 2:28 P.M., EMP11 added additional dirty clamps to the container. Many clamps were not submerged. On August 19, 2025, at 1:54 P.M., EMP15 submerged a dirty clamp into the bleach container but did not replace the container lid, thereby allowing degradation of the bleach solution by light. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated the “clean” and “dirty” areas were clearly marked and dirty items should not be placed in the clean areas. EMP6 also indicated that soaking clamps should be fully submerged in bleach solution in order to disinfect them and the lid should always be placed over the disinfecting solution.”

“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, facility staff (EMP) interview and document review, it was determined the facility failed to ensure that dialysis chairs were appropriately disinfected between patients in three (3) out of three (3) observations made. 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....” On August 18, 2025, at 10:18 A.M., EMP10 failed to disinfect the outside of the dialysis chair, underneath each side tray. On August 18, 2025, at 10:25 A.M., EMP13 failed to disinfect the outside of the dialysis chair, underneath each side tray. On August 19, 2025, at 2:05 P.M., EMP14 failed to disinfect the outside of the dialysis chair, underneath each side tray. During an interview on August 19, 2025, EMP2 indicated that all surfaces of the dialysis chair should be disinfected, to include underneath the side trays.”

“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, facility staff (EMP) interview and document review, it was determined the facility failed to ensure medications are prepared using aseptic technique and ensure the security of prefilled medication syringes. The findings: The facility’s policy entitled, “Medication Policy,” policy 12-08-01, last revision date November 2023, reads, in part: ... “Policy: ... 20. An aseptic environment and aseptic technique is used when preparing medications.” On August 18, 2025, at 2: 15 P.M., EMP11 failed to wipe the septum of a multidose vial of heparin with an alcohol pad prior to inserting a needle. On August 19, 2025, at 2:05 P.M., a labeled prefilled syringe of heparin was lying on the chair side table of an unoccupied chair. Patient (MR)6 never arrived for a treatment. On August 19, 2025, EMP2 indicated that the septum of a medication vial should be cleaned with an alcohol pad prior to entering the vial with a needle. EMP2 also agreed that medications should not be left unattended at the treatment stations.”

“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, facility staff (EMP) interview and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC) in four (4) out of seven (7) observations. Specifically, facility staff failed: 1 - to clean the CVC catheter hubs during preparation for dialysis; 2 - and/or place a clean field under the CVC during discontinuation of dialysis. The findings: A review of facility’s policy entitled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” procedure 1-04-02B, revision date April 2025, reads, in part: ... “Notes: ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. ... Procedure ... 16. Very both catheter clamps are closed. Using aseptic technique, remove each cap. One at a time disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue.... ... Upon completion of Dialysis ... 28. Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination.” On August 18, 2025, at 11:05 A.M., while initiating dialysis on patient (MR)3 at station #5, EMP10 did not disinfect the CVC hubs with an appropriate antiseptic. On August 18, 2025, at 1:58 P.M., EMP11 did not place a clean barrier under the CVC prior to discontinuing dialysis, but left the dirty field in place that had been there throughout the entire treatment. On August 18, 2025, at 3:26 P.M., EMP13 did not place a clean barrier under the CVC prior to discontinuing dialysis, but left the dirty field in place that had been there throughout the entire treatment.. On August 19, 2025, at 1:59 P.M., EMP14 did not place a clean barrier under the CVC prior to discontinuing dialysis, but left the dirty field in place that had been there throughout the entire treatment.. During an interview on August 19, 2025, at approximately 3:30 P.M., EMP2 indicated that the CVC hubs should be scrubbed for fifteen (15) seconds, per facility policy.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49355 Based on observations, facility staff (EMP) interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in two (2) out of four (4) observations when deaccessing a patient (MR) with a fistula or graft. The findings: A review of the facility’s policy entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure 1-04-01B, revision April 2023, reads, in part: ... “Procedure ... 8. With safety device engaged, dispose of safety fistula needle in the sharps container.” On August 18, 2025, at 10:05 A.M., employee (EMP)11 deaccessed MR5’s fistula at station #1 and placed the contaminated needle on the chair side table. Once tape and gauze were applied to the site, EMP11 took the contaminated needle to the sharps container beside the adjacent chair. EMP11 then removed the second needle from MR5 and placed it on the chair side table. Once finished dressing the site, EMP11 took the contaminated needle to the sharps container beside the adjacent chair. On August 18, 2025, at 2:27 P.M., employee (EMP)10 deaccessed MR1’s fistula at station #2 and placed the contaminated needle on the chair side table. Once tape and gauze were applied to the site, EMP10 took the contaminated needle to the sharps container beside the adjacent chair. EMP10 then removed the second needle from MR1 and placed it on the chair side table. Once finished dressing the site, EMP10 took the contaminated needle to the sharps container beside the adjacent chair. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated fistula/graft needles should be immediately placed in a sharps container after pulling.”

“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, facility staff (EMP) interviews and document review, it was determined the facility failed to document abnormal findings and notification to the charge nurse of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in four (4) out of seven (7) medical records reviewed; 2) and/or documentation of completed pre-treatment nursing assessments by the policy-specified time in six (6) out of seven (7) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “Pre-Treatment Data Collection/Assessment ... 5. The assessment is a nursing responsibility. ... 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.... ... 11. Abnormal finding or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... Abnormal Findings Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight.” A review of the following medical records revealed: Patient (MR)1: Flowsheet dated August 6, 2025: treatment start time was 10:36 A.M., documented nursing pre-assessment note completion was 11:38 A.M. Flowsheet dated August 8, 2025: treatment start time was 10:44 A.M., documented nursing pre-assessment note completion was 12:53 P.M. Flowsheet dated August 13, 2025: treatment start time was 10:40 A.M., documented nursing pre-assessment note completion was 12:37 P.M. Flowsheet dated August 15, 2025: treatment start time was 10:28 A.M., documented nursing pre-assessment note completion was 11:36 A.M. MR2: Flowsheet dated August 1, 2025: treatment start time was 10:55 A.M., documented nursing pre-assessment note completion was 12:53 P.M. Flowsheet dated August 4, 2025: treatment start time was 11:11 A.M., documented nursing pre-assessment note completion was 1:50 P.M. MR3: Flowsheet dated August 5, 2025: treatment start time was 9:41 A.M., documented nursing pre-assessment note completion was 2:58 P.M. Flowsheet dated August 9, 2025: PTW was documented as 91.9 kg, TW was 86 kg, a deviation of 5.9 kg. No documentation was noted on the flowsheet. treatment start time was 10:49 A.M., documented nursing pre-assessment note completion was 11:54 A.M. Flowsheet dated August 12, 2025: PTW was documented as 90 kg, TW was 86 kg, a deviation of 4 kg. No documentation was noted on the flowsheet. Flowsheet dated August 18, 2025: treatment start time was 11:10 A.M., documented nursing pre-assessment note completion was 2:28 P.M. MR4: Flowsheet dated July 30, 2025: PTW was documented as 107.4 kg, TW was 103.5 kg, a deviation of 3.9 kg. No documentation was noted on the flowsheet. treatment start time was 10:46 A.M., documented nursing pre-assessment note completion was 1:29 P.M. Flowsheet dated August 1, 2025: PTW was documented as 106.4 kg, TW was 103.5 kg, a deviation of 2.9 kg. No documentation was noted on the flowsheet. treatment start time was 10:45 A.M., documented nursing pre-assessment note completion was 12:39 P.M. Flowsheet dated August 4, 2025: PTW was documented as 105.2 kg, TW was 103.5 kg, a deviation of 1.7 kg. No documentation was noted on the flowsheet. treatment start time was 11:00 A.M., documented nursing pre-assessment note completion was 12:23 P.M. Flowsheet dated August 8, 2025: treatment start time was 10:28 A.M., documented nursing pre-assessment note completion was 12:49 P.M. MR5: Flowsheet dated August 8, 2025: treatment start time was 5:56 A.M., documented nursing pre-assessment note completion was 7:09 A.M. Flowsheet dated August 13, 2025: PTW was documented as 140.3 kg, TW was 138 kg, a deviation of 2.3 kg. No documentation was noted on the flowsheet. Flowsheet dated August 15, 2025: PTW was documented as 139.4 kg, TW was 138 kg, a deviation of 1.4 kg. No documentation was noted on the flowsheet. treatment start time was 6:05 A.M., documented nursing pre-assessment note completion was 7:19 A.M. MR6: Flowsheet dated July 31, 2025: treatment start time was 11:16 A.M., documented nursing pre-assessment note completion was 1:52 P.M. Flowsheet dated August 2, 2025: PTW was documented as 66.2 kg, TW was 68.5 kg, a deviation of -2.3 kg. No documentation was noted on the flowsheet. treatment start time was 11:21 A.M., documented nursing pre-assessment note completion was 12:42 P.M. Flowsheet dated August 5, 2025: PTW was documented as 67 kg, TW was 68.5 kg, a deviation of -1.5 kg. No documentation was noted on the flowsheet. treatment start time was 11:06 A.M., documented nursing pre-assessment note completion was 1:47 P.M. Flowsheet dated August 7, 2025: PTW was documented as 66.8 kg, TW was 68.5 kg, a deviation of -1.7 kg. No documentation was noted on the flowsheet. Flowsheet dated August 9, 2025: PTW was documented as 67.2 kg, TW was 68.5 kg, a deviation of -1.3 kg. No documentation was noted on the flowsheet. treatment start time was 10:26 A.M., documented nursing pre-assessment note completion was 12:25 P.M. Flowsheet dated August 14, 2025: PTW was documented as 65.8 kg, TW was 68.5 kg, a deviation of -2.7 kg. No documentation was noted on the flowsheet. treatment start time was 10:28 A.M., documented nursing pre-assessment note completion was 2:00 P.M. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated any deviation 1 kg above or below the target weight should be noted on the flowsheet. EMP6 also noted a nursing pre-treatment assessment note should be completed within one (1) hour of initiation of treatment. During an interview on August 19, 2025, at 11:54 A.M., EMP8 indicated the expectation that any deviation plus or minus one (1) kg from the target weight be noted and tracked, to determine if an adjustment is necessary.”

“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 reviews, facility staff (EMP) interviews and document review, it was determined the facility failed to follow physician’s orders and failed to document the reason for the deviation for prescribed blood flow rate (BFR) for three (3) out of seven (7) records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour.... Prescription components include but are not necessarily limited to: ... f. Blood flow rate ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... 17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility.” A review of the following medical records revealed: Patient (MR) 1: Flowsheet dated August 6, 2025: prescribed BFR 450 ml/min, actual BFR ranged from 349 ml/min to 400 ml/min during the 210 minute treatment. No documentation noted in the flowsheet. MR2: Flowsheet dated August 1, 2025: prescribed BFR 400 ml/min, actual BFR ranged from 299 ml/min to 300 ml/min during the 180 minute treatment. No documentation noted in the flowsheet. MR4: Flowsheet dated August 4, 2025: prescribed BFR 450 ml/min, actual BFR ranged from 399 ml/min to 400 ml/min during the 240 minute treatment. No documentation noted in the flowsheet. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated any deviation from the prescribed BFR should be noted on the flowsheet and the charge nurse notified. During an interview on August 19, 2025, at 11:54 A.M., EMP8 indicated the expectation that any deviation from the prescribed BFR should be documented on the flowsheet and the nurse notified as to why.”

“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, facility staff (EMP) interview 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 two (2) out of two (2) observations, EMPs touched the cannulation sites of arteriovenous (AV) fistulas/grafts after the insertion sites were prepped with antiseptic. The findings: The facility’s procedure entitled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” procedure 1-04-01E, 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 possibly allow for the introduction of bacteria during cannulation.” On August 18, 2025, at 10:03 A.M., EMP10 palpated patient (MR)10’s AV fistula site at station #7 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On August 18, 2025, at 10:40 A.M., EMP11 palpated MR1’s AV fistula site at station #2 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. During an interview on August 18, 2025, at 1:43 P.M., EMP6 indicated the site should be recleansed after palpating and before cannulating and not touched again.”