Davita Peninsula Dialysis Center

“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: 46466 Based on interview, observation and facility document review, the facility staff failed to provide equipment that was maintained to prevent cross contamination. The findings include: On December 3, 2024 at 10:30 AM, patient in treatment chair at station #15 was observed. The chair’s leather on the seat was worn down and exposed the fabric beneath. At 11:15 AM, the surveyor observed patient chair at station #1. The leather on the seat was worn down with the fabric beneath exposed. Both chairs had been used by patients receiving dialysis treatment during the observations. On December 3, 2024 at 1:30 PM, Staff Member #1 explained that the facility staff was aware of the worn areas to the patient seat chairs and an order was placed to replace the chairs. A review of the facility’s policy “Physical Environment”, revised April, 2018, indicated in part “...5. The space for treating each patient will ...prevent cross contamination...”. The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”

“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: 46466 Based on observation and document review, it was determined that the facility’s staff failed to properly clean and disinfect contaminated surfaces of the medical devices and equipment. The findings included: On 12/3/24 at 10:45 AM, Staff Member #12 was observed disinfecting patient dialysis station #16. The staff member did not remove, empty or disinfect the prime waste bucket. On 12/3/24 at 11:10 AM, Staff Member #9 was observed disinfecting patient dialysis station #1. The staff member did not remove, empty or disinfect the prime waste bucket and did not disinfect the left side of the dialysis machine closest to the computer. A review of the facility’s policy “Infection Control For Dialysis Facilities”, Policy: 1-05-01, revised April 2023, stated in part: “...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...and frequently contacted by healthcare personnel (e.g., control panel, front and sides of dialysis machine...ii. Priming containers are to be emptied prior to disinfection...”. The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”

“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: 45736 Based on observations and facility document review, the facility failed to maintain a safe environment for dialysis patients by not discarding one expired medications and not labeling three syringes according to facility policy. The findings include: During the flash tour on December 3, 2024, at approximately 9:45 AM, one (1) vial of Turbesol (Purified protein derivative- used for tuberculosis (TB) skin testing) was opened on October 3, 2024 and was available for use in the medication/vaccine refrigerator on December 3, 2024. The discard date for the vial of Turbesol should have been October 31, 2024 (28 days after opening). The surveyor requested documentation of any patients who received TB testing with the expired Turbesol. Patient #5 received TB testing on November 26, 2024. A facility policy, Medication Policy- Policy 1-06-01, revision date November 2023, revealed, in part, “...29. Medications containing a preservative must be discarded 28 days after opening... 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...” 46466 On December 3, 2024 at 9:25 AM, one (1) pre-drawn syringe heparin medication was observed on a counter on the treatment floor. The syringe was labeled appropriately with Patient #6’s name, but the time written on the label documented “10”. According to the patient schedule, the Patient #6 was scheduled to arrive at 10:30 AM. On December 3, 2024 at 10:25 AM, Patient #6’s labeled syringe was still unused laying on the counter. Staff Member #8 was asked about Patient #6’s syringe with the written time of 10:00 on the syringe. Staff Member #8 stated that they did not know why it was labeled with that time, but the time must be the time of expiration since it was timed prior to the patient’s arrival. Staff Member #8 stated that they would dispose and redraw the medication prior to administering it to the patient. Patient #6 arrived to the facility on December 3, 2024 at 10:45 AM,. Staff Member #8 was observed removing and disposing of syringe labeled with Patient #6’s name and timed at 10:00 AM. On December 3, 2024 at 9:27 AM, one (1) pre-drawn syringe with an unknown medication was observed on a counter near the medication area. The syringe label was wrapped around it. The label was blank and did not include a patient name, name of medication, date, time prepared, dose and/or initials of the teammate who prepared the medication. On December 3, 2024 at 9:45 AM, a pre-drawn syringe filled with heparin medication was found on the tray table of patient station #2. The syringe was labeled, but missing the time the medication was drawn, the needle and the stopper to the syringe. A review of the facility’s policy “Medication Policy”, revised October 2023, indicated in part “...20...If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication...”. The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”

“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: 45736 Based on observation and document review, the facility failed to ensure adequate open hub disinfection during one (1) of two (2) CVC (central venous catheter) dialysis treatment initiation. The findings include: During observations on treatment floor on December 3, 2024, at approximately 10:45 AM, the surveyor observed Staff Member #12 perform CVC treatment initiation on Patient #1 at Station #2. Staff Member #12 disinfected one open hub for four (4) seconds and the other open hub for six (6) seconds. A facility procedure, Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure- Procedure: 1-04-02B, last revision October 2024, revealed, in part, “...10. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds...” The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”

“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: 46466 Based on clinical record review, and facility document review, the facility staff failed to document standing blood pressure readings on ambulatory patients for one (1) of five (5) patient records sampled. The findings include: On December 3, 2024, a review of treatment records for the sampled patients revealed the following: Patient #6: Six (6) treatment records were reviewed from 11/14/24 through 11/28/24. On 11/14/24, 11/16/24, 11/19/24, 11/23/24, 11/26/24 and 11/28/24, there were no standing blood pressures documented for Patient #6 or explanation why the measurements were not obtained. Patient #6’s record documented that Patient #6 “Ambulates - No Assistance Needed”. A review of the facility’s policy “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, last revised October 2023, indicated in part: “...1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to...ii. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...”. The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”

“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: 46466 Based on interview, medical record and facility document review, facility staffed failed to document as per facility policy when patients requested to shorten their treatment times in one (1) of five (5) patient records sampled. The findings include: On December 3, 2024, five (5) sampled patient records were reviewed. Patient #6’s medical record documented that Patient #6 shortened their treatment times on 11/19/24, 11/23/24 and 11/26/24. A request was made to Staff Member #4 to provide Patient #6’s “Early Termination of Treatment Against Medical Advice” (AMA) forms that were signed by the patient for the above listed dates. Staff Member #4 stated that they were unable to locate any AMA forms that were signed by Patient #6 on those dates. A review of the facility’s policy “Prescribed Treatment Time Not Met”, revised April, 2024, indicated in part: “1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time...”. The findings were discussed with Staff Members #1, #4, #5, #11 and #13 at the exit conference on 12/3/24 at 3:45 PM.”