Davita Haymarket Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 42725 Based on observation and document review, it was determined the facility failed to remove expired supplies from the emergency evacuation box. Findings: A review of the facility’s emergency management plan, revealed the following under a section titled, Emergency Evacuation Kit: “... 7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly...”. During the flash tour on 07/29/2024, the surveyor conducted a review of the contents in the facility’s emergency evacuation kit. The following was discovered: Eleven (11) intravenous (IV) administration sets - expired 07/04/2024 The expired supplies were removed from the kit and given to Staff Member #1 who acknowledged the expiration and said the supplies would be replaced.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 42725 Based on observation and document review, it was determined the facility failed to ensure appropriate personal protective equipment (PPE) was used on the treatment floor. Findings: The facility’s policy titled, Infection Control for Dialysis Facilities (revised April 2023), was reviewed and partly reads under the section titled “PPE”: “... 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area...”. On 07/29/2024 at 2:35 PM, the surveyor observed two (2) transportation visitors enter the treatment floor to pick up a patient after treatment. Neither visitor donned a gown prior to entering the treatment floor. The visitors remained on the treatment floor for approximately ten (10) minutes while they were preparing the patient for transport.”

“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: 42725 Based on observation and document review, it was determined the facility failed to ensure expired medications were not available for patient use. Findings: A review of the facility’s policy titled, Medication Policy (revised October 2023), was reviewed and partly reads, “... 30. ... All medications are checked monthly for expiration dates. 31. Medications are ordered and replaced prior to expiration...”. During the flash tour on 07/29/2024, the surveyor conducted a review of the contents in the facility’s medication preparation area. The following was discovered in one of the cabinets: Seven (7) unopened vials of Hectorol 4mcg/2mL that expired on 04/30/24. The expired medications were removed from the cabinet and given to Staff Member #1 for disposal.”

“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: 42725 Based on interviews and document review, it was determined that the facility failed to document the reason and notification to the registered nurse of the change in blood flow rate (BFR) and/or dialysis flow rate (DFR) for three (3) of four (4) patients sampled. Findings: The facility’s policy titled, Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (revised April 2024) was reviewed. Under the section titled, Intradialytic Data Collection/Assessment, it partly reads: “... 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 license nurse informed...”. On 07/30/2024, the surveyor conducted medical record reviews on the four (4) in-center hemodialysis patients sampled. A review of the flow sheets revealed the facility staff failed to document a reason and notify the nurse when the prescription was not being met for Patient #1 (BFR and DFR), Patient #2 (DFR), and Patient #4 (BFR). Staff Member #3 was present during the review and acknowledged that the staff should be documenting and notifying the nurse when there is a change.”