Davita Butler Farm Dialysis

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to provide a sanitary environment to minimize the transmission of infectious agent by having dirty (used) gloves and trash on the floor in the treatment area for two (2) of twenty-eight (28) stations, Stations # 14 and # 22. The findings include: On December 9, 2024 during the initial tour of the facility, the following were observed: At 1:50 PM, dirty (used) gloves were observed on the floor at Station # 22 while a patient was dialyzing. At 2:00 PM, dirty (used) gloves were observed on the floor at Station # 14 while a patient was dialyzing. On December 11, 2024, a review of the facility’s policy titled “Infection Control” reads in part “to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment”. On December 11, 2024 at approximately 12:00 PM, Staff Members (SM) # 1, # 2, # 3 and # 11 indicated that trash was expected to be placed in trash cans not on the floor.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure staff wear gloves when touching patient’s equipment for one (1) of nine (9) Staff Members (SM), SM # 10, and staff perform hand hygiene after glove removal for two (2) of nine (9) SM, SM # 6 and # 9. The findings include: On December 9 and 11, 2024 during observations while patients treatments were initiated and terminated the following was observed: December 9, 2024 at 2:05 PM, SM # 6 was observed at Station # 18 during the termination of the treatment. SM # 6 removed dirty blood tubing from the machine and placed in the rolling biohazard cart. SM # 6 pushed the tubing into the cart and then rolled the cart across the treatment floor and placed the lid on the cart. SM # 6 removed dirty gloves and failed to perform hand hygiene before leaving the treatment area. December 11, 2024 at 10:45 PM, SM # 9 was observed at Station # 7 during the termination of the treatment. SM # 9 removed dirty gloves after securing the Patient access and pulled clean gloves out of the box, contaminating the clean gloves. SM # 9 then turned around used hand sanitizer while holding contaminated gloves in hand. SM # 9 then donned the contaminated gloves. December 11, 2024 at 10:50 AM, SM # 10 was observed at Station # 28. SM # 10 wrapped a glove around one finger before touching the dialysis machine to silence the alarm. On December 11, 2024, a review of the facility’s policy titled “Infection Control” reads in part “All teammates will perform hand hygiene prior to gloving and immediately after removal of gloves. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station”. On December 11, 2024 at approximately 12:00 PM, Staff Members (SM) # 1, # 2, # 3 and # 11 indicated that staff are expected to wear gloves when touching dialysis equipment and perform hand hygiene immediately after glove removal.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to provide a safe environment by having trash, dirty (used) gloves and water on the floor in the treatment area. The findings include: On December 9 and 11, 2024 during observations while patient treatments were initiated and terminated the following was observed: December 9, 2024 at 1:45 PM, water was observed on the floor near the clean sink between Pods 1 and 2. The water on the floor presented a risk for trips and falls for Staff and Patients in the area. Staff Member (SM) # 2 was notified of the water. SM # 2 determined there was a leak at clean sink. The water was not turned off and there was no signage placed on the sink to warn Staff and Patients not to use the sink. December 9, 2024 at 1:50 PM, dirty (used) gloves and small strips of white paper were observed on the floor at Station # 22 while a patient was dialyzing presenting a risk for trips and falls. At 2:00 PM, dirty (used) gloves and small strips of white paper were observed on the floor at Station # 14 while a patient was dialyzing presenting a risk for trips and falls. On December 10, 2024 at 10:25 PM a tour of the treatment revealed the clean sink between Pods 1 and 2 still leaking. The water was not turned off and there was no signage placed on the sink to warn Staff and Patients not to use the sink. SM # 4 was notified of the leak. SM # 4 placed signage on the sink to not use and turned the water off. At 11:00 AM, an interview with SM # 3 revealed “there was no work order placed to repair the sink”. On December 11, 2024 at 10:44 AM, small strips of white paper were observed on the floor in Pods 1 and 2 and between Stations # 11 and # 12 while patients were dialyzing presenting a risk for trips and falls. On December 11, 2024, a review of the facility’s policy titled “Patient fall prevention” reads in part “teammates will address basic safety issues for patients... Environmental clutter: Keep spills wiped up and keep floors free of debris”. On December 11, 2024, Staff Members (SM) # 1, # 2, # 3 and # 11 indicated there were safety concerns.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to display patient’s rights including the current State Agency mailing address and telephone complaint numbers. The findings include: On December 9, 2024 at 1:00 PM, upon entrance to the facility, it was determined the Patient Rights signage did not include information for the State Agency. A review of the facility’s Patient’s Right policy revealed a part of the policy that included State Agency information had been omitted from the signage. On December 10, 2024, SM # 2 indicated the signage would be corrected.”

“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: 41450 Based on medical record review, staff interview and facility documentation review, the medical director failed to ensure that facility staff implemented the facility’s nutrition services policy for one (1) patient, Patient #5, out of six (6) dialysis patients reviewed for nutrition services. The findings include: For Patient (P) #5, the facility staff failed to provide documented nutritional interventions every 90 days as indicated in the facility’s policy for the provision of nutrition services. On 12/11/24 at approximately 11:00 AM, medical record reviews were conducted and revealed P #5 had no nutritional services documentation between 4/1/24 and 11/20/24. On 12/11/24 at approximately 12:30 PM, an interview was conducted with Staff Member (SM) #11 who confirmed the findings and stated, “It is my expectation that all patients receiving dialysis will have documentation of any nutritional services, including regular assessments and support or interventions at a minimum of every 90 days or sooner if needed”. Review of the facility’s policy titled, “Provision of Nutritional Services”, revision date October 2024, page 1, item 3 read, “The services provided are below and based upon the qualifications of the Registered Dietician...Documentation of nutrition interventions at least every 90 days or as necessary to update patient’s nutrition status and needs...”. On 12/11/24 at approximately 1:30 PM, SM #1 was updated on the findings. No further information was provided.”