Davita Leesburg Virginia 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: 42725 Based on four (4) infection control observations and document review, it was determined the facility staff failed to follow required infection control and prevention practices related to hand hygiene. Findings: The facility’s policy titled, Infection Control for Dialysis Facilities, under the heading “Hand Hygiene” reads, in part: “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...”. Under the heading “PPE” reads, in part: “... 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 task to a “clean” area or task...”. On April 15, 2025, the state agency (SA) conducted observations on the treatment floor from approximately 11:30 AM to 1:30 PM. At 12:40 PM, employee (EMP) 12 was observed discontinuing treatment on a patient with a central venous catheter (CVC). EMP12 was cleaning one of the CVC limbs, stopped the process, touched the machine, and then continued cleaning the limb. EMP12 did not change gloves after touching the “dirty” machine and before returning to cleaning the CVC limb. On April 16, 2025, the SA conducted observations on the treatment floor from approximately 10:15 AM until 11:45 AM. Between 10:15 AM and 10:50 AM, EMP11 was observed performing multiple tasks requiring glove changes. EMP11 did not perform hand hygiene between seven of the glove changes. During a CVC treatment initiation at 10:50 AM, EMP12 did not perform hand hygiene between three glove changes. At 11:30 AM, EMP11 was observed initiating CVC treatment for a patient. EMP11 did not change gloves after removing the old dressing and gauze from the site and before touching the clean supplies to begin cleaning.”

“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: 42725 Based on observations and document review, it was determined the facility staff failed to follow proper protocol for the cleaning and disinfection of the dialysis station and equipment for two (2) of three (3) observations. Findings: The facility’s policy titled, Infection Control for Dialysis Facilities, under the heading “Disinfection” reads, 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 and their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machine; touchscreens; countertops)...”. During the SA’s treatment floor observations on April 15, 2025, EMP12 was observed cleaning a dialysis station. EMP12 did not fully recline the chair to ensure that all areas of the chair were disinfected. On April 16, 2025, the SA observed EMP11 cleaning a dialysis station. During the task, EMP11 did not wipe underneath the side trays of the chair and did not open the circulator door on the machine to clean that area. The counter behind the chair at each station was observed being used to sit patient’s belongings on. The SA did not observe that area routinely cleaned as part of the station cleaning process.”

“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: 42725 Based on observations and document review, it was determined the facility staff failed to maintain asepsis when initiating treatment for two (2) of two (2) patients with a central venous catheter site. Findings: The facility’s policy titled, Central Venous Catheter (CVC) with Clearguard HD Antimicrobal End Caps Procedure, under “Procedure” reads, in part: “... 4. Remove old dressing and discard. 5. Observe site for signs and symptoms of infection... 6. Verify that both arterial and venous catheter limbs are clamped. 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove... 9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap. 10. Remove gloves and discard, perform hand hygiene per procedure and re-glove... 12. Place sterile 2x2 gauze over the catheter exit site leaving connections accessible... 14. Remove gloves and discard, perform hand hygiene per procedure and re-glove...”. During a CVC treatment initiation at 10:50 AM, EMP12 did not perform glove changes and hand hygiene after removal of old dressing, applying new dressing, and cleaning the CVC limbs. At 11:30 AM, EMP11 was observed initiating CVC treatment for a patient. EMP11 did not perform a glove change and hand hygiene after removing the old dressing and gauze from the site and before cleaning the CVC limbs.”

“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: 42725 Based on observations and document review, it was determined the facility staff failed to ensure access to the treatment floor remained restricted to authorized personnel only. Findings: The facility’s policy titled, Physical Environment, under the heading “Policy” reads, in part: “... 9. Systems to assure patient safety will be in place, ... Access to patient treatment areas, ... is restricted to authorized personnel only...”. While observing on the treatment floor April 16, 2025 from approximately 10:15 AM until 11:45 AM, the SA observed the treatment floor door (that opens up to the patient lobby) be propped open on two different occasions. On both occasions, the door remained propped open for several minutes before a staff member removed the rubber wedge and closed it.”

“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: 42725 Based on medical record review, document review and interview, it was determined the facility staff failed to acknowledge and address abnormal findings during and after treatment for three (3) of four (4) medical records (MR) sampled, MR2, MR3, MR4. Findings: The facility’s policy titled, Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, under the heading “Policy” reads, in part: “... 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)...”. Under the heading “Pre-Treatment Data Collection/Assessment” reads, in part: “... 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis...”. Under the heading “Intradialytic Data Collection/Assessment” reads, in part: “... 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately... The licensed nurse will use his/her clinical judgment 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...”. Under the heading “Post Treatment Data Collection/Assessment” reads, in part: “15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings... 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. The licensed nurse will use their clinical judgment 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.” Under the heading “Abnormal Findings” reads, in part: “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... Blood pressure: Pre-dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg; ... Blood Pressure Post Treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg; ... Sitting BP for patient’s that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg...”. MR2 The patient’s target weight is 88kg. Four of the six flowsheets reviewed, the patient ended treatment over the target weight by more than one kilogram (2.4kg, 3kg, 3.9kg, and 2kg). On 04/15/2025, the patient’s pre-treatment sitting BP was 72/37 and the post-treatment sitting BP was 73/50. There was no evidence of acknowledgment or reporting of the abnormal findings. Between 04/01/2025 and 04/15/2025, the patient’s lowest BP reading during treatment ranged from 82/52 to 53/35. The documentation of acknowledgment and reporting was inconsistent. MR3 There was no documentation that a pre-treatment standing BP measurement was collected for treatments completed between 03/31/2025 through 04/14/2025. There was no documentation indicating a reason why the measurement was not obtained. For two treatments, the pre-treatment sitting BPs documented were 189/118 and 221/118. For five treatments, the post-treatment standing BPs documented were 145/95, 145/92, 140/91, 131/94, and 140/105. For two treatments, the post-treatment sittings BPs documented were 160/102 and 164/106. The documentation acknowledging and reporting the abnormal findings was inconsistent. MR4 Between 03/26/2025 and 04/14/2025, there were three abnormal pre-treatment sitting BPs documented: 92/36, 99/54, and 85/69. There were three abnormal post-treatment sitting BPs documented: 150/64, 161/68, and 124/95. Between 03/26/2025 and 04/14/2025, the patient’s lowest BP reading during treatment ranged from 95/38 to 83/38. The documentation of acknowledgment and reporting was inconsistent. The SA conducted the reviews with EMP8. EMP8 acknowledged and agreed that abnormal blood pressure readings (pre-treatment, intradialytic, and post-treatment) were not consistently being acknowledged (through documentation of the finding) and reported to the licensed nurse for further assessment. Additionally, the documentation acknowledging the patients who are not meeting their target weight post-treatment is inconsistent.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on interview and record review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues cited during the previous recertification survey. The findings include: V-0113 Current recertification survey ending April 24, 2025 Based on four (4) infection control observations and document review, it was determined the facility staff failed to follow required infection control and prevention practices related to hand hygiene. Recertification survey ending March 22, 2023 Based on eleven (11) infection control observations, interviews, and document review, it was determined that facility staff failed to follow required infection control and prevention practices related to hand hygiene. V-0122 Current recertification survey ending April 24, 2025 Based on observations and document review, it was determined the facility staff failed to follow proper protocol for the cleaning and disinfection of the dialysis station and equipment for two (2) of three (3) observations. Recertification survey ending March 22, 2023 Based on three (3) infection control observations and document review, it was determined the facility staff failed to ensure dialysis stations and chairs were properly disinfected between patients to reduce the risk of spreading infectious agents. V-0147 Current recertification survey ending April 24, 2025 Based on observations and document review, it was determined the facility staff failed to maintain asepsis when initiating treatment for two (2) of two (2) patients with a central venous catheter site. Recertification survey ending March 22, 2023 Based on observations and document review, it was determined the facility staff failed to maintain aseptic technique when accessing the central venous catheter (CVC) for two (2) of three (3) patients observed. V-0543 Current recertification survey ending April 24, 2025 Based on medical record review, document review and interview, it was determined the facility staff failed to acknowledge and address abnormal findings during and after treatment for three (3) of four (4) medical records (MR) sampled, MR2, MR3, MR4. Recertification survey ending March 22, 2023 Based on observations, interviews, and document review, it was determined that the facility staff failed to: document notification to the registered nurse of abnormal blood pressure for two (2) of four (4) patients sampled; and obtain pre and/or post treatment weights for three (3) of three (3) patients dialyzed in a geriatric chair.”