Davita Park Hill Dialysis

“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: 42929 Based on four (4) infection control observations, review of facility documents, and interview with staff (EMP), it was determined the facility staff failed to clean and disinfect contaminated surfaces as per infection control standards and the facility’s policy. Findings: Review of facility document “Infection Control for Dialysis Facilities” last revised April 2023 reads in part: “... Disinfection 12. ... b. ... i. ... Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfectant should be applied so that surfaces are visibly wet.... 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 (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). i. The Wall box, Drain, and Water supply lines are considered part of the dialysis delivery system....” Observation on June 30, 2025, at 9:48 AM, EMP9 did not disinfect the outside arms of the chair under the tray tables at station 4. Observation on June 30, 2025, at 10:01 AM, EMP4 did not disinfect the outside arms of the chair under the tray tables, or the crease along the arm of the chair and edge of tray table when the tray table was put down at station 2. Observation on June 30, 2025, at 10:07 AM, EMP9 disinfected the prime waste bucket then placed it back on the dirty machine. EMP9 did not disinfect the outside arms of the chair under the tray tables or put the tray tables down to disinfect the crease along the arm of the chair, and put the dirty blood pressure cuff on the disinfected chair seat, then cleaned the blood pressure cuff. EMP9 did not disinfect the television monitor or the sharps container. Observation on June 30, 2025, at 10:21 AM, a staff member did not disinfect the outside arms of the chair under the tray tables or the wall box. Interview on June 30, 2025, in the afternoon, EMP2 indicated that all parts of the dialysis station should be disinfected after each patient treatment.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 42929 Based on observations, review of facility documents, and interview with staff (EMP), it was determined the facility failed to ensure that all equipment was maintained. Specifically, six (6) dialysis chairs had long cracks on the chair seat. Findings: Observations on June 30, 2025, at 10:01 AM, revealed long cracks in the material on the seat of the dialysis chairs at stations 1, 2, 9, 12, 14, and the isolation station. Review of grievance from February 26, 2025, revealed MR14 was upset about a crack in the chair stating the chair was uncomfortable and would like it fixed by the patient’s next treatment. Review of grievance from April 24, 2025, revealed MR15 complained that the cracks in the chair make the chair uncomfortable. Review of grievance from June 24, 2025, revealed MR16 requested tape on the cracked chair. Interview on June 30, 2025, at 9:20 AM, as the surveyor was entering the treatment floor, EMP2 indicated that the facility has chairs that have tears but they are working to get them fixed. Interview on July 1, 2025, at 10:03 AM, EMP2 indicated that new chairs were ordered in April 2025, and are due for delivery in December 2025.”

“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: 42929 Based on observations and interview with staff (EMP), it was determined the facility failed to prominently display a copy of the patient’s rights in the facility, including the current State Agency (SA) and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. Findings: Observation upon entry to the facility on June 30, 2025, at 8:30 AM, there was no prominently displayed patient rights observed in the facility’s waiting room. Interview on July 1, 2025, in the morning, EMP1 observed the waiting room and confirmed that there was no patient rights posted. In the afternoon, EMP1 confirmed that EMP1 ordered patient rights plaques to display, and has placed printed copy of patient rights in the waiting room until the plaques arrive.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of facility documents, and interview with staff (EMP), it was determined that EMP16 (nephrologist) failed to document a monthly progress note for one (2) of four (4) of EMP16’s patients’ (MR) medical records reviewed (MR2 and MR17). Findings: Review of facility document “Progress Note Policy” last revised October 2024 reads in part: “... Physician: The attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times....” Review of MR2 and MR17 progress notes revealed there was no documentation of a nephrologist (EMP16) note for May 2025 for both MR2 and MR17. Interview on July 1, 2025, at 12:27 PM, EMP2 confirmed that there was no nephrologist (EMP16) note documented for May 2025 for MR2 and MR17. EMP2 indicated that the nephrologist must write a monthly progress note.”

“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 related to dialysis station cleaning. The current recertification survey Based on four (4) infection control observations, review of facility documents, and interview with staff (EMP), it was determined the facility staff failed to clean and disinfect contaminated surfaces as per infection control standards and the facility’s policy. The recertification survey ending June 7, 2022 Based on observations and document review, it was determined the facility staff failed to ensure proper protocol for the cleaning and disinfection of the dialysis station for four (4) of five (5) observations.”

“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: 42929 Based on review of medical records (MR), review of facility documents, and interview with staff (MR), it was determined that EMP16 (Nephrologist) failed to document progress notes as per the facility’s policy for five (5) of fourteen (14) patients’ (MR) medical records reviewed (MR2, MR12, MR13, MR17, and MR18). Findings: Review of facility document “Progress Note Policy” last revised October 2024 reads in part: “Purpose: ... Documentation needs to include treatment given or planned, patient encounters and the condition of the patient. Policy: 1. Progress notes are completed to verify documentation of patient’s problems/needs, intervention, and response to intervention and are expressed in a narrative format. 2. Progress notes are used to communicate information among the various disciplines, or to expand upon information or problems noted in other parts of the medical records, or obtained from other sources (consults, treatment records, etc.) ... 7. Progress notes should demonstrate implementation of the plan of care, complete and pertinent information about condition of patient, and clearly portray the patient, the care and outcomes of that care. Physician: The attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times....” Review of the medical records for MR2, MR12, MR13, MR17, and MR18 revealed EMP16 failed to: document progress notes that verify documentation of patient’s problems, needs, intervention, response to intervention, and condition of the patient; and to record progress notes for any clinical event and provide other interdisciplinary team members with an up-to-date picture of the status of the patient at all times. Review of MR2 progress note from April 7, 2025, revealed the documentation “Completed H&P [history and physical] with Encounter” but there was no history or physical documented in the note. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR2 progress note from April 25, 2025, revealed the documentation “Completed H&P with Encounter”, but the Medical, Surgical, Social, and Family Histories noted “No documented ... History”. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. There was no note to address the following abnormal lab results: hemoglobin 8.8 low, Ferritin 1144.0 high, phosphorus 5.7 high, parathyroid hormone 314 high. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR2 revealed that the patient was hospitalized for elevated potassium from May 2, 2025, to May 8, 2025. The patient’s hemodialysis prescription indicated the patient receive dialysis three times a week. MR2 missed the following dialysis treatments: eight (8) in March 2025, seven (7) in April 2025, seven (7) in May 2025, and nine (9) in June 2025. There was no progress note by EMP16, the patient’s nephrologist, for May 2025 and note addressing the patient’s hospitalization or missed treatments. Review of MR2 progress note from June 20, 2025, revealed the documentation “Completed H&P with Encounter” but the Medical, Surgical, Social, and Family Histories noted “No documented ... History”. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. There was no note to address the following abnormal lab results: Ferritin 1064 high, phosphorus 5.5 high, parathyroid hormone 353 high. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR2 progress note from June 27, 2025, revealed the documentation “Completed H&P with Encounter” but there was no history or physical documented in the note. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR12 progress note from June 4, 2025, revealed the Medical, Surgical, Social, and Family Histories noted “No documented ... History”. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. There was no note to address the following abnormal lab results: hemoglobin 10.1 low, potassium 2.9 low, phosphorus 2.1 low, and parathyroid hormone 181 high. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR12 progress note from June 25, 2025, revealed “Completed H&P with Encounter” but there was no history or physical documented. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR13 nursing progress note from April 30, 2025, revealed the patient had altered mental status during treatment, the facility staff called 911, and the patient was transported to the emergency department. There was no documentation in EMP16’s subsequent progress notes from May 19, 2025, and May 28, 2025, addressing the patient’s altered mental status and transfer to hospital. Review of MR13 progress note from May 28, 2025, revealed the Medical, Surgical, Social, and Family Histories noted “No documented ... History”. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. Review of MR13 progress note from June 30, 2025, revealed “Completed H&P with Encounter” but there was no history or physical documented. The note contained documentation of data to include vital signs, adequacy lab result, and in-center hemodialysis prescription, but there was no documentation addressing the data or the patient’s current condition. EMP16’s documentation revealed “Clinical assessment at goal unless otherwise documented”, “No comments added”, or was left blank. There was no documentation providing an up-to-date picture of the status of the patient. There was no progress note by EMP16 for MR17 for May 2025. Review of MR18 treatment flow sheet from June 20, 2025, revealed the patient’s abdomen was distended and had swelling in both ankles. There was no documentation in EMP16’s subsequent progress note on June 27, 2025, addressing the patient’s distended abdomen or ankle swelling. Review of the “Physical Exam” documented in progress notes for: MR2 on April 25, 2025, and June 20, 2025; MR12 on June 4, 2025; MR13 on May 28, 2025; MR17 on June 4, 2025; and MR18 on May 21, 2025; revealed EMP16 documented the exact same physical exam for those patients. The documentation was “General Appearance: Comfortable, Lungs: Normal, Heart: Normal, Neck: No Increase in JVP [jugular venous pressure], Abdominal: Normal, Extremities: No Edema, and Other Pertinent Findings: [blank].” Although the nursing assessment for MR2 and MR18 from June 20, 2025, revealed “Edema Location: Abdomen Distended” and trace edema in both ankles. Interview on July 1, 2025, at 12:17 PM, EMP2 indicated that there was no other documentation providing an up-to-date picture of the status of the patient from EMP16 for MR2, MR12, MR13, MR17, and MR18. EMP2 indicated that EMP16’s progress notes were lacking documentation about the status of the patient and did not address the condition of the patient. EMP2 indicated that some of the notes documented that an H&P was completed, but there was no documentation of an H&P in the note, and EMP16’s physical assessment was exactly the same for the progress notes reviewed for those patients.”