Davita Rutherford Crossing 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: 42929 Based on four (4) infection control observations and facility document review, it was determined the facility staff failed to change gloves and conduct proper hand hygiene during patient care to reduce the spread of infectious diseases. Findings: On 02/12/2024 at 11:10 a.m., the surveyor observed the patient care technician (PCT) at station #7 touch the PCT’s goggles with gloved hands and remove them from the PCT’s head and place them on the PCT’s face, then with the same gloved hands, the PCT accessed the patient’s arteriovenous (AV) fistula with needles. On 02/12/2024 at 11:15 a.m., the surveyor observed Staff Member (SM) 11 palpate the AV fistula site of the patient at station #12, then walk to the supply cabinet and retrieve numbing spray without removing gloves and performing hand hygiene, then return back to the patient at station #12. On 02/13/2024 at 10:45 a.m., SM11 taped a clean drape under the CVC of the patient at station #12, then left the station and retrieved additional supplies from the clean supply cabinet without removing gloves and performing hand hygiene, then returned back to the patient at station #12. On 02/13/2024 at 10:50 a.m., after wiping the CVC of the patient at station #12, SM11 went to the clean supply cabinet and retrieved more supplies without removing gloves and performing hand hygiene. SM11 returned to station #12, placed the retrieved supplies on the patients chairside tray table, then removed gloves and performed hand hygiene. A review of the facility’s policy titled “Infection Control For Dialysis Facilities” revised April 2023 states in part: ... Hand Hygiene 1. All teammates, Physicians and Non-Physician [sic] (NPP) will perform hand hygiene ... d. after patient and dialysis delivery system contact, f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. The above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 42929 Based on one (1) infection control observation and facility document review, it was determined the facility staff failed to ensure that items taken into the dialysis station were disposed of and not returned to a common clean area. Findings: On 02/13/2024 at 11:00 a.m., after performing a CVC dressing change and catheter cleaning for the patient at station #12, SM11 removed the remaining roll of tape from the patient’s chairside table and placed it on the clean common area instead of disposing after use as per facility’s policy. A review of the facility’s policy titled “Infection Control For Dialysis Facilities” revised April 2023 states in part: ... 10. Unused supplies (syringes, alcohol swabs, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients.... The above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”

“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 observations and facility document review, it was determined the facility staff failed to follow standard infection control precautions related to cleaning and disinfection of contaminated surfaces, medical devices, and equipment for two (2) of two (2) dialysis station disinfections observed. Findings: On 02/13/2024 at 10:36 a.m., Staff Member (SM) 12 failed to wipe the outside of the chair arms under the tray table and failed to put the tray table down to wipe between the tray table and chair. SM12 failed to wipe the sides of the chair cushion. On 02/13/2024 at 11:01 a.m., Staff Member (SM) 12 failed to wipe the outside of the chair arms under the tray table and failed to put the tray table down to wipe between the tray table and chair. SM12 failed to wipe the sides of the chair cushion. A review of the facility’s policy titled “Infection Control For Dialysis Facilities” revised April 2023 states in part: ... Disinfection ... 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).... The above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”

“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: 42929 Based on observations and document review, it was determined the facility staff failed to maintain a safe environment for dialysis patients, staff, and the public by not including all of the necessary components of medication labeling for two (2) intravenous medications. Findings: During the flash tour on 02/12/2024 at 10:35 a.m., the surveyor observed two (2) heparin filled syringes labeled with a patient name but there was no date, time prepared, or initials of the teammate preparing the medication. The above concern was discussed with Staff Member (SM) 1 and SM2 on 02/12/2024. A review of the facility’s policy titled “Medication Policy” last updated October 2023 states in part: ... 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 above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”

“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: 42929 Based on observations and facility document review, it was determined the facility staff failed to maintain aseptic technique when accessing the central venous catheter (CVC) for one (1) of two (2) patients observed. Findings: On 02/13/2024 at 10:45 a.m., Staff Member (SM) 11 failed to remove gloves and perform hand hygiene immediately after removing the old dressing from the CVC for the patient at station #12. After SM11 removed the dressing, SM11 then proceeded to clean the exit site with the chlorhexidine swab, then after cleaning the exit site, SM11 removed gloves and performed hand hygiene. A review of the facility’s policy titled “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” last revised October 2023 states in part: ... 4. Remove old dressing and discard. ... 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 8. Holding the 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 ...”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 42929 Based on observations and interviews, it was determined the facility failed to ensure that chlorine testing strips were not expired. Findings: During observations of the water treatment room on 2/12/2024 at 11:31 a.m. with Staff Member (SM) 6, the surveyor observed the chlorine/chloramine testing strips that staff were using to test the chlorine at the beginning of the day had an expiration date of 3/1/2023. The surveyor made SM6 aware and SM6 immediately disposed of the test strips and replaced them with a bottle of strips that was not expired. The facility uses a CM130 on-line chlorine/chloramine monitor throughout the rest of the treatment day. The strips are only used for initial water testing at the beginning of the day. SM1 and SM2 were made aware of the expired strips on 2/12/2024 and during the exit conference on 2/13/2024 at 5:00 p.m.”

“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: 42929 Based medical record review, and policy review, it was determined the facility staff failed to document notification to the charge nurse or physician of post treatment weight greater than 1 kg above or below the target weight for three (3) of five (5) in-center patients reviewed. Findings: On 02/12/2024, the surveyor reviewed the medical records for five (5) in-center hemodialysis patients. There was no documentation that the post treatment weight greater than 1 kg above or below the target weight was reported to the licensed nurse or physician for: Patient #2 02/01/2024 post treatment weight was 69.9 kg, 2.9 kg above the target weight of 67 kg; 02/06/2024 post treatment weight was 68.9 kg, 1.9 kg above the target weight of 67 kg; 02/08/2024 post treatment weight was 69.4 kg, 2.4 kg above the target weight of 67 kg. Patient #4 01/30/2024 post treatment weight was 84.3 kg, 1.3 kg above the target weight of 83 kg; 02/03/2024 post treatment weight was 84.2 kg, 1.2 kg above the target weight of 83 kg; 02/06/2024 post treatment weight was 84.9 kg, 1.4 kg above the target weight of 83.5 kg; 02/08/2024 post treatment weight was 86 kg; 2.5 kg above the target weight of 83.5 kg. Patient #7 01/31/2024 post treatment weight was 95.4 kg, 2.1 kg below the target weight of 97.5 kg; 02/02/2024 post treatment weight was 99.1 kg, 2.6 kg above the target weight of 96.5 kg; 02/05/2024 post treatment weight was 99.2 kg, 1.7 kg above the target weight of 97.5 kg. The above concerns were discussed with Staff Member (SM) 1 and SM2 during a review of the medical records on 02/13/2024. A review of the facility’s policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised October 2023 states in part: ... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: ... c. Target weight ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... Abnormal Findings 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 ... In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. ... Fluid Status: ... Post-treatment: IF patient is above or below 1 kg from target weight... The above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”

“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: 42929 Based on medical record review, and facility policy review, it was determined the facility staff failed to follow the dialysis treatment orders, specifically for blood flow rate (BFR) for three (3) of five (5) patients reviewed, and for dialysate flow rate (DFR), for four (4) out of five (5) patients reviewed. Findings: The six (6) most recent flow sheets for five (5) in-center hemodialysis patients were reviewed on 02/12/2024. Dialysis orders for blood flow rate (BFR) were not followed in three (3) of the five (5) patients reviewed. There was no documentation of the reason or of notification to the charge nurse of the change in blood flow rate from the prescribed rate. P4 01/30/2024 - BFR was documented at 225 ML/min from 10:30 a.m. through 12:00 p.m. when the prescribed rate was 250 ML/min. 02/01/2024 - BFR was documented at 400 ML/min for the entire treatment when the prescribed rate was 250 ML/min. 02/03/2024 - BFR was documented at 200 ML/min for the entire treatment when the prescribed rate was 250 ML/min. 02/06/2024 - BFR was documented at 400 ML/min for the entire treatment when the prescribed rate was 250 ML/min. 02/10/2024 - BFR was documented at 350 ML/min from 8:57 a.m. through 11:01 a.m. when the prescribed rate was 250 ML/min. P6 01/30/2024 - BFR was documented at 405 ML/min for the entire treatment when the prescribed rate was 450 ML/min. 02/10/2024 - BFR was documented at 425 ML/min from 8:30 a.m. through 9:30 a.m. when the prescribed rate was 450 ML/min. P7 01/29/2024 - BFR was documented at 200 ML/min for the entire treatment when the prescribed rate was 400 ML/min. No documentation was noted on the flow sheet. Dialysis orders for dialysate flow rate (DFR) were not followed in four (4) of the five (5) patients reviewed. There was no documentation of the reason or of notification to the charge nurse of the change in dialysate flow rate from the prescribed rate. P3 02/01/2024 - DFR was documented at 800 ML/min from 10:57 a.m. through 1:32 p.m. when prescribed rate was 500 ML/min. 02/06/2024 - DFR was documented at 400 ML/min for the entire treatment when prescribed rate was 500 ML/min. . P4 02/08/2024 - DFR documented at 800 ML/min for entire treatment when prescribed rate was 500 ML/min. P6 02/06/2024 - DFR documented at 800 ML/min for entire treatment when prescribed rate was 500 ML/min. 02/10/2024 - DFR documented at 800 ML/min for entire treatment when prescribed rate was 500 ML/min. P7 01/29/2024 - DFR documented at 500 ML/min for entire treatment when prescribed rate was 600 ML/min. 02/07/2024 - DFR documented at 500 ML/min for entire treatment when prescribed rate was 600 ML/min. 02/09/2024 - DFR documented at 500 ML/min for entire treatment when prescribed rate was 600 ML/min. A review of the facility’s policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised October 2023 states in part: ... 2. The Nursing Assessment will be performed and documented by a licensed nurse ... a. The assessment includes the following components: ... ii. Verification of prescription including machine parameters ... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: ... f. Blood flow rate g. Dialysate flow rate Intradialytic Data Collection/Assessment b. At a minimum, obtain and document the following: ... iii. Blood and dialysate flows, arterial and venous pressures ... 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 licensed nurse informed. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings: section in this policy). ... 13. All findings, interventions and patient response will be documented in the patient’s medical record.... The above concerns were discussed with SM1, SM2, and SM6 at the exit conference on 02/13/2024 at 5:00 p.m.”