Davita Stone Ridge 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: 49355 Based on four (4) infection control observations, interviews, and document review, it was determined that the staff failed to conduct hand hygiene to prevent the spread of infections diseases. The findings include: On 06/03/2024 at 10:50 a.m., Staff Member #7 was deaccessing Patient #2’s fistula at station #5. The Staff Member failed to perform hand hygiene several times before donning a new pair of gloves. At 12:11 p.m., Staff Member #7 was accessing a fistula on Patient #11 at station #8. The Staff Member did not perform hand hygiene numerous times before donning new gloves. At 1:36 p.m., Staff Member #7 at station #4 with Patient #6 failed to perform hand hygiene on several occasions before donning a new pair of gloves. On 06/04/2024 at 11:05 a.m., Staff Member #13 was deaccessing Patient #13 at station #10. The Staff Member did not perform hand hygiene several times before donning fresh gloves. In a meeting with Staff Members # 1, 12 and 15 at 4:22 p.m. on 06/03/2024, there was agreement by all that hand hygiene should always be performed when removing soiled gloves and before donning new gloves. A review of the facility’s document entitled, “Infection Control For Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: ... “Hand Hygiene 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves” The above concerns were discussed at the exit conference on 06/04/2024 with Staff Members #1, 8 and 12.”

“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: 49355 Based on observations and document review, it was determined the facility staff failed to ensure aseptic technique when preparing intravenous (IV) medications in one (1) out of two (2) observations. The findings include: On 06/04/2024 at 11:13 a.m., this surveyor observed Staff Member #14 drawing up two (2) syringes of heparin from a 30 milliliter (ml) multidose vial. The staff member cleaned the rubber stopper of the vial and withdrew the desired amount into the first syringe. The Staff Member did not clean the stopper again with a new alcohol wipe before withdrawing the desired volume of heparin into the second syringe. A review of the facility’s policy entitled, “Medication Policy,” policy #1-06-01, revision date October 2023, reads, in part: ... “21. An aseptic environment and aseptic technique is used when preparing medications.” The above observation was discussed at the exit conference on 06/04/2024 with Staff Members #1, 8 and 12.”

“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: 49355 Based on medical record reviews, interviews and document review, it was determined the facility staff failed to document deviations in target weight (TW) versus post treatment weight (PTW) (+/- 1kg) and pulse (P) readings that were not within facility guidelines in four (4) out of four (4) in-center hemodialysis patient flow sheets reviewed and failed to complete pre-treatment nursing assessments within one (1) hour of the dialysis start time in four (4) out of four (4) patient flow sheets reviewed. The findings include: The six (6) most recent flow sheets for each of four (4) sampled in-center hemodialysis patients were reviewed on 06/03/2024. Patient #2: On treatment date 05/20/2024, the patient’s P ranged from 48 beats per minute (bpm) to 56 bpm during the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. On 05/22/2024, the patient’s P ranged from 42 (bpm) to 55 (bpm) throughout the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. On 05/24/2024, the patient’s P ranged from 50 (bpm) to 56 (bpm) throughout the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. On 05/27/2024, the patient’s P ranged from 54 (bpm) to 59 (bpm) throughout the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. The patient’s treatment began at 7:37 a.m. The pre-treatment nursing assessment wasn’t completed until 9:58 a.m. On 05/29/2024, the patient’s P ranged from 41 (bpm) to 59 (bpm) throughout the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. On 05/31/2024, the patient’s P ranged from 50 (bpm) to 55 (bpm) throughout the entire 3.5 hour treatment. There was no documentation on the flow sheet as to whether the technician or the charge nurse were aware of the deviation. Patient #5: On 05/23/2024, the patient’s treatment started at 7:23 a.m. The pre-treatment nursing assessment wasn’t completed until 8:26 a.m. On 05/24/2024, the patient’s PTW was 56.9 kilograms (kg) as compared to the TW of 58 kg, a deviation of 1.1 kg. There was no documentation in the treatment note acknowledging the variance. On 05/25/2024, the patient’s PTW was 56.7 kg as compared to the TW of 58 kg, a deviation of 1.3 kg. There was no documentation in the treatment note acknowledging the variance. On 05/27/2024, the patient’s treatment started at 7:36 a.m. The pre-treatment nursing assessment wasn’t completed until 10:10 a.m. On 05/30/2024, the patient’s treatment started at 8:00 a.m. The pre-treatment nursing assessment wasn’t completed until 9:23 a.m. Patient #6: On 05/20/2024, the patient’s PTW was 61.8 kg as compared to the TW of 59 kg, a deviation of 2.8 kg. There was no documentation in the treatment note acknowledging the variance. On 05/22/2024, the patient’s PTW was 62.1 kg as compared to the TW of 60 kg, a deviation of 2.1 kg. There was no documentation in the treatment note acknowledging the variance. On 05/27/2024, the patient’s treatment started at 12:40 p.m. The pre-treatment nursing assessment wasn’t completed until 1:51 p.m. The patient’s PTW was 62.3 kg as compared to the TW of 60 kg, a deviation of 2.3 kg. There was no documentation in the treatment note acknowledging the variance. On 05/29/2024, the patient’s PTW was 61.8 kg as compared to the TW of 60 kg, a deviation of 1.8 kg. There was no documentation in the treatment note acknowledging the variance. On 05/31/2024, the patient’s PTW was 61.7 kg as compared to the TW of 60 kg, a deviation of 1.7 kg. There was no documentation in the treatment note acknowledging the variance. Patient #7: On 05/20/2024, the patient’s treatment started at 12:26 p.m. The pre-treatment nursing assessment wasn’t completed until 1:37 p.m. The patient’s PTW was 80.0 kg as compared to the TW of 81.5 kg, a deviation of 1.5 kg. There was no documentation in the treatment note acknowledging the variance. On 05/27/2024, the patient’s treatment started at 12:21 p..m. The pre-treatment nursing assessment wasn’t completed until 1:41 p.m. In interviews with Staff Members #4 and 5, both said that parameters outside of facility guidelines should be documented on the flow sheets and the charge nurse should be notified of any variances. Staff Member #4 also stated that pre-treatment nursing assessments should be completed within one (1) hour of treatment initiation. A review of the facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy #1-03=08, revision date April 2024, reads, in part: ... “Intradialytic Collection/Assessment ... 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation... ... 11. Abnormal findings, interventions and patient response will be documented in the patient’s medical record... ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Members of the patient care team should report ANY changes in patient condition 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 the target weight ... Heart or Pulse Rate Pre/Intra/Post: ... Less than 60 beats per minutes.... The above findings were discussed at the exit conference on 06/04/2024 with Staff Members #1, 8 and 12.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on three (3) observations, interviews and document review, it was determined the facility staff failed to aseptically access an arteriovenous (AV) graft/fistulas and failed to properly use clamps designed for hemostasis. The findings include: At 12:05 p.m. on 06/03/2024, this surveyor returned to the treatment floor. At that time, Patient #5 at station #4 in Staff Member #6’s area, had a clamp in place on the left arm, over a AV site that had been deaccessed. When the surveyor exited the treatment floor at 12:40 p.m., the clamp was still in place. At that time, the clamp had been observed in use for thirty-five (35) minutes. At 12:11 p.m., Staff Member #7 was cleansing the fistula site in preparation for access on Patient #11 at station #8. The Staff Member palpated the site and then accessed the site with the cannulation needles, without cleaning the area again. At 12:36 p.m., this surveyor observed Staff Member #6 cleansing the AV site of Patient #12 at station #3. The Staff Member palpated the cleansed site and then accessed the site, without cleaning the site again. In a discussion at 4:22 p.m. on 06/03/2024, Staff Members #1, 12 and 15 agreed that the AV sites should have been cleansed again with antiseptic before cannulating and that the usage of a clamp for that duration was not within the facility’s policy guidelines. A review of the facility’s policy entitled, “AV Fistula or Graft Cannulation with Nipro or Medicsystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose, policy #1-04-01E, revision date October 2022, reads, in part:... “Procedure... ... 8. Locate and palpate the needle cannulation sites prior to skin preparation. ... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” A facility policy entitled, “Utilizing Vascular Access Clamps,” policy # 1-04-08, revision April 2019, states, in part:... “Policy: ... 3. Vascular access clamps should not be used routinely. However, if a patient is unable to hold his/her own sites, it is recommended that only one (1) clamp is used at a times and should not be left on longer than 20 minutes.” The above concerns were discussed with Staff Members #1, 8 and 12 at the exit conference on 06/04/2024.”