Davita Onancock 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, interview and document review, it was determined that the facility failed to ensure a sanitary environment to minimize the transmission of infectious agents in treatment area by having stained ceiling tiles for two (2) of sixteen (16) Stations, Stations # 9 an d# 10. The findings include: On April 15, 2024 at 2:50 p.m. during the initial tour of the In-Center Hemodialysis (ICHD) unit, the ceiling tiles above Stations # 9 and # 10 were observed to be stained. There were several rings of stain ranging from approximately 3 to 6 inches in diameter causing what appeared to be overlapping stains. A stained ceiling tile is typically the result of a water damage from a leak. This can cause mold or mildew growth to form on the ceiling tile which can present an infection risk to patients. On April 16, 2024 at 9:00 a.m., a review of the facility policy titled “Infection Control” reads in part “purpose to minimize the spread of infection or blood borne pathogens in the dialysis facility environment.” On April 16, 2024 at 2:00 p.m., the findings were discussed with Staff Members # 1, # 2, # 6 and # 7 during the exit interview.”

“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 staff failed to ensure: all staff wear gloves when touching clean equipment (rolling cart) for one (1) of five (5) Staff Members (SM), SM # 5; all staff perform hand hygiene after glove removal for three (3) of five (5) SM, SM # 3, # 4 and # 5; and all staff perform hand hygiene after touching the front of the face mask for two (2) of five (5) SM, SM # 3 and # 4. The findings include: On April 15, 2024 between 2:00 p.m. and 3:30 p.m. observations in the treatment area during initiation and termination of treatments, the following were observed: At 2:55 p.m., SM # 3 was observed at Station # 3 adjusting the dialysis machine while wearing only one glove. SM # 3 failed to perform hand hygiene after removing the glove. At 3:10 p.m., SM # 3 was observed touching the front of the face mask and not performing hand hygiene while at Station # 3. At 3:15 p.m., SM # 3 was observed at Station # 13 adjusting the dialysis machine while wearing only one glove. SM # 3 failed to perform hand hygiene after removing the glove. At 3:17 p.m., SM # 4 was observed touching the front of the face mask and not performing hand hygiene while at Station # 4. At 3:18 p.m., SM # 4 was observed at Station # 2. SM # 4 removed dirty gloves and donned clean gloves without performing hand hygiene. At 3:21 p.m., SM # 5 was observed at Station # 3. SM # 5 removed dirty gloves and failed to perform hand hygiene before beginning to type on the clean rolling computer. On April 16, 2024 at 9:00 a.m., a review of the facility policy titled “Infection Control” reads in part “All teammates, physicians and non-physician (NPP) 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.” Guidance by the Center for Disease Control (CDC) (www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html) reads in part “When putting on a facemask: Clean your hands and put on your facemask so it fully covers your mouth and nose. Secure the elastic bands around your ears or secure the ties at the middle of your head and the base of your head. When wearing a facemask, Don’t do following: Don’t wear your facemask under your nose or mouth. Don’t allow a strap to hang down. Don’t cross the straps. Don’t touch or adjust your facemask without cleaning your hands before and after. Don’t wear your facemask on your head. Don’t wear your facemask around your neck. Don’t wear your facemask around your arm.” On April 16, 2024 at 2:00 p.m., the findings were discussed with SM # 1, # 2, # 6 and # 7 during the exit interview.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to wear face shields for one (1) of five (5) Staff Members (SM), SM # 5; and failed to wear masks correctly for two (2) of five (5) SM, SM # 3 and # 4. The findings include: On April 15, 2024 between 2:00 p.m. and 3:30 p.m. observations in the treatment area during initiation and termination of treatments, the following were observed: At 2:10 p.m., SM # 5 was observed at Station # 2 wearing the face shield above eyes. The Patient at Station # 2 was holding access sites post treatment. At 3:10 p.m., SM # 3 was observed at Station # 3 wearing the face mask below the nose. At 3:16 p.m., SM # 4 was observed at Station # 4 wearing the face mask below the nose. At 3:17 p.m., SM # 4 was observed at Station # 3 wearing the face mask below the nose. At 3:20 p.m., SM # 3 was observed at Station # 13 wearing the face mask below the nose. On April 15, 2024 at approximately 2:00 p.m., an interview with SM # 1 revealed face masks are required for all staff members and it is optional for Patients. On April 16, 2024 at 9:00 a.m., a review of the facility policy titled “Infection Control” reads in part “PPE (i.e., gown, gloves, eye protection, face shield) Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces.” Guidance by the Center for Disease Control (CDC) (www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html) reads in part “When putting on a facemask: Clean your hands and put on your facemask so it fully covers your mouth and nose. Secure the elastic bands around your ears or secure the ties at the middle of your head and the base of your head. When wearing a facemask, Don’t do the following: Don’t wear your facemask under your nose or mouth. Don’t allow a strap to hang down. Don’t cross the straps. Don’t touch or adjust your facemask without cleaning your hands before and after. Don’t wear your facemask on your head. Don’t wear your facemask around your neck. Don’t wear your facemask around your arm.” On April 16, 2024 at 2:00 p.m., the findings were discussed with SM # 1, # 2, # 6 and # 7 during the exit interview.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure staff: complete the Registered Nurse (RN) assessment within an hour of treatment initiation for one (1) of five (5) Patients (P) (P # 3); complete the RN treatment verification within an hour of treatment initiation for one (1) of five (5) Patients (P # 3); and ensure intradialytic vitals to include blood pressure (BP) were completed every thirty minutes during treatment for one (1) of five (5) patients (P # 3). The findings include: On April 16, 2024 between 9:00 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 3- The flowsheet dated April 1, 2024 revealed the treatment was initiated at 11:01 a.m. The RN assessment was documented at 1:00 p.m. (more than one hour). The flowsheet dated April 3, 2024 revealed the treatment was initiated at 11:04 a.m. The RN assessment was documented at 12:19 p.m. (more than one hour). The RN treatment verification was documented at 12:30 p.m. (more than one hour). The flowsheet dated April 5, 2024 revealed the treatment was initiated at 11:17 a.m. The RN assessment was documented at 12:32 p.m. (more than one hour). There was no intradialytic vitals to include blood pressure (BP) between 12:19 p.m. and 13:19 p.m. (more than 30 minutes). The flowsheet dated April 8, 2024 revealed the treatment was initiated at 11:04 a.m. The RN treatment verification was documented at 12:06 p.m. (more than one hour). On April 16, 2024 at 1:00 p.m., a review of the facility policy titled “Pre-Intra-Post treatment data” reads in part “Vital signs and treatment monitoring: For non-nocturnal treatments is completed at least every thirty (30) minutes. 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 and verification of prescription.” On April 16, 2024 at 2:00 p.m., the findings were discussed with Staff Members # 1, # 2, # 6 and # 7 during the exit interview.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to develop a plan of care for one (1) of five (5) Patients (P), P # 1. The findings include: On April 16, 2024 at approximately 9:15 a.m., a clinical record review for P # 1 revealed the Patient was admitted to the facility on February 14, 2024. There was no documented plan of care for P # 1. At 12:00 p.m., an interview with Staff Member (SM) # 1 revealed the plan of care for P# 1 had not been completed. On April 16, 2024 at 1:00 p.m., a review of the facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” reads in part “The comprehensive Interdisciplinary Assessment and plan of care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician, qualified master’s social worker and qualified registered dietitian. The Plan of Care must be signed at the time of the interdisciplinary team meeting for those attending in person or if attending remotely within 30 days of the interdisciplinary team meeting. A comprehensive assessment and plan of care will be conducted on all new patients within 30 calendar days.” On April 16, 2024 at 2:00 p.m., the findings were discussed with SM # 1, # 2, # 6 and # 7 during the exit interview.”