Davita Mid Columbia Kidney Center

“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: 45034 . Based on document review, observation, and interview, the facility failed to ensure that all staff followed facility policies and procedures for glove use and hand hygiene. Failure to change gloves and perform hand hygiene places patients at risk for exposure to and transmission of infectious agents. Findings included: 1. Document review of the facility policy titled “Infection Control for Dialysis Facilities,” last revised 04/23, showed that disposable gloves must be worn by staff during patient care and when touching equipment at the dialysis station. Hand hygiene must be performed following: - Before gloving and immediately after removal of gloves. - After interacting with the dialysis machine. - Before touching clean areas, supplies, and the keyboard - When exiting the patient’s treatment area. 2. On 09/23/25 at 10:20 AM, Surveyor #1 observed a Patient Care Technician (PCT) (Staff #113) discontinue dialysis on Patient #131 at Station #8. The observation showed Staff #113 adjusting the patient in the chair and readjusting the blood pressure without changing gloves or performing hand hygiene prior to touching the dialysis machine. 3. On 09/23/25 at 11:23 AM, Surveyor #1 observed a Patient Care Technician (PCT) (Staff #113) initiate dialysis treatment for Patient #126 at Station #6. The observation showed Staff #113 touched the clothing and CVC site without changing gloves or performing hand hygiene prior to touching the dialysis machine. 4. On 09/23/25 at 2:55 PM, Surveyor #1 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding the missed glove changes and hand hygiene practices. Staff #101 and Staff #102 acknowledged the observations and confirmed that staff failed to follow infection control policies. .”

“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: 45034 . Based on document review, observation, and interview, the facility failed to ensure that staff members followed infection prevention technique standards, policies, and procedures during central venous catheter (CVC) related care. Failure to ensure that staff members follow infection prevention technique standards, policies, and procedures when working with a patient’s CVC, risks infection of the access site, which can result in serious patient harm. Findings included: 1. Document review of the facility policies titled “Central Venous Catheter (CVC) Care,” last revised 04/25, showed that staff are to secure patients’ clothing away from the work area to minimize the risk of cross-contamination. CVC care requires staff to use aseptic technique while performing CVC-related procedures. 2. On 09/23/25 at 11:15 AM, Surveyor #1 observed a PCT (Staff #113) during a CVC dressing change on Patient #126. Staff #113 failed to secure clothing away from the work area, resulting in Patient #126’s clothing contaminating the CVC site multiple times during the dressing change. 3. On 09/23/25 at 2:50 PM, Surveyors #1 and #6 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding CVC related procedures. Staff #101 and 102 confirmed that clothing should be secured while performing CVC-related procedures to ensure aseptic technique. .”

“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: 45034 . Based on observation, interview, and review of facility policies, the facility failed to maintain a safe and functional treatment environment by failing to ensure medications are secured and properly stored. Failure to maintain a safe and functional treatment environment can lead to possible medication or syringe tampering or diverting legend drugs and can place patients at risk for potentially receiving the wrong medication, leading to possible adverse patient outcomes. Findings included: 1. Review of the facility’s policy titled, “Medication Policy,” revised 10/23, showed non-refrigerated medications are to be stored in a safe and locked location not accessible to persons other than licensed nurse and Facility Administrator or designee. 2. On 09/23/25 at 10:40 AM, Surveyor #1 observed an unlocked medication drawer that contained the following medications: - 600 tablets of Nitroglycerine (medication to relieve chest pain). - 200 tablets of Clonidine (medication to treat high blood pressure). - 5 vials of Diphenhydramine (antihistamine medication). 3. On 09/23/25 at 10:44 AM, Surveyor #1 interviewed the Staff Nurse (Staff #107) about the unlocked medication drawer. Staff #107 confirmed that the medication drawer was unlocked. 4. On 09/23/25 at 10:50 AM, Surveyor #1 observed a bag of 6 prefilled syringes labeled Heparin (medication to prevent blood clots) in a supply drawer in the dialysis treatment area. 5. On 09/23/25 at 10:55 AM, Surveyor #1 interviewed the Clinical/Nurse Manager (Staff #109) about prefilled syringes of Heparin in the treatment area. Staff #109 confirmed the finding and acknowledged the medications are to be secured. . .”

“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: 45034 . Based on document review and interviews, the facility failed to provide the necessary care and services to manage patients’ volume status by failing to document the notification of abnormal findings to the licensed nurse in 6 of 10 patient records reviewed (Patient #604, #605, #606, #607, #609, and #610) (1), failing to document assessment of the patient related to post-treatment target weight in 7 of 10 patient records reviewed (Patient #601, #602, #604, #605, #607, #609, and #610) (2), and failing to manage the patient’s blood pressure during treatment in 4 of 10 patient records reviewed (Patient #605, #606, #607, and #609) (3). Failure to provide the necessary care and services to manage patients’ volume status places patients at higher risk of harm from ineffective dialysis treatments and associated complications. Findings Include: Item #1: Licensed Nurse Notification of Abnormal Findings 1. Document review of the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated 04/24, showed that abnormal findings, including an intradialytic systolic blood pressure greater than 180 mm/Hg or less than 90 mm/Hg and an intradialytic diastolic blood pressure greater than or equal to 100 mm/Hg or less than 50 mm/Hg, should be reported to the licensed nurse and documented immediately. 2. Document review of patient treatment records showed the following: a. Patient #604’s medical record showed on 09/10/25, a PCT (Staff #617) documented abnormal findings for 3 of 14 intradialytic blood pressure readings (96/43 mm/Hg, 53/23 mm/Hg, and 72/47 mm/Hg) without evidence that the licensed nurse was notified. b. Patient #605’s medical record showed on 09/12/25, a PCT (Staff #618) documented abnormal findings for 7 of 10 intradialytic blood pressure readings (186/109 mm/Hg, 177/108 mm/Hg, 176/102 mm/Hg, 175/107 mm/Hg, 211/112 mm/Hg, 213/103 mm/Hg, and 209/108 mm/Hg) without evidence that the licensed nurse was notified. - On 09/15/25, Staff #618 documented abnormal findings for 9 of 10 intradialytic blood pressure readings (209/97 mm/Hg, 207/110 mm/Hg, 210/102 mm/Hg, 207/111mm/Hg, 207/108 mm/Hg, 216/104 mm/Hg, 200/133 mm/Hg, 222/112 mm/Hg, and 229/111mm/Hg) without evidence that the licensed nurse was notified. - On 09/17/25, Staff #618 documented abnormal findings for 7 of 9 intradialytic blood pressure readings (195/112 mm/Hg, 206/112 mm/Hg, 208/112 mm/Hg, 200/111mm/Hg, 210/116 mm/Hg, 191/99 mm/Hg, and 160/135 mm/Hg) without evidence that the licensed nurse was notified. c. Patient #606’s medical record showed on 09/13/25, a PCT (Staff #614) documented abnormal findings for 4 of 10 intradialytic blood pressure readings (190/144 mm/Hg, 174/123 mm/Hg, 136/114 mm/Hg, and 163/106 mm/Hg) without evidence that the licensed nurse was notified. d. Patient #607’s medical record showed on 09/18/25, a PCT (Staff #619) documented abnormal findings for 9 of 11 intradialytic blood pressure readings (214/122 mm/Hg, 205/96 mm/Hg, 194/105 mm/Hg, 186/107 mm/Hg, 203/117 mm/Hg, 188/107 mm/Hg, 193/113 mm/Hg, 190/112 mm/Hg, and 184/108 mm/Hg) without evidence that the licensed nurse was notified. e. Patient #609’s medical record showed on 09/15/25, a PCT (Staff #610) documented abnormal findings for 4 of 10 intradialytic blood pressure readings (169/100 mm/Hg, 185/104 mm/Hg, 192/107 mm/Hg, and 205/106 mm/Hg) without evidence that the licensed nurse was notified. - On 09/19/25, Staff #610 documented abnormal findings for 8 of 9 intradialytic blood pressure readings (182/105 mm/Hg, 187/105 mm/Hg, 186/103 mm/Hg, 192/110 mm/Hg, 207/113 mm/Hg, 188/106 mm/Hg, 202/105 mm/Hg, and 195/103 mm/Hg) without evidence that the licensed nurse was notified. f. Patient #610’s medical record showed on 09/15/25, a PCT (Staff #616) documented abnormal findings for 3 of 9 intradialytic blood pressure readings (84/52 mm/Hg, 83/35 mm/Hg, and 70/60 mm/Hg) without evidence that the licensed nurse was notified. - On 09/17/25, a PCT (Staff #619) documented abnormal findings for 7 of 12 intradialytic blood pressure readings (79/57 mm/Hg, 85/52 mm/Hg, 89/58 mm/Hg, 84/62 mm/Hg, 98/48 mm/Hg, 88/47 mm/Hg, and 75/44 mm/Hg) without evidence that the licensed nurse was notified. 3. On 09/24/25 at 3:30 PM, Surveyor #6 interviewed the Facility Administrator (Staff #601) and the Manager of Clinical Services (Staff #602) regarding the above findings. Staff #601 and Staff #602 acknowledged the missing documentation of licensed nurse notifications with abnormal intradialytic blood pressure findings. Item #2: Abnormal Post-Treatment Target Weight Without Assessment 1. Document review of the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated 04/24, showed that abnormal findings, including a patient’s post-treatment weight being above or below 1 kg from their target weight, should be reported to the licensed nurse and documented immediately. The licensed nurse will assess the patient before discharge. 2. Document review of patient treatment records showed the following: a. Patient #601’s medical record showed they were discharged on 09/13/25, 1.5 kilograms (kgs) over target weight. The Registered Nurse (Staff #620) failed to document the assessment of the patient related to the target weight before discharge. b. Patient #602’s medical record showed they were discharged on 09/16/25, 1.3 kilograms (kgs) over target weight. The Registered Nurse (Staff #620) failed to document the assessment of the patient related to the target weight before discharge. c. Patient #604’s medical record showed they were discharged on 09/15/25, 1.5 kilograms (kgs) over target weight. The Registered Nurse (Staff #608) failed to document the assessment of the patient related to the target weight before discharge. d. Patient #605’s medical record showed they were discharged on 09/08/25, 1.9 kilograms (kgs) over target weight. The Registered Nurse (Staff #608) failed to document the assessment of the patient related to the target weight before discharge. e. Patient #607’s medical record showed they were discharged on 09/09/25, 1.3 kilograms (kgs) over target weight. The Registered Nurse (Staff #607) failed to document the assessment of the patient related to the target weight before discharge. - On 09/11/25, Patient #607 was discharged 2.5 kilograms (kgs) under target weight. The Registered Nurse (Staff #621) failed to document the assessment of the patient related to the target weight before discharge. f. Patient #609’s medical record showed they were discharged on 09/19/25, 6.3 kilograms (kgs) over target weight. The Registered Nurse (Staff #608) failed to document the assessment of the patient related to the target weight before discharge. g. Patient #610’s medical record showed they were discharged on 09/08/25, 1.4 kilograms (kgs) over target weight. The Registered Nurse (Staff #608) failed to document the assessment of the patient related to the target weight before discharge. 3. On 09/24/25 at 3:30 PM, Surveyor #6 interviewed the Facility Administrator (Staff #601) and the Manager of Clinical Services (Staff #602) regarding the above findings. Staff #601 and Staff #602 acknowledged the missing documentation of licensed nurse post-treatment assessments for abnormal findings related to patient target weights. Item #3: Management of Blood Pressure 1. Document review of the facility document “Hemodialysis Standing Orders,” dated 09/24, showed the Medications/ PRN (as needed) Protocol included administering Clonidine 0.1 mg PO (by mouth) x 1 for systolic BP>210 mm/Hg or diastolic BP >110 mm/Hg, may repeat x1 after one hour. 2. Document review of patient treatment records showed the following: a. Patient #605’s medical record showed systolic and diastolic blood pressures meeting criteria for PRN Clonidine administration on 09/12/25, 09/15/25, and 09/17/25. The record showed no evidence of patient assessment or medication administration related to PRN use of Clonidine for blood pressure control. b. Patient #606’s medical record showed systolic and diastolic blood pressures meeting criteria for PRN Clonidine administration on 09/13/25. The record showed no evidence of patient assessment or medication adminisration related to PRN use of Clonidine for blood pressure control. c. Patient #607’s medical record showed systolic and diastolic blood pressures meeting criteria for PRN Clonidine administration on 09/18/25. The record showed no evidence of patient assessment or medication administration related to PRN use of Clonidine for blood pressure control. d. Patient #609’s medical record showed systolic and diastolic blood pressures meeting criteria for PRN Clonidine administration on 09/19/25. The record showed no evidence of patient assessment or medication administration related to PRN use of Clonidine for blood pressure control. 3. On 09/24/25 at 3:30 PM, Surveyor #6 interviewed the Facility Administrator (Staff #601) and the Manager of Clinical Services (Staff #602) regarding the above findings. Staff #601 and Staff #602 acknowledged documentation showed systolic and diastolic blood pressures meeting criteria for PRN Clonidine administration with no evidence of patient assessment related to PRN use of Clonidine for blood pressure control. .”

“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: 45034 . Based on document review and interviews, the facility failed to ensure that staff followed patient prescriptions for dialysis treatments in 3 of 10 patient medical records reviewed (Patients #601, #602, and #610). Failure to ensure dialysis treatments are delivered according to each patient’s treatment prescription places patients at risk for inadequate or unsafe dialysis and at risk for subsequent health complications, including death. Findings included: 1. Document review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” dated 04/24, showed that if the dialysis prescription is not being met, including changing or the inability to meet the blood flow rate (BFR), the reason should be documented. 2. Document review of patient medical records showed the following: a. On 09/09/25 at 10:26 AM, an RN (Staff #607) verified the prescription settings for Patient #621’s BFR of 400 milliliters per minute (mL/min). A PCT (Staff#611) and Staff #607 documented the BFR at 375 ml/min for 3 hours of Patient #621’s treatment time. No reason for the change in blood flow rate was documented. b. On 09/09/25 at 4:22 PM, an RN (Staff #607) verified the prescription settings for Patient #622’s BFR of 350 milliliters per minute (mL/min). A PCT (Staff#614) and Staff #607 documented the BFR at 300 ml/min for 1 hour and changing the BFR to 305 ml/min for the remaining 2 hours of Patient #621’s treatment time. No reason for the change in blood flow rate was documented. c. On 09/10/25 at 11:59 AM, an RN (Staff #608) verified the prescription settings for Patient #622’s BFR of 350 milliliters per minute (mL/min). A PCT (Staff #615) documented the BFR at 300 ml/min for 40 min. Staff #615 then documented the BFR at 225 ml/min for an additional 30 min. A PCT (Staff #616) documented the BFR at 200 ml/min for 30 minutes. No reason for the change in blood flow rate was documented. 3. On 09/24/25 at 3:30 PM, Surveyor #6 interviewed the Facility Administrator (Staff #601) and the Manager of Clinical Services (Staff #602) regarding the blood flow rate documentation. Staff #601 and Staff #602 acknowledged that the staff did not document the reason for changes in the patients’ prescribed blood flow rate. .”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 45034 . Based on document reviews and interviews, the facility failed to ensure all members of the interdisciplinary Team (IDT), including the patient or patient’s designees, participated in and signed the plan of care (POC) in 4 of 10 patient medical records reviewed (Patient #121, #123, #124, and #128). Failure to include patients in the creation and implementation of the POC, and failure to ensure all members of the IDT sign each patient’s POC, places patients at risk for having incomplete, inadequate, or unapproved plans of care. Finding included: 1. Document review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care (POC),” last revised 10/24, showed that patient POC must be completed and signed by all members of the IDT, including patients, within 30 days. 2. Document review of patient medical records showed the following: - On 07/24/25, the facility’s IDT met to complete Patient #121’s plan of care (POC). The POC signature page contained no signature from the Provider, the Registered Nurse (RN), or the Patient. - On 01/16/25, the facility’s IDT met to complete Patient #123’s POC, and the patient/representative signature was collected after 30 days on 03/10/25. - Review of Patient #124 and Patient #130 POC’s showed no evidence of a signature page indicating when the IDT met and who was in attendance. 3. On 09/24/25 at 3:15 PM, Surveyors #1 and #6 interviewed the Facility Social Worker (Staff #106), who stated that attendees of the IDT meetings should sign the POCs signature page at the POC meeting and review it with the patient within 30 days of the meeting. 4. On 09/24/25 at 3:35 PM, Surveyors #1 and #6 interviewed the Facility Administrator (Staff #101) and the Manager of Clinical Services (Staff #102) regarding missing and late POC signatures. Staff #101 and Staff #102 confirmed the findings. .”