Davita Vancouver Dialysis Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 52218 Based on observation, interviews, and policy review, the facility failed to meet the requirements of the Conditions for Coverage (CfC) for Infection Control, by failure to: 1) ensure one of one staff (Patient Care Technician (PCT)2) performing patient care secure their hair to prevent their hair from touching the patient while performing Central Venous Catheter (CVC) care. 2) failed to ensure one of one sharps containers not dedicated to one patient are cleaned/disinfected before returning them back to the center of the treatment room. 3) failed to ensure three of three medical waste containers on the treatment floor were secured with tight fitting lids when not in use. This deficient practice has the potential to cause harm to all patients, visitors, staff, and anyone handling medical waste during collection and disposal. Findings Include: 1. The facility failed to ensure one of one staff (PCT2) performing patient care secure their hair to prevent the hair from touching the patient while performing CVC care. (Refer to V111) 2. The facility failed to ensure that one of one sharps containers not dedicated to one patient were cleaned/disinfected before returning them back to the center of the treatment room. (Refer to V116) 3. The facility failed to ensure three of three medical waste containers on the treatment floor were secured with tight fitting lids when not in use. (Refer to V121)”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 22198 Based on observation, interviews, and document review, the facility failed to meet the requirements of the Conditions for Coverage (CfC) for the Physical Environment, when it failed to ensure the means of egress for one of two emergency exits was not used to storage dialysis supplies and failed to ensure that the Water room equipment was maintained. This deficient practice has the potential to cause harm to 119 dialysis patients (87 in-center and 32 home program patients in an emergency.) Findings Include: 1. The facility failed to ensure the means of egress for one of two emergency exits was not used for storage home dialysis supplies. (Refer to V401) 2. The facility failed to ensure the water room equipment was maintained to prevent leaking, bicarbonate mixing stem mixing gauges to be clouded up, and rust build up on back flow prevented funnels. (Refer to V403)”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 52218 Based on documents review, policy review, and staff interview, the facility failed to ensure their emergency evacuation kit included a complete list of staff’s emergency contact information. This has the potential to affect all 119 patients and staff during an emergency evacuation. Findings include: Review of “Teammate Phone List,” updated 05/30/23, in the “Evacuation Kit,” stored on the treatment floor, on 01/15/25 at 8:04 AM, revealed that Patient Care Technician (PCT) 2’s emergency contact information was not included on the list. Review of the facility policy titled “Evacuation Kit” revised September 2014 revealed, “ ...6. Each evacuation kit(s) should contain: c) A roster of all facility teammate’s emergency contact information. Update information as needed.” During an interview on 01/15/25 at 8:10 AM, the Acting Facility Administrator confirmed that PCT2 was employed by the facility and that “PCT2’s emergency contact information should have been included on the Teammate Phone List.””

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 22198 Based on review of employee files & Emergency Management Plan, and interview, the facility failed to ensure that emergency training was completed for one of three employee files reviewed (Master’s Social Work (MSW). The failure to ensure that all staff were educated on Emergency Preparedness and the facility’s Emergency Management Plan annually as indicated in their plan placed all 119 dialysis patients at this facility at risk during a facility emergency. Findings include: Interview on 01/14/25 at 4:00 PM, MSW stated that he/she had received Emergency Preparedness Training within the past 12 months. Review of MSW’s employee file revealed that for the calendar year 2024 to date (01/15/25), there was no evidence in MSW’s electronic learning or paper records “Training Transcript” that MSW had received training for Emergency Preparedness. Interview on 01/14/25 at 2:45 PM during an interview the Manager of Clinical Services (MCS) confirmed that MSW did not have the current Emergency Preparedness Training completed and was uncertain what happened or why it was missed. Review of the facility’s Emergency Preparedness document titled “Facility Emergency Management Plan (ICHD, Home)” [for in-center and home program] dated 10/24 revealed, “Training and Education: ... The FA [Facility Administrator], or designee, is responsible for providing training of EMP [employee]: a. Teammates: i. Annually 1. Policy and Facility Emergency Management Plan 2. Appropriate hazards policies, per HVA 3. Clinical emergency policies 4. Facility specific emergency repose procedures ...v. Document training in teammate file 1. Training/In-service Documentation Form””

“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: 52218 Based on observation, interview, and policy review, the facility failed to ensure one of one staff (Patient Care Technician (PCT)2) performing patient care secured his/her hair to prevent the hair from touching the patient or becoming accidentally entangled in equipment. This deficient practice has the potential to affect all patients receiving care at the facility. Findings include: During an observation of the treatment floor on 01/13/25 at 10:32 AM, was observed performing patient (Patient (P)8)’s sterile dressing change for central venous catheter (CVC) initiation. PCT2’s hair was hanging over the PCT’s face shield and came in contact with P8’s arm. During an interview on 01/13/25 at 10:45 AM, PCT2 confirmed his/her hair was hanging over the face shield and P8. During an interview on 01/13/25 at 10:50 AM, Registered Nurse Manager (RN-M) stated, “All hair should be tied up or secured so that it doesn’t get in the way of patient care.” Review of the facility’s policy titled, “Personal Appearance Policy,” revised 08/28/23 revealed, “Hair ...long hair must be worn up or otherwise secured to prevent hair from falling onto any clean or sterile field or from becoming accidentally entangled in equipment.””

“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: 22198 52218 Based on observation, interview and policy review, the facility failed to clean/disinfect all non-disposable items brought to the patient treatment chair after use to prevent cross contamination between patients. This deficient practice has the potential to spread infection to all patients at the facility. Findings include: 1. During an observation of the treatment floor on 01/13/25 at 10:45 AM, Patient Care Technician (PCT)1 was observed performing Central Venous Catheter (CVC) exit site care for patient (Patient (P)11). PCT1 brought a small, rollable, sharps with a wheeled base tray from the center of the treatment area and placed it next to P11’s treatment chair. At 11:00 AM, PCT1 placed two blood contaminated syringes into the sharps container and at 11:15 AM, PCT1 rolled the sharps container back to the center of the treatment area without disinfecting it. The base tray which holds the sharps container was stained with darkened dried residue and had substantial amounts of dust on it. During an interview on 01/13/25 at 11:20 AM, Registered Nurse (RN) 1 stated, “Yes, all objects brought to the patient’s chair should be disinfected after every use.” Review of the facility’s policy titled, “Infection Control (IC) Quick Reference Guide” dated 2024 revealed, “Station/Training Room .... Teammates will give special attention to cleaning ...and other surfaces that are frequently touched and potentially contaminated with patients’ blood/effluent. The equipment including the dialysis delivery system .....outside of sharps containers.” 2. Observation on 01/14/25 at 10:50 AM, during the cleaning and disinfection of dialysis Station 15, an open box of gloves and two containers of pH test strips (for independent testing of the dialysis machine) was observed behind Station 15, after PCT4 completed the dialysis station cleaning. Interview on 01/14/25 at 10:50 AM, PCT4 was asked about the gloves and two containers of pH test strips sitting on the countertop behind dialysis Station 15, and stated, the items should not be there. PCT4 confirmed that items brought into the dialysis station should be dedicated, disinfected, or disposed of. Review of the facility’s policy titled, “Infection Control For Dialysis facilities” dated 04/23, revealed, “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 ...Disposable gloves and alcohol-based hand rub containers maybe stored on the chair side cart shelves but not stored on counters where terminals are mounted.” 3. On 01/14/25 at 11:35 AM during an observation of Arteriovenous Fistula (AVF) discontinuation, PCT5 was observed wheeling in the mobile cart that housed the biohazardous sharps bucket from the middle of the dialysis section in POD A into the dialysis Station 1 to dispose of the two AVF needles removed during dialysis discontinuation. Interview on 01/14/25, PCT5 confirmed that he/she had brought the mobile cart that housed the biohazardous sharps bucket from the middle of the dialysis section into POD A. PCT5 stated that it was their process to use one mobile cart with the biohazardous sharps bucket for multiple stations. PCT5 confirmed after it was pointed out that the mobile cart that housed the biohazardous sharps bucket had dust, debris, and dried dark red/brown substance on it, PCT5 was asked when the mobile carts were cleaned. PCT5 stated, “they were not.” Interview on 01/15/25 at 12:00 PM with the Acting Facility Manager, the Manager of Clinical Services (MCS) and Regional Operation Director (ROD) during the Facility Health Report, confirmed that the facility’s “Infection Control For Dialysis Facilities” policy and DaVita’s “Infection Control Quick Reference Guide” do not include environmental cleaning, so it had not been done.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 52218 Based on observations, interview and policy review, the facility failed to ensure three of three non-foot-operated medical waste containers had closed, tight fitting lids to prevent leakage of potentially hazardous bodily fluids and minimizing the risk of exposure to bloodborne pathogens, thereby infecting all patients, staff, and anyone handling the waste during collection and disposal. Findings include: During observations of the treatment floor from 01/13/25 at 9:00 AM, through 01/15/25 at 4:30 PM, three non-foot-operated medical waste containers; one by treatment chair nine, one against a post between treatment chair three and four, and one by the nurse’s station, contained used dialysis tubing, blood-stained gloves, gauze, and other medical waste. The biohazard bags used to line the containers covered the folding lids, preventing them from having a tight seal, and leaving them open to air. During an interview on 01/13/25 at 9:15 AM, the Registered Nurse Manager (RN-M), confirmed that the three medical waste containers lids were not able to be closed properly thereby leaving them open to the air. RN-M said, “These are the containers that our medical waste company gives us. We will have to get different ones with lids that close.” Review of facility’s policy titled, “Segregation of Medical Waste,” revised October 2023, revealed, “2. Medical waste containers are defined as: ...b. A labeled medical waste transfer container with a wheeled base tray and foot mechanism to open the lid. c. A labeled plastic container with no foot mechanism to open the lid. 3. When using option c above, the following infection control practices need to be followed: Lid should be tight fitting.””

“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: 22198 Based on observations, interviews, and policy review, the facility failed to ensure that the dialysis treatment floor and designated clean areas were maintained to provide a sanitary environment to minimize the transmission of infectious agents within the dialysis unit for two of two observation days. This failure to clean the designated clean storage areas put all 87 in-center dialysis patients at risk for cross contamination. Findings include: On 01/13/25 at 11:10 AM, during an observation of the dialysis treatment floor there was an open mobile cart with clean supplies (glucometer, clean blue clamps, and clean white hemostasis clamps). The cart was not clean with visible dust and debris and crinkled wrappers in the handle crevasse section and on the bottle shelf. Interview on 01/13/25 at 11:10 AM, Registered Nurse Manager (RN-M) confirmed that the cart was not clean. RN-M was asked to provide the cleaning schedule for the clean cart. RN-M stated the facility did not have a cleaning schedule but should consider having one since their contracted cleaning company does environmental cleaning and does not touch the facility equipment. Observation on 01/14/25 at 10:30 AM of the dialysis treatment floor revealed five biohazardous mobile carts to have dust and dried brown spots on each of the biohazardous mobile carts that housed the needles sharps containers while on the dialysis treatment floor. There were three four drawer clean storage cabinets on plastic pallets and had visible dust, debris and dusty wrappers were present. Interview on 01/14/25 at 10:30 AM, confirmed that all five biohazardous mobile carts were dusty and had brown spots on them that appeared to be blood. RN-M confirmed that the facility does not have a cleaning schedule for the mobile carts that contain the biohazardous sharps buckets that are wheeled in and out of the dialysis stations. Observation on 01/14/25 at 10:35 AM of an open hallway behind dialysis Station 1, near the Biomedical office and repair room, the laboratory and secure clean storage room were plastic pallets with 14 boxes of “Nipro” dialyzers on four plastic pallets and one light grey/white storage rack with clean supplies and fluids in the hallway/open space. The pallets and rack were visibly dirty with dust and debris paper wrappers under the light grey/white storage rack. There was also white crystallization on the floor and the floor was discolored. Interview on 01/14/25 at 10:35 AM, RN-M confirmed the areas identified for clean storage were not clean and the facility did not have a cleaning schedule or policy for cleaning the four-tiered racks holding clean supplies, or the pallets holding the clean storage or supply areas. The RN-M confirmed he/she understood the need to have a cleaning schedule and to keep these areas clean. Review of the facility’s policy titled “Infection Control For Dialysis Facilities” dated 04/23 revealed, “Supplies will be stored in a manner that maintains their integrity. Anytime the integrity of a package with or without an expiration date is in question, i.e., torn, ripped, wet or contaminated, the package and its contents must be disposed of and not used. ... Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood i. ... Facility Hygiene: Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” Interview on 01/15/25 at 12:00 PM with the Acting Facility Manager, the Manager of Clinical Services (MCS) and Regional Operation Director (ROD) during the Facility Health Report, confirmed that the facility’s “Infection Control For Dialysis Facilities” policy and DaVita’s “Infection Control Quick Reference Guide” do not include environmental cleaning of designated clean storage areas, and the facility did not have a cleaning schedule for the areas identified above, so it had not been done.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 22198 Based on observation, document review and interview, the facility failed to ensure that the water room that housed the dialysis acid and bicarb mixing and holding tanks, and dialysis water purification system was secure from unauthorized users. This failure to secure the water room from unauthorized users has the potential to negatively affect all 87 incenter dialysis patients if the water becomes contaminated. Findings include: Observation during the Flash Tour on 01/13/25 at 10:45 AM, the team entered the clean storage area that was connected to the water room that did not have a door between the clean storage and the locked water room. The clean storage room had a glass door that was a visible direct exit to the back parking lot and garbage disposal area and indicated that it was the “Receiving” door. Interview on 01/13/25 at 10:55 AM, the Biomedical Technician (BMT) and Acting Facility Administrator, the BMT stated that the glass “receiving” door was where the dialysis supplies came into the facility from the outside. The BMT stated he/she could not confirm that the dialysis staff were able to stay with the delivery person(s) while they unloaded supplies in the storage room. BMT confirmed that there was no door to prevent unauthorized users in the storage room from entering the water purification room. Review of the DaVita document titled “Water Scope Of Work Document” provided by the BMT and revised 01/13/25, revealed a door was needed between the water room system and the dialysis storage room. Interview on 01/15/25 at 9:00 AM, the Patient Care Technician (PCT) 5 confirmed he/she was not sure if dialysis staff stayed in the water room/storage room when deliveries were coming in through the “Receiving” door. PCT5 stated sometimes the Administrative Assistant will come back to let them in, and sometimes it is the dialysis floor staff. Review of the facility’s policy titled “Water Treatment System Minimum Component Requirement” dated 10/21 revealed, “Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system and supply ordering. An exception to this may be made for janitorial services for maintenance of the physical environment. All deliveries made in close proximity to the water treatment system must be supervised.””

“MIXING SYSTEMS-CLEANING CFR(s): 494.40(a) 6.4.1 Mixing systems: cleaning Concentrate mixing equipment should be either: (1) completely emptied, cleaned, and disinfected according to the manufacturer’s instructions; or (2) cleaned and disinfected using a procedure demonstrated by the facility to be effective in routinely producing concentrate meeting [these regulations related to allowable bacterial and endotoxin levels]. The disinfection data should be recorded for each ...disinfection cycle using a dedicated log. This Standard is not met as evidenced by: 22198 Based on observation, interview, document review and policy review, the facility failed to ensure that the Granuflo mixer was cleaned after use to prevent corrosion and buildup of acid product splash on the equipment. This deficient practice has the potential to affect all 87 in-center hemodialysis patients. Failure to clean the Granuflo mixer after use has the potential to leave splash residue and decrease the life of the equipment. Findings include: Observation on 01/13/25 at 10:55 AM during the Flash Tour in the Water room, the Granuflo mixer had white crystallization all over the mixing machine tank sides and top of the machine. During an interview on 01/13/25 at 10:55 AM the Biomedical Technician (BMT) stated he/she thought they had just mixed a batch of acid today 01/13/25, that might account for the mixer not being cleaned. Review of the “Granuflo mixing log” document provided by the BMT revealed the last batch of acid mixed was mixed on 01/09/25. Review of the facility’s policy titled “Granuflo ® Concentrate Dissolution Unit (132 Gallon) Mixing Procedure” dated 10/24 revealed, “Clean the exterior of the Granuflo dry acid dissolution unit with a mild detergent after each batch of acid concentrate is mixed.””

“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: 22198 Based on observations, interviews, document review, the Fire Marshall report, and the National Fire Protection Association (NFPA) 101 standards, the facility failed to ensure that the emergency evacuation route for the Home Training program section of the dialysis unit was not used for storage of Home dialysis supplies and overflow of equipment. The failure to ensure that storage and overflow equipment was not stored in the emergency evacuation route places all 32 Home Training program patients, their family/visitors, and staff at risk in the event of an emergency evacuation. Findings include: During an observation upon entrance to the facility on 01/13/25 at 8:30 AM, in a back hallway past the Home Training program rooms and staff offices, leading to the conference room was an emergency light above double door. Observation revealed pallets of storage covering half of the hallway with boxes of fluids stacked above the tape line on the wall. A sign on the wall indicated, “No Storage Within 18” [inches] Of Ceiling.” A Hoyer lift, a metal type case, and a pallet with empty shipping boxes (pictures were taken) were in this area. Observation on 01/14/25 at 7:45 AM, revealed pallets covering half of the hallway with boxes of fluids stacked, a metal type case and a pallet with empty shipping boxes. Observation on 01/14/25 at 8:45 AM, the Manager of Clinical Services (MCS) entered the Home Training Storage area that had empty spaces, and the Conference room had multiple wire racks that had empty storage space. During an interview on 01/14/25 at 8:45 AM, the MCS confirmed that the Home Training program stored supplies for the Home Training program in the emergency evacuation hallway. MCS confirmed there was space in the designated Home Training storage room and the Conference room. MCS stated the facility has stored supplies in the emergency evacuation hallway for a long time, and the most recent Fire Marshall approved it if the facility has a 4-foot clearance in the hallway. MCS confirmed that the boxes of dialysis water bags were stored above the line placed on the wall indicating “No Storage Within 18” Of Ceiling” and should not be. During an interview on 01/14/25 at 10:15 AM, the Registered Nurse Home Training Peritoneal Dialysis (RN-H-PD) confirmed that he/she has worked in the facility for about two years and the storage has been in the hallway since RN-H-PD started working. RN-H-PD confirmed that the boxes of dialysis water bags were stored above the line placed on the wall indicating “No Storage Within 18” Of Ceiling” and should not be. RN-H-PD confirmed that the home program did have one patient that required the use of the Hoyer lift (stored in that emergency evacuation hallway), and confirmed that in the open portion, the Hoyer lift expanded to 4-feet. Review of the most current facility’s Vancouver Fire Department Fire Marshal’s Office report titled “FIRE CODE CORRECTION NOTICE Immediate Action Required” dated 02/21/24 revealed, The “Fire Code Correction Notice” failed to address the emergency evacuation hallway with pallets of dialysis storage or the Fire Marshall’s approval for dialysis storage in the emergency evacuation route/hallway. Review of the undated “Emergency Exit Plan” revealed the Emergency Evacuation route for the Home Training Program was the hallway listed as corridor 101. Review of the facility’s emergency program titled “Facility Emergency Management Plan (ICHD, HOME)” [In-center hemodialysis and Home Training Program] dated 10/24 revealed, “Maintaining a clear understanding and ongoing awareness of hazardous that may affect the patient’ teammates and the facility’s operating ability. ... Fire Safety Preparedness 1. FA [Facility Administrator], or designee, is responsible to: a. Maintain a fire safety preparedness program to prevent or minimize the likelihood of a fire that may result in death, injury, or property damage in accordance with the CMS [Centers for Medicare & Medicaid Services] and OSHA [Occupational Safety and Health Administration] regulations and National Fire Protection Association [NFPA] and applicable local and state life safety code requirements.” Review of the “NFPA 101 (2012), SECTION 7.1.10.1 General” indicated, “Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.””

“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: 22198 Based on observations, interviews, document review and policy review, the facility failed to ensure the water room equipment was maintained to prevent leaking, bicarbonate mixing stem mixing gauges to be clouded up, and rust build up on back flow prevented funnels. This failure had the potential to affect 87 in-center dialysis patients at this facility. Findings include: Observation during the Flash Tour on 01/13/25 at 10:55 AM the large blue filter on the wall behind the Central Water Plant (CWP) in the water room a part of the Reverse Osmosis (RO) section of the water system was leaking with a visible stream of water running down the side of the filter with the floor under the blue filter wet and water running down towards the drain. The back flow preventer funnel cups were made of metal and rusted. Interview on 01/13/25 at 10:55 AM, Biomedical Technician (BMT) stated that the staff had not mentioned anything to him/her about the filter leaking and “I [BMT] changed that on the fifth[01/05/25, 8 days ago].”. BMT confirmed that the back flow preventer funnel cups were made of cast iron and were rusted. Review of the “Water room Filter Maintenance” log confirmed the pre-RO filter was changed on 01/05/25. No work order or report was entered related to the leaking filter. Interview on 01/13/25 at 11:15 AM, BMT stated there was no work order and he/she had not been notified of the leak prior to the Water room observation on 01/13/25. During an observation of the Water room Bicarbonate mixing and storage system on 01/15/25 at 9:00 AM, the Patient Care Technician (PCT) 5 walked through the system components and noted that the pressure gauge above the mixer and between the two holding tanks was cloudy from the inside hindering the visualization of the bottom third of the face of the pressure gage. Above the cloudy pressure gauge was an on/off valve dripping directly onto the pressure gauge. Interview on 01/15/25 at 9:00 AM, PCT5 confirmed the above observation but was uncertain when the leaking started or when the gauge became cloudy. Review of the Bicarbonate Mixing and Storage system diagram confirmed that the O-ring required replacement. Interview on 01/15/25 at 9:30 AM, the BMT confirmed that there was no work order and documentation of the leaking valve or the cloudy gauge. BMT confirmed that the valve was leaking and should not be. BMT confirmed that the bottom third of the pressure gauge was not visible and without visibility, staff were ensure if the equipment was functioning properly. Review of the facility’s policy titled “Water Treatment Systems Minimum Component Requirement” dated 10/21 revealed, “Facilities are required to establish specific procedures that verify and demonstrate functionality of all critical alarm monitoring for both remote and proximal devices ...””

“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: 22198 Based on interviews, record review, and policy review the facility failed to ensure two of four in-center sampled (patients (P)and P2) low blood pressure (BP) was assessed per policy. The failure to properly monitor and assess the patient had the potential for worsening patient conditions without a timely intervention that could affect 87 in-center hemodialysis patients. Findings include: 1. Review of P1’s medical record revealed for two of six of the current “Treatment Details Report” the following: a. On 12/30/24, the last Registered Nurse (RN) assessment/intervention for a low BP was completed at 6:46 PM. The BP was documented as 126/59 mm/Hg. i. At 8:02 PM, Patient Care Technician (PCT) documented BP as 113/53 mm/Hg and documented that the RN was notified. ii. At 8:32 PM, PCT documented BP was 102/54 mm/Hg and documented the RN was notified. The dialysis treatment ended at 8:53 PM, however, there was no RN assessment and documentation related to the low BP in the post dialysis assessment or the narrative section on the dialysis “Treatment Details Report.” b. On 01/01/25 the last RN assessment/intervention for a low BP was completed at 6:02 PM. The BP was documented as 121/62 mm/Hg. i. At 6:32PM, PCT documented the BP as 104/53 mm/Hg and documented the RN was notified. ii. At 7:01 PM, PCT documented the BP as 93/46 mm/Hg. There was no documentation, the RN was notified. iii. At 7:02PM, PCT retook the BP and documented the BP as 82/46 mm/Hg and the PCT documented the cuff was changed and retook the BP at 7:07 PM as 99/51 mm/Hg. There was no documentation, the RN was notified and documented the “UF [ultrafiltration] turned off due to low bp.” iv. At 7:31 PM, PCT documented BP was 125/59 mm/Hg and documented the RN was notified. v. 8:01 PM, PCT documented BP was 102/45 mm/Hg. There was no documentation the RN was notified. vi. At 9:01 PM, PCT document BP was 90/45 mm/Hg and documented retake. At 9:03PM for the BP retake, the PCT documented the BP 75/40 mm/Hg. There was no documentation the RN was notified of the low BP. vii. At 9:04 PM, PCT documented BP was 105/54 mm/Hg and did not document RN notification. The dialysis treatment ended at 9:04 PM, however, there was no RN assessment and documentation related to the low BP in the post dialysis assessment or the narrative section on the dialysis “Treatment Details Report. 2. Review of the medical record for P1 revealed the following for two of six of the most current “Treatment Details Report”: a. On 01/03/25 the treatment started at 3:56 PM with a BP of 115/44 mm/Hg and the PCT documented the RN was notified. i. 4:05 PM, PCT documented the BP as 163/116 mm/Hg and documented “retake”. At 4:06 PM the BP was 114/35 mm/Hg and again documented retake. At 4:07 PM BP, was documented as 127/89 mm/Hg. There was no RN notification. ii. At 4:32 the PCT documented BP was 133/46 mm/Hg. There was no documentation the RN was notified. iii. At 5:02 PM the PCT documented BP was 116/46 mm/Hg. There was no documentation the RN was notified. iv. At 5:32 PM the PCT documented BP was 130/51 mm/Hg. There was no documentation the RN was notified. v. At 6:02 PM the PCT documented BP was 112/49 mm/Hg. There was no documentation the RN was notified. vi. At 6:32 the PCT documented BP was 107/45 mm/Hg. There was no documentation the RN was notified. vii. At 6:36 PM [2.5 hours after the PCT reported the low BP] the RN documented “monitoring bp q (every) 15 (minutes); bp trending down.” Blood pressure taken every 15 minutes until the end of the dialysis treatment at 7:24 PM, however, the low BP for the entire dialysis treatment was not documented in the post dialysis assessment or the narrative section on the dialysis “Treatment Details Report.” During an interview on 01/14/25 at 4:00 PM the Manager of Clinical Services (MCS) confirmed that the PCTs should notify the RN. The RNs were responsible to document interventions and/or outcomes and then the MCS pointed out two sections in the “Treatment Details Report” where the RN could document dialysis concerns. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” dated 04/24 revealed, “This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. ... Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. ... ii. Measurement of Blood Pressure (BP) ...Abnormal Findings: Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg.””

“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: 22198 Based on record review, interview, and policy review the facility failed to ensure that four of 10 patients” (Patient (P)1, P2, P4, and P10) medical records reviewed failed to have the Dietitian, Medical Director and/or Patient sign the Patient Plan of Care (PPOC). Failure to ensure everyone has acknowledged and received the completed PPOC has the potential to affect all 119 in-center hemodialysis and Home program patients at this facility. Findings include: Review of P1’s “PPOC” in the medical record indicated P1 was stable. The Interdisciplinary Team (IDT) team meeting occurred on 11/20/24 and the Registered Dietitian (RD) and P1 did not sign the 11/20/24 PPOC until 01/13/25. Review of P2’s “PPOC” in the medical record indicated P2 was stable. The IDT team meeting occurred on 11/21/24 and the RD and the P2 did not sign the 11/21/24 PPOC until 01/13/25. Review of P4’s “PPOC” in the medical record indicated P4 was stable. The IDT team meeting occurred on 11/20/24 and the RD did not sign the 11/20/24 PPOC until 01/13/25. The Medical Director failed to sign the PPOC. Review of P10’s “PPOC” in the medical record indicated P10 was stable. The IDT team meeting occurred on 10/23/2 and the RD did not sign the 10/23/24 PPOC until 01/13/25. The IDT failed to obtain P10’s signature to verify P10 had received and accepted the current PPOC. Interview on 01/14/25 at 4:00 PM, the Manager of Clinical Services (MCS) confirmed that the PPOCs for P1, P2, P4 and P10 were not signed to verify their agreement with the current PPOC. Review of the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan Of Care” dated 10/24, indicated, “The patient’s plan of care will.be completed by facility’s interdisciplinary team, including patient or personal representative, and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.””