Davita Lynnwood Dialysis

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 49119 . Based on document review and interview, the facility failed to develop and implement emergency preparedness policies and procedures that address a means to shelter in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. Failure to develop and implement emergency preparedness policies and procedures that address a means of sheltering in place for those who remain in the facility during a disaster or emergency could lead to adverse outcomes for patients, staff, and volunteers. Findings included: 1. Document review of the facility’s “Emergency Preparedness Plan” showed no evidence of a policy addressing a means to shelter in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. 2. On 08/18/25 at 2:20 PM, Surveyor #6 interviewed the Facility Administrator (Staff #623) about the facility lacking a policy regarding a means to shelter in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. Staff #603 confirmed that the facility lacks a policy for sheltering in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. .”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 49119 . Based on document review and interview, the facility failed to track and document the contact information for tribal officials as a source of assistance in its emergency preparedness policies and procedures. Failure to maintain contact information of official agencies for use during an emergency places patients and staff at risk for harm due to ineffective communication. Findings included: 1. Document review of the facility’s “Emergency Preparedness Plan” showed no evidence of the contact information for tribal officials as a source of assistance in its emergency preparedness policies and procedures. 2. On 08/18/25 at 2:20 PM, Surveyor #6 interviewed the Facility Administrator (Staff #623) regarding the facility’s emergency preparedness plan failing to track and document the contact information for tribal officials as a source of assistance. Staff #603 confirmed that the plan failed to track and document the contact information for tribal officials as a source of assistance. .”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 49119 . Based on observations, interviews, and document review, the facility failed to dedicate equipment used for dialysis treatment of hepatitis B antigen (HBsAg) positive patients. Failure to dedicate equipment used for dialysis treatment of HBsAg-positive patients risks cross-contamination and use of the equipment by hepatitis B virus (HBV) susceptible (non-immune) patients. Reference: Centers for Disease Control and Prevention (CDC). Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients, No. RR-5, Vol. 50, dated 04/07/01. Downloaded from https://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf. Findings included: 1. Document review of the facility policy “Hepatitis B Surveillance, Vaccination, Infection Control Measures, and Isolation Guidance,” dated 04/24, showed that a designated dialysis machine will be used for treatment in the isolation room. The dialysis machine should have a visible label on the front stating “Isolation Machine only” or “Temporary Isolation Machine.” 2. On 08/19/25 at 12:45 PM, Surveyor #6 observed that the dialysis machine being used in the isolation room was missing the isolation signage. 3. On 08/19/25 at 12:50 PM, Surveyor #6 interviewed a Patient Care Technician (Staff #624) regarding the missing isolation machine signage. Staff #624 confirmed that the isolation signage was not on the dialysis machine being used in the isolation room. 4. On 08/19/25 at 1:30 PM, Surveyor #6 interviewed the Biomed Manager (Staff #629) regarding the missing isolation machine signage. Staff #629 confirmed that the isolation signage was missing from the machine being used in the isolation room and from the back-up isolation machine located in the bio-med work area. .”

“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: 49119 . Based on document review, observation, and interview, the facility failed to restrict access to the water purification and storage system to authorized users responsible for monitoring and maintaining the system by failing to keep the door closed. Failure to restrict access to the water purification and storage system only to authorized personnel who monitor and maintain them can lead to unauthorized access, water contamination, and harm to dialysis patients. Findings included: 1. Document review of the facility’s policy titled, “Daily Water Treatment System Monitoring,” revised 04/2025, showed that access to the water treatment system should be restricted to trained personnel responsible for monitoring and maintaining the system and supply ordering. 2. On 08/18/25 at 10:05 AM, during a flash tour of the facility, Surveyors #6 and #7 observed that the water purification and dialysate mixing room door was propped open. The Surveyors entered the water treatment system room without using a key code. 3. On 08/18/25 at 10:15 AM, Surveyors #6 and #7 interviewed the facility Social Worker (Staff #621) and Regional Health Manager (Staff #622) regarding access to the water purification and storage system room. Staff #621 and Staff #622 observed and acknowledged that the door was propped open during the flash tour. 4. On 08/18/25 at 2:20 PM, Surveyor #6 interviewed the Facility Administrator (Staff #623) and Clinical Services Manager (Staff #632) regarding the propped open water purification and dialysate mixing room door. Staff #623 and Staff #632 stated that the room is to remain locked to prevent unauthorized access per facility policy. .”

“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: 49119 . 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 10/2023, showed non-refrigerated medications are to be stored in a safe and locked locations not accessible to persons other than licensed nurse and Facility Administrator or designee. 2. On 08/18/21 at 11:50 AM, Surveyor #7 observed unlocked medication drawer labeled as “PRN Meds” that contained the following medications: - Nitroglycerine (sublingual medication to relieve chest pain) - Diphenhydramine (intravenous antihistamine medication) - Clonidine (oral medication to treat high blood pressure) - Ondansetron (intravenous medication to treat nausea and vomiting) - Acetaminophen (oral medication to relieve pain) 3. On 08/18/21 at 11:55 AM, Surveyor #7 observed two unlocked medication drawers that contained the following medications: - Iron sucrose (intravenous iron medication used to treat anemia) - Calcitriol (oral vitamin D3 medication used to treat calcium deficiency and bone disease) - Doxercalciferol (intravenous vitamin D2 medication used to treat secondary hyperparathyroidism) - Heparin (intravenous anticoagulation medication used to prevent clotting) - Lidocaine 1% (injectable medication for local anesthesia) 4. On 08/18/25 at 12:20 PM, Surveyor #7 interviewed the Staff Nurse on duty (Staff #625) about the unlocked medication drawers. Staff #625 confirmed that the medication drawers were unlocked and should be locked when they are not being accessed by the licensed nurse. .”

“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: 49119 . Based on document review and interview, the facility failed to manage patients’ volume status by failing to manage patient blood pressure (BP) per facility protocol in 1 of 7 patient medical records reviewed (Patient #604). Failure to manage patients’ volume status places patients at risk for ineffective dialysis and at risk for undetected complications. Findings included: 1. Document review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, showed that any abnormal findings or findings outside physician specific ordered parameters pre-treatment will be documented and reported immediately to the licensed nurse. The licensed nurse will assess the patient prior to initiation of dialysis. The Patient Care Technician (PCT) observing or collecting patient information should report and document any changes, abnormal findings, or patient concerns to the licensed nurse including pre and intra dialysis systolic BP greater than 180 mm/Hg and diastolic BP greater than or equal to 100 mm/Hg and post dialysis standing systolic BP greater than 140 mm/Hg and standing diastolic BP greater than 90 mm/Hg. All findings, interventions, and patient responses will be documented in the patient’s medical record. 2. Document review of the treatment records from 08/04/25 to 08/18/25 for Patient #604 showed the following: a. There were abnormal pre dialysis diastolic BP readings in 12 of 14 BP readings. There was no evidence of documentation reporting the abnormal pre dialysis BPs by the PCTs (Staff #624 and #631) to the licensed nurse in 12 of 14 findings. There was also no evidence of documentation of pre dialysis patient assessments regarding the abnormal BPs by the licensed nurse (Staff #625). b. There were abnormal intra dialysis diastolic BP readings in 47 of 70 BP readings. There was no evidence of documentation reporting of the abnormal intra dialysis BPs by the PCTs (Staff #624 and #631) to the licensed nurse in 47 of 70 abnormal findings. c. There were abnormal post dialysis diastolic BP readings in 11 of 14 BP readings. There was no evidence of documentation reporting the abnormal post dialysis BPs by the PCTs (Staff #624 and #631) to the licensed nurse in 11 of 14 findings. There was also no evidence of documentation of post dialysis patient assessments regarding the abnormal BPs by the licensed nurse (Staff #625). 3. On 08/20/25 at 1:30 PM, Surveyor #7 interviewed the Facility Administrator (Staff #623) and Manager of Clinical Services (Staff #632) regarding the unmanaged patient BPs for Patient #604. Staff #623 acknowledged the findings, and they stated that they were unable to provide documentation of follow-up assessments and interventions regarding the high diastolic BPs. .”