Davita Shawano Lake 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: 35561 Based on observation, interview, and review of the facility’s policy, it was determined the facility failed to ensure two of three Patient Care Technicians (Patient Care Technician (PCT)2, PCT3), one of one Registered Nurses (Registered Nurse (RN)1), and the Facility Administrator, who were observed during care delivery, implemented proper infection control measures during monitoring, and discontinuation of dialysis. Failure to use recommended infection control practices increases the risk of cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all patients receiving treatment in the dialysis unit. Findings include: 1. During observation on the treatment floor on 07/23/25 at 11:30 AM, RN 1 was observed donning clean gloves and assisting Patient (P)11 at Station 8 with repositioning the blood pressure cuff on the patient’s arm several times to obtain an accurate measurement. RN 1 then, without removing gloves and performing hand hygiene, used the keyboard at the chairside computer stand to type a note. When asked if the keyboard and computer were considered to be clean or dirty according to facility policy, RN 1 stated “clean.” 2. During observation on the treatment floor on 07/23/25 at 12:05 PM, PCT3 was observed discontinuing hemodialysis for P2 with both a peripheral arm access, in addition to a CVC (central venous catheter) access at Station 14. It was noted that PCT3 had great difficulty in gathering the necessary equipment required to complete this task. So much difficulty that in 13 instances, PCT3 stopped the procedure, removed gloves, and proceeded to the clean supply drawer for additional supplies without performing hand hygiene. When questioned about this during an interview on 07/25/25 at 11:40 AM, PCT3 stated that “the correct way would be to wash my hands when I took my gloves off. I think I just forgot.” 3. During observation on the treatment floor on 07/23/25 at 12:15 PM, the Facility Administrator was observed silencing a machine alarm at Station 15 where P6 was receiving a dialysis treatment by using a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. During an interview on 07/25/25 at 3:10 PM, when the Facility Administrator was asked what the correct procedure was when silencing an alarm on the treatment floor, the Facility Administrator stated, “I know the right thing to do, I’m sure I probably just didn’t do it that time.” 4. During observation on the treatment floor on 07/23/25 at 12:35 PM, PCT 2 was observed silencing a machine alarm at Station 13 where P7 was receiving a dialysis treatment by using a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. During an interview on 07/25/25 at 11:10 PM, when PCT 2 was asked what the correct procedure was when silencing an alarm on the treatment floor, PCT 2 stated “put the glove on your hand.” 5. During observation on the treatment floor on 07/25/25 at 9:50 AM, PCT3 was observed donning clean gloves and assisting P6 at Station 14 with repositioning the blood pressure cuff on the patient’s arm. PCT 3 then, without removing gloves and performing hand hygiene, used the keyboard at the chairside computer stand to type a note. When questioned about this during an interview on 07/25/25 at 11:45 AM, PCT3 stated that “We’re not supposed to type with gloves on, the computer is clean.” During an interview on 07/25/25 at 3:20 PM the Facility Administrator stated, “the PCT’s have all been taught the importance of hand hygiene and when to wear gloves. These observations are not in accordance with our infection control policy.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” last revision date April 2023, indicated “All teammates will perform hand hygiene prior to and immediately after removal of gloves, after patient and dialysis delivery system contact, before touching clean areas such as supplies, supply care and chairside keyboard / mouse ... Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.””

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 35561 Based on observation, interview, and review of policies and procedures, the facility failed to ensure that an area designated for the clean sink and clean supplies was clearly separated from the biohazard waste and trash receptacles where there was a potential for contamination with blood or body fluids as noted for two of two survey days when in center dialysis treatments were on going. The failure to separate clean areas from dirty areas had the potential for contamination of clean areas and could affect all in-center patients receiving dialysis treatments. Findings include: Observations of the treatment floor on 07/23/25 from 9:30 AM to 1:00 PM, on 07/23/25 from 4:00 PM to 5:30 PM, and again on 07/25/25 from 9:00 AM to 12:30 PM revealed a large trash receptacle and a biohazard waste receptacle immediately adjacent to the clean sink across from Stations 4 and 5. These receptacles were the same height as the sink and were so close as to be in direct contact with the clean area of sink and supplies. There was no means of separation between the clean and the contaminated waste. Patient care staff were observed multiple times taking contaminated waste and bloody supplies post dialysis and tossing them into the trash receptacle and biohazard waste receptacle next to the clean sinks. During a facility walk through on 07/25/25 at 10:00 AM, conducted with the Facility Administrator, revealed the same observations as noted above. When questioned, the Facility Administrator acknowledged that as observed, the biohazard waste receptacles for contaminated equipment had not been separated from clean sinks and supplies to prevent cross contamination of the clean sinks. The Facility Administrator stated, “no one has ever told me that before.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” last revision date April 2023, indicated “Clean areas should be clearly separated from contaminated areas where supplies and equipment are handled.””

“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: 35561 Based on observation, interview, and review of policies and procedures, the facility failed to ensure staff removed personal protective equipment (PPE) before leaving the treatment area, in one of two water room observations. Failure to remove PPE outside the treatment area presents a potential for cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all patients receiving treatment in the dialysis unit. Findings include: During observation on 07/25/25 at 11:20 AM, Patient Care Technician (PCT) 3 left the treatment room area with this surveyor to complete a water test in the water treatment room. PCT 3 failed to remove the PPE gown prior to entering the water treatment room to check the water for chlorine. After completing the water test, PCT3 returned to the treatment area wearing the same PPE gown. During an interview on 07/25/25 at 11:35 AM, PCT3 was asked whether wearing PPE in the water treatment area was in accordance with facility policy. PCT3 stated, “no, I should have taken my gown off washed my hands before going into the water treatment room, I wasn’t thinking.” When PCT 3 was asked why it was important to remove PPE and wash hands prior to entering the water room, PCT 3 stated, “because it’s supposed to be clean in there.” During an interview on 07/25/25 at 3:15 PM, these findings were discussed with the Facility Administrator at which time the Facility Administrator acknowledged that this practice presented a risk for cross contamination and stated, “we all know that we should remove PPE when leaving the treatment area.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” last revision date April 2023, indicated “PPE is to be removed prior to leaving the treatment area. PPE is not to be worn in non-treatment areas,””

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) 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. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 35561 Based on observation, interview and review of policies and procedures, it was determined the facility failed to ensure one of one Patient Care Technicians (Patient Care Technician (PCT)2) observed during medication preparation, implemented proper infection control measures by ensuring the separation of clean and dirty areas during observation of medication preparation. Failure to maintain strict separation of clean and dirty during medication preparation increases the risk for cross contamination and has the potential of exposure to bloodborne pathogens. This deficient practice had the potential to adversely affect all current in-center dialysis patients. Findings include: On 07/23/25 at 11:40 AM, Patient Care Technician (PCT) 2 was observed walking from Station 10, where PCT was preparing the dialysis station, and entering the designated medication area, adjacent to the nursing station. PCT2 failed to remove the non-sterile gloves currently being worn in the patient treatment area prior to entering the clean medication area. PCT2 was then observed preparing intravenous medications (heparin (an anticoagulant) while still wearing the same gloves worn in the treatment area. During an interview on 07/25/25 at 11:00 AM, PCT2 was asked whether wearing gloves in the clean medication area was in accordance with facility policy. PCT 2 stated “no, I should have taken my gloves off first and washed my hands before drawing up medications, I think I was in a hurry and just forgot.” When PCT 2 was asked why it was important to remove gloves and wash hands prior to preparing medications, PCT2 stated “because my gloves were contaminated, and medications are always clean.” During an interview on 07/25/25 at 3:30 PM, the Facility Administrator stated “our policy, and our expectation is that staff remove personal protective equipment prior to entry to the medication preparation area. The PCT’s have all been taught this, in addition to the importance of hand hygiene and when to wear gloves.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” last revision date April 2023, indicated “All teammates will perform hand hygiene after patient and dialysis delivery system contact and before touching clean areas.” This policy also stated “Clean areas should be clearly designated for the preparation, handling, and storage of medication. Clean areas should be clearly separated from contaminated areas where supplies and equipment are handled.””