Davita Fort Atkinson Dialysis

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure that an area designated for clean supplies was clearly separated from the dirty area where there is a potential for contamination with blood or body fluids and areas where contaminated or used supplies are stored for one of three survey days. The failure to separate clean areas from dirty area had the potential for contamination of clean supplies and could affect 34 in-center patients. Findings include: Observation on 07/21/25 at 9:55 AM revealed the red biohazard container used to dispose of used dialyzers and hemodialysis lines was stored right next to the clean supply cart across from Station 8. Patient Care Technician (PCT) 1 was observed taking a soiled dialyzer and lines from Station 9 to the red biohazard container stored next to the clean supplies and was in very close contact with the clean supplies. During an interview on 07/21/25 at 9:55 AM PCT 1 stated he/she was not aware the red biohazard container could not be stored next to clear supplies for fear of contamination of clean supplies. PCT1 did acknowledged he/she carried the dirty biohazard from the station to the biohazard container. During an interview on 07/21/25 at 10:15 AM the Facility Administrator observed the red biohazard container stored next to the clean supply cart that had items such as tape, syringes, gauze, box of gloves and other various clean items used for patient care. The Facility Administrator stated the red biohazard container should not be next to the clean supply cart as there was a risk of splattering from soiled biohazard items when they are disposed of in the biohazard container. Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” revised April 2023, indicated, “Clean areas should be clearly separated from contaminated areas where used supplies, and equipment are handled.””

“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: 29972 Based on observation, record review and interview the staff failed to maintain a safe and sanitary environment to mitigate infection control risks in 2 of 5 areas observed (water room, nurses station), in a total sample of 5 areas observed. Findings Include: Review of policy and procedure # 8-04-01 titled, “Physical Environment” last revised April 2018 revealed, “The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. On 11/29/2023 at 11:00 AM, during observations of the Water Room, observed large amount of saw dust debris, packaging material, and a container top, on the floor surrounding the water heaters and on the floor under the electrical boxes. Per interview with Biomedical Technician (Bio) E on 11/29/2023 beginning at 3:00 PM, BIO E stated that staff had not had a chance to clean the floor after BIO E had a removed a large Acid drum from the area. On 11/29/2023 at 11:40 AM, during observations of the nurses station, observed 3 wheeled tray tables positioned against the wall under stethoscopes and faceshield hanging from hooks; the tray tables were covered with a visible layer of dust. Per interview with Clinical Coordinator (CC) C during the observation, CC C stated that staff has not had a chance to clean the tables. CC C was shown the dust on the tables and stated that the tables are “a mess” and agreed the tables should have been cleaned.”

“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: 29972 Based on record review and interview the facility staff failed to ensure patients with Central Venous Catheter (CVC) access sites are assessed and interventions are provided for signs and symptoms of infection in 2 of 5 medical records reviewed (Patient (Pt) #3, 5), in a total sample of 5 records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” last revised October 2023 revealed the following: - “The nursing assessment will be performed and documented by a licensed nurse...A physical assessment of the patient which includes...Patient statement of well-being, level of pain or discomfort...And other components which if observed/informed will be documented, including but not necessarily limited to the following: ...Complaint of...skin changes...” Review of policy and procedure #1-09-04 A titled, “Elevated Patient Temperatures” last revised October 2023 revealed the following: -“A fever is...any temperature greater than 100 (degrees) F (Fahrenheit).” -“Notify licensed nurse teammate that patient has an elevated temperature.” -“Licensed nurse teammate will assess patient for possible cause of fever: Infection or infected access...Elevated dialysate temperature...Pyrogenic (inducing fever) reaction following exposure to bacterial endotoxin.” -“Notify nephrologist if pre-dialysis temperature is higher than 100 (degrees) F...” -“If ordered by nephrologist, obtain blood cultures per procedure and send to the laboratory.” -“Document event, orders, treatment and patient response in the patient’s electronic health record.” Review of Pt #3’s Treatment Details Report for Treatment Date of 10/18/2023 revealed Pt #3’s had a CVC. Per Pt #3’s Pre-Treatment Vitals, at 6:09 AM, Pt #3’s temperature was 100.1 (normal 98.6). Review of Pt #3’s Pre-Treatment Nurse Assessment dated 6:19 AM revealed, “Pt was covid (positive) one month ago, fever and cough today that started yesterday.” Review of Pt #3’s adverse event documentation dated 10/20/2023 revealed, “Patient came to unit on 10/18/2023, documented oral temp of 100.1, charge RN (registered nurse) gave patient acetaminophen and dialyzed him. Patient came to unit on 10/20/2023 (2 days later), documented...oral temp of 101.5, charge RN gave acetaminophen, dialyzed him, but also drew blood cultures. Patient went into hospital on 10/22/2023 not feeling well. Blood cultures came back on 10/23/2023 positive for MRSA (methicillin resistant staphylococcus aureus).” Review of the facility hospitalization log revealed that Pt #3 was hospitalized from 10/22/2023 through 11/06/2023 with a blood stream infection (Septicemia). Per interview with Facility Administrator (FA) A, while reviewing Pt #3’s medical record on 11/29/2023 beginning at 3:30 PM, FA A stated that there was no documentation of the RN assessing possible cause for Pt #3’s fever and notifying the nephrologist of the elevated temperature on 10/18/2023 (4 days before hospitalization) as per policy; FA A stated that the RN should notify the nephrologist when the temperature is greater than 100.0 degrees F. Review of Pt #5’s provider progress note dated 10/31/2023 at 11:43 AM revealed, “...RN worried about permcath (CVC) exit site infection d/t (due to) increased redness/tenderness. Will prescribe oral doxycycline...” Per review of Pt #5’s Treatment Nurse Assessment documented on 10/31/2023 at 10:00 AM, the RN did not document any concerns with Pt #5’s CVC assessment. Per nursing assessment, “Yes” was documented for “...Catheter with no identified problems.” This documentation was inconsistent with the provider’s progress note. Per interview with FA A, while reviewing Pt #5’s medical record on 11/29/2023 beginning at 3:45 PM, FA A confirmed there was no documentation of a nursing assessment and interventions addressing concerns with signs and symptoms of a potential CVC infection. FA A stated that the RN should have documented an assessment of CVC concerns.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 29972 Based on observation, record review, and interview the facility staff failed to follow construction and renovation policies and procedures to mitigate patient safety risks during construction in 1 of 1 facility renovations (in-center hemodialysis); failed to ensure the dialysis supplies are appropriately stored and safe from potential unauthorized access in 1 of 4 areas observed (Patient waiting room) in a total sample of 4 areas observed; and failed to ensure fire extinguishers are easily accessible in 1 of 4 observations of emergency equipment (fire extinguisher), in a total of 4 emergency equipment observed. Findings Include: Review of policy and procedure #8-04-01 titled, “Physical Environment” last revised April 2018 revealed the following: - ...”Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only...” -“The dialysis facility will store supplies in a manner that is consistent with fire safety...Supplies will not obstruct any fire exits and or hallways...supplies will not be stored directly on the floor but stored on shelves or pallets...” Review of policy and procedure #8-04-02 titled,”Construction and Renovation” last revised April 2022 revealed the following: -“The Governing Board will enforce this policy related to construction and renovation activities.” -“Monitoring for violations of this policy will be accomplished through site inspections of construction activities...using the “Construction Activity Audit.” Audits will be performed at a minimum of weekly by the Facility Administrator (FA) or acceptable designee...Indicators found not in compliance will be reported to the...Project Manager and Regional Operations Director and corrective actions taken. The Administrator will be responsible for reviewing the results of these audits during the Facility Health Meeting (FHM).” -“The (FA) will complete a daily walk, on patient treatment days, through tour of the construction renovation site and verify use of barrier containment when indicated, and that general infection control procedures are followed. -“Prior to any construction activity, the (FA) will hold a teammate meeting to review all applicable policies and procedures as well as any measures necessary to verify uninterrupted safe treatments.” -“Prior to any construction activity that has the potential to disrupt, inconvenience, or impact patients being treated at the facility, the (FA) will inform the patients of the activity to take place and the measures to be implemented to verify uninterrupted safe treatments.” Per review of the facility Pre-Construction Meeting minutes dated 09/13/2023, facility renovation and construction project was set to start on 09/25/2023 and be completed by 12/05/2023. Per the meeting minutes, the renovation/construction areas included, but was not limited to; the water room, treatment area/nurses station, and patient waiting room. Per interview with FA A on 11/29/2023 at 4:00 PM, FA A stated that she/he was unable to find documented evidence of Construction Activity Audits being completed weekly as per policy. Per FA A there was no documented evidence of staff discussing physical environment/construction audits in FHM as per policy. FA A stated that there was no documented evidence of the FA completing a daily walk throughs on patient treatment days and observing construction areas and ensure policy and procedures are being followed. Per FA A, she/he was unable to find documentation showing evidence of the patients and staff being informed and educated on the construction/renovation project expectations and precautions to ensure patient safety as per policy. Per interview with Clinical Coordinator (CC) C on 11/29/2023 at 11:50 AM, CC C stated that staff were not given any education or information pertaining to safety expectations during the construction/renovation project; CC C stated “construction workers just showed up...” CC C stated that patients were not given any education/information about the construction project prior to the the implementation of the renovation. Per observations during tour of the unit on 11/29/2023 beginning at 11:00 AM observed the following: -Multiple cardboard boxes containing dialysis supplies stacked directly on floor in the patient waiting area. The patient waiting area was unsecured to the outside and no staff were present. -Multiple cardboard boxes containing dialysis supplies stacked on the floor directly in front of/and blocking the fire extinguisher located near the lab room. Per interview with Biomedical Technician (BIO) E, while touring the construction areas on 11/29/2023 beginning at 12:00 PM, BIO E stated that due to construction, staff have been storing supply boxes in the patient waiting room. BIO E confirmed that supply boxes should not be stored directly on floor and should be stored in the supply room, but BIO E stated there was not enough space in the supply room for the additional dialysate jugs that are needed during construction. Per interview with FA A on 11/29/2023 beginning at 11:00 AM, while touring the facility and observing emergency equipment, FA A confirmed that the fire extinguisher was blocked by the stacked boxes and stated that the fire extinguisher should not be blocked from emergency access.”