Davita Spring City 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, the facility failed to ensure two of three Patient Care Technicians (Patient Care Technician (PCT)2 and PCT3) who were observed during care delivery, implemented proper infection control measures during initiation and discontinuation of dialysis. Failure to use recommended infection control practices increases the risk 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 the treatment floor on 06/18/25 at 11:15 AM, PCT2 was observed discontinuing hemodialysis for Patient (Patient (P)9) at Station 8. While preparing supplies, P9’s machine alarmed at which time PCT2 used a glove to cover the tip of a finger and reached to the machine to silence the alarm. During observation on the treatment floor on 06/18/25 at 11:55 AM, PCT3 was observed initiating hemodialysis for P1 with a CVC access at Station 4. It was noted that PCT3 had great difficulty donning clean gloves. So much difficulty that in several instances, PCT3 proceeded through the dialysis initiation process with the gloves covering only one half of each hand. When questioned about this after the treatment initiation was completed, PCT3 stated that “these gloves don’t really fit my hands, they are hard to get on.” When asked if PCT3 had tried a different size, PCT3 stated, “no.” During observation on the treatment floor on 06/20/25 at 11:05 AM, PCT2 was observed preparing a hemodialysis machine for P10 at Station 3. While setting the machine parameters, PCT2 was noted to use a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. During observation on the treatment floor on 06/20/25 at 11:40 AM, PCT2 was observed preparing a hemodialysis machine for P1 at Station 7. While setting the machine parameters, PCT2 was noted to use a glove, which had not been donned, as a barrier by holding the glove between the fingers while touching the machine. When interviewed on 06/20/25 at 2:15 PM, PCT2 was asked if touching the machine without a fully gloved hand was in accordance with facility policy, PCT2 stated “I do think it is, because the machine is actually clean at that point, before dialysis is started.” PCT2 stated, “I think that is correct anyway.” During observation on the treatment floor on 06/20/25 at 3:45 PM, PCT3 was observed silencing an alarm on a hemodialysis machine for P11 at Station 3 with an ungloved hand. When questioned, PCT3 stated, “no I’m supposed to wear a glove to silence alarms. I was in a hurry.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” last revision date April 2023, indicated, “Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.” During an interview on 06/20/25 at 4:30 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.””

“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, the facility failed to ensure three of three Patient Care Technicians (Patient Care Technician (PCT)1, PCT2, and PCT3) observed during care delivery, wore personal protective equipment (PPE) properly when performing procedures during which spurting or spattering of blood might occur. Failure to wear PPE properly while providing care in 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 the treatment floor on 06/18/25 at 11;05 AM, PCT1 was observed discontinuing dialysis for Patient (P)8) at station 7. The protective cover gown that PCT1 was wearing did not cover the entire length of PCT1’s arms, exposing approximately two inches of each arm to the wrist. After this treatment had been discontinued, when questioned about the ill-fitting gown, PCT1 stated “I have long arms. The arms on this gown are just too short.” When asked why the lack of gown coverage was a concern, PCT1 stated, “it’s an exposure risk.” During observation on the treatment floor on 06/18/25 at 11:55 AM, PCT3 was observed initiating hemodialysis for P1 with a CVC access at Station 4. It was noted that PCT3 had great difficulty donning clean gloves. So much difficulty that in several instances, PCT3 proceeded through the dialysis initiation process with the gloves covering only one half of each hand. When questioned about this after the treatment initiation was completed, PCT3 stated, “these gloves don’t really fit my hands. They are hard to get on.” When asked if PCT3 had tried a different size, PCT3 stated, “no.” During observation on the treatment floor on 06/20/25 at 3:35 PM, PCT2 was observed initiating dialysis for P3 at station 12. The protective cover gown that PCT2 was wearing did not cover the entire length of PCT2’s arms, exposing approximately three inches of each arm to the wrist. After this treatment had been initiated, when questioned about the uncovered wrists and arms, PCT2 stated “I know, not quite long enough, and they keep pulling up.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities” last revision date April 2023 indicated, “Appropriate fluid resistant / fluid impervious gowns will be worn by all teammates ... while in the treatment area ... whenever there is the potential for contact with body fluids. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.” During an interview on 06/20/25 at 4:30 PM,. the Facility Administrator stated, “they need to wear the larger gowns with longer sleeves. These PPE observations do not meet the requirements of our infection control policy.””

“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: 35561 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure two of two Patient Care Technicians (Patient Care Technicians (PCT2 and PCT3) observed caring for Central Venous Catheters (CVC - a large plastic tube placed in a vein in the neck for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment), implemented proper infection control measures during initiation of dialysis through a CVC. Failure to use recommended infection control practices increased the relative risk for bacteremia in patients with dialysis catheters. This deficient practice had the potential to affect all current and future facility patients that dialyzed with CVC accesses. Findings include: On 06/18/25 at 11:15 AM, PCT2 was observed initiating hemodialysis for Patient (Patient (P)1) with a CVC access at Station 4. When removing the dressing covering the CVC insertion site, PCT3 touched the catheter insertion site multiple times with a gloved hand. PCT3 then cleansed the area surrounding the catheter insertion site with a moistened swab. After cleaning the site, PCT3 waved a hand over the cleansed insertion site until it was dry. When interviewed on 06/20/25 at 2:00 PM, PCT3 was asked if waving above the insertion of an indwelling catheter was the policy of the facility, PCT3 stated “No, I shouldn’t do that because I could introduce germs to the catheter site.” On 06/18/25 at 11:55 PM, PCT3 was observed initiating hemodialysis for P1 with a CVC access at Station 4 as noted above. PCT3 removed the protective end cap from the arterial limb and cleaned the open hub for 3 seconds, then removed the end cap from the venous limb and cleaned the open hub for 2 to 3 seconds before connecting sterile syringes to each limb. On 06/18/25 at 12:40 PM, PCT3 was observed initiating hemodialysis for P6 with a CVC access at Station 5. PCT3 removed the protective end cap from the arterial limb and cleaned the open hub for 3 seconds, then removed the end cap from the venous limb and cleaned the open hub for 2 to 3 seconds before connecting sterile syringes to each limb. After this treatment initiation was complete, when PCT3 was asked how many seconds facility policy required for a “hub scrub,” PCT3 stated “30 seconds ... I probably should have counted.” Review of the facility’s policy titled, “Central Venous Catheter (CVC) Procedure” last revised October 2025 indicated, “Holding catheter with non-dominant had and using aseptic technique, clean exit site for a minimum of 30 seconds ... Then wait 60 seconds for air dry time.” The policy further stated, “Scrub each CVC hub for 15 seconds including the sides, threads, and end of hub thoroughly with friction. Hold limbs until the antiseptic has dried.” During an interview on 06/20/25 at 4:30 PM, these findings were discussed with the Facility Administrator Manager and the Manager of Clinical Services at which time the Facility Administrator responded, “These observations do not meet the requirements of our infection control policy. Sterile technique is essential when accessing any CVC in order to prevent infection.””

“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: 35561 Based on interview, record review, and policy review, the facility failed to ensure patient target weight or estimated dry weight (what the patient would weigh if dry, meaning without excess fluid accumulation) was achieved during each dialysis treatment for two of five records reviewed. (Patient (P)2 and P3). This failure had the potential to place the patient at risk for serious medical complications related to removal of too little or too much fluid during the treatment, and could affect all in-center dialysis patients receiving treatment at the facility. Findings include: 1. Review of P3’s treatment sheets found in the medical record dated 06/04/25 through 06/18/25 titled, “Treatment Details Report” under the section titled, “Post Treatment Weight” revealed the following for six of seven treatments: a. Treatment Details Report on 06/04/25 documented a target weight of 71.0 kg (kilogram). The pretreatment weight was documented as “67.50 kg.” The post treatment weight was documented as “67.0 kg” The difference from target weight was 4.0 kg (8.8 pounds (lbs.). There was no documentation of the physician being notified or interventions initiated when P3’s post dialysis weight was 8.8 lbs. lower than the target weight ordered by the physician in the dialysis plan of care. b. Treatment Details Report on 06/06/25 documented a target weight of 71.0 kg. The pretreatment weight was documented as “86.1 kg.” There was no notation of the dramatic difference in the post weight on 06/04/25 (67.0 kg) and today’s pre weight of 86.1 kg - a difference of 19.1 kg (42.0 lbs.). There was no documentation that PCT 3 verified the patient’s weight pre dialysis to ensure accuracy and enable correct calculation of ultrafiltration (fluid removal) for the treatment. The post treatment weight was documented as “79.2 kg” The difference from target weight was 8.2 kg (18.1 lbs.). There was no documentation of the Registered Nurse (RN) being notified by the PCT of this large discrepancy in P3’s weights. There was no documentation of the physician being notified or interventions initiated when P3’s post dialysis weight was 18.1 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. c. Treatment Details Report on 06/09/25 documented a target weight of 71.0 kg. The pretreatment weight was documented as “84.9 kg.” The post treatment weight was documented as “78.7 kg” The difference from target weight was 7.7 kg (17.0 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P3’s post dialysis weight was 17.0 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. d. Treatment Details Report on 06/11/25 documented a target weight which had been increased to 78.5 kg. The pretreatment weight was documented as “82.9 kg.” The post treatment weight was documented as “80.4 kg” The difference from target weight was 1.9 (4.2 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P3’s post dialysis weight still was 4.2 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. e. The Treatment Details Report on 06/18/25 documented a target weight of 78.5 kg. The pretreatment weight was documented as “82.7 kg.” The post treatment weight was documented as “81.3 kg” The difference from target weight was 2.8 kg (6.2 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P3’s post dialysis weight was 6.2 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. f. Treatment Details Report on 06/18/25 documented a target weight of 78.5. kg. The pretreatment weight was documented as “84.6 kg.” The post treatment weight was documented as “84.1 kg” The difference from target weight was 5.6 kg (12.3 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P3’s post dialysis weight was 12.3 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. 2. Review of P2’s most current treatment sheets found in the medical record dated from 06/04/25 through 06/18/25, titled “Treatment Details Report” under the section titled, “Post Treatment Weight” revealed the following for three of seven treatments: a. The Treatment Details Report on 06/06/25 documented a target weight of 99.0 kg. The pretreatment weight was documented as “104.5 kg.” The post treatment weight was documented as “101.9 kg” The difference from target weight was 2.9 kg (6.4 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P2’s post dialysis weight was 6.4 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. b. Treatment Details Report on 06/09/25 documented a target weight of 99.0 kg. The pretreatment weight was documented as “103.4 kg.” The post treatment weight was documented as “100.9 kg” The difference from target weight was 1.9 kg (4.2 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P2’s post dialysis weight was 4.2 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. c. Treatment Details Report on 06/11/25 documented a target weight of 99.0 kg. The pretreatment weight was documented as “103.5 kg.” The post treatment weight was documented as “100.4 kg” The difference from target weight was 1.4 kg (3.1 lbs.). There was no documentation of the nurse or physician being notified or interventions initiated when P2’s post dialysis weight was 3.1 lbs. higher than the target weight ordered by the physician in the dialysis plan of care. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 stated, “Abnormal Findings: The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Post-Treatment: If patient is above or below 1 kg (kilogram) from the target weight ...The licensed nurse notifies the physician as needed of changes in patient status. The physician will be notified of any concerns that may preclude the initiation of dialysis.” During an interview on 06/20/25 at 4:30 PM, the Facility Administrator confirmed the above findings. The Facility Administrator stated the PCTs should have reported each failure to achieve the target weight to the Registered Nurse (RN) and both are responsible for documenting such findings in the treatment record. The Facility Administrator also stated, “the nurse is responsible for notifying the physician of such large discrepancies in patient weights.””