Davita Bay Shore 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: 28297 Based on observation, interview, and policy review the facility failed to ensure staff adhered to proper hand hygiene practices for one of three survey days. Failure to complete proper hand hygiene had the potential for cross contamination and could affect 131 in-center patients. Findings include: 1. Observation on 10/07/24 at 2:15 PM revealed Registered Nurse (RN) 18 was at Station West 10 doing a patient assessment. RN18 removed gloves and discarded them in the trash then walked over to the clean supply drawer and removed disinfectants pads without sanitizing hands. During an interview on 10/07/24 at 2:15 PM RN18 confirmed he/she did not wash or sanitize hands after glove removal as required. 2. Observation on 10/07/24 at 2:45 PM revealed the Nurse Practitioner was at Station East 3 with Patient (P) 12 while the patient was on dialysis. During the conversation the Nurse Practitioner was reviewing data on the machine and pushing button without wearing gloves. During an interview on 10/07/25 at 2:45 PM the Nurse Practitioner confirmed he/she was not wearing gloves while touching the dialysis machine. He/she confirmed gloves were required when touching the dialysis machine. During an interview on 10/09/24 at 1:20 PM the Facility Administrator and Manager of Clinical Services confirmed that hand hygiene was required after glove removal and gloves were required to be worn when touching the dialysis machine to prevent cross contamination. Review of the facility policy “Infection Control for Dialysis Facilities,” revised April 2023 indicated, “. . .Hand Hygiene: All teammate, Physicians and Non Physicians will perform hand hygiene. . .prior to gloving and immediately after removal of gloves. . .before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. . .Disposable gloves will be work when caring for the patient or touching the patient’s equipment at the dialysis station. . .””

“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: 28297 Based on observation, interview and policy review the facility failed to ensure staff wore Personal Protective Equipment (PPE) as required for two of three survey days. The failure to wear PPE appropriately had the potential for splash contamination of staff and this could affect 131 in-center patients. Findings include: 1. Observation on 10/07/24 at 2:30 PM Registered Nurse (RN) 18 was initiating the treatment via a left upper arm fistula (a vascular access created under the skin to access the blood stream used for hemodialysis) for Patient (P)11 at Station West 10. RN18 did the entire procedure without full face covering. RN18 had goggles and a mask however the mask was below the nose. During an interview on 10/07/24 at 2:30 PM RN18 confirmed the mask was not covering the nose and stated mask were not mandatory. RN18 confirmed there was a risk for splash without full face covering as required. 2. During an observation on 10/08/24 at 10:00 AM the Nurse Manager was at Station East 2 discontinuing the treatment via a Central Venous Catheter (CVC) (a flexible tube inserted under the skin into a vein to access the blood stream used for hemodialysis) for P13. The Nurse Manager had glasses that did not have on side coverings to protect from splashes. During an interview on 10/08/24 at 10:25 AM the Nurse Manager confirmed he/she did not have proper eye protection that included side protection on the glasses and that there was a risk of splashing with the current glasses. During an interview on 10/09/24 at 1:20 PM the Facility Administrator and Manager of Clinical Services confirmed full face covering includes covering of the eyes, nose, and mouth to prevent potential splash contamination, and that observations found were not appropriate. Review of the facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD [Hemodialysis] Antimicrobial End Caps Procedure,” revised October 2024, indicated, “. . .Personal Protective Equipment (face protection, gloves, fluid resistant/fluid imperious garment). . .” Review of the facility’s policy titled, Treatment Initiation Utilizing B Braun Dialog+ Dialysis Delivery Systems with All Single Use Dialyzer Types and Streamline Blood Lines,” revised October 2024, indicated, “. . .Personal Protective Equipment (face protection, gloves, fluid resistant/fluid imperious garment). . .””

“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: 28297 Based on observations, interview and policy review, the facility failed to ensure staff completed Central Venous Catheter (A hemodialysis central venous catheter is a type of access used for hemodialysis. CVCs are placed under the skin and into a large central vein, preferably the internal jugular veins.) care as required for one of two observations. The failure to provide appropriate CVC care had the potential for contamination and this could affect 29 patients in the facility who have CVC’s. Finding includes: Observation on 10/07/24 at 2:30 PM revealed Patient Care Technician (PCT) 16 was at Station West 10 with Patient (P) 11 completing CVC care. PCT16 withdrew blood from both arterial and venous ports and flushed both ports with normal saline without disinfection of the ports/limbs. PCT16 then disinfected the ports/limbs and applied the end caps. PCT16 completed CVC care after withdrawing blood from the ports/limbs and flushing the CVC ports/limbs. During an interview on 10/07/24 at 2:35 PM PCT16 confirmed he/she did not disinfect the ports/limbs until just prior to end cap placement. He/she also confirmed he/she did not complete the CVC dressing change until after flushing because he/she did not want to contaminate the dressing. During an interview on 10/09/24 at 1:20 PM the Facility Administrator and Manager of Clinical Services confirmed that the CVC dressing change should have been completed prior to flushing the CVC to ensure the catheter was not dislodged and to assess for other issues for P11. In addition, the Facility Administrator and Manager of Clinical Services confirmed PCT16 should have disinfected the catheter prior to blood removal from the arterial and venous ports/limbs per the facility policy for P11. Review of the facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD [Hemodialysis] Antimicrobial End Caps Procedure,” revised October 2024, indicated, “ ...4. Remove old dressing and discard, observe site for signs and symptoms of infection such as redness, drainage, swelling, or tenderness. If present, report to RN[Registered Nurse]/Physician, if drainage is present, obtain order for exit site culture. Observe CVC at exit site for evidence of cuff migration, cracks, or leaks in the catheter limbs. If present, do not initiate dialysis. Report to RN physician for further follow-up ...9. Clean each CVC limb/cap with new LARGE alcohol prep pad, starting close to the exit site and finish with the cap ...16 Verify both catheter clamps are closed. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads, and end of the hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried. Attach sterile 10 ml syringes to the arterial and venous limbs. Open the catheter clamps. Aspirate an amount greater than the catheter limb lumen, generally about 5 ml from each limb ...””

“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: 18750 Based on interview, record review, and policy review, the facility failed to ensure three of 10 sampled patients (Patient (P) 2, P6, and P10) were monitored every 30 minutes as required. The failure to monitor patients every 30 minutes had the potential not to capture a potential adverse event in a timely manner and could affect all 131 in-center hemodialysis patients. Findings include: 1.Review of P2’s “medical record” revealed admission date of 09/03/24 with a diagnosis of acute kidney injury. Review of P2’s six “Dialysis Flow Records,” provided by the facility from 09/24/24-10/05/24, revealed on 10/01/24, P2’s blood pressure was checked at 10:30 AM with a reading of 103/55 and was not checked again until 12:04 PM, with a reading of 117/66, one hour and 34 minutes later. 2. Review of P6’s “medical record” revealed admission date of 01/12/24 with diagnoses of End Stage Renal Disease (ESRD) and diabetes mellitus. Review of P6’s six “Dialysis Flow Records,” provided by the facility from 09/23/24-10/04/24, revealed on 10/04/24 the patients’ blood pressure was checked at 5:30 PM with a reading of 144/81 and was not checked until 6:26 PM, with a reading of 107/61, 56 minutes later. 3. Review of P10’s “medical record” revealed admission date of 12/12/17 with diagnoses including ESRD and diabetes mellitus. Review of P10’s six “Dialysis Flow Records” provided by the facility from 09/21/24-10/02/24 revealed on 09/21/24 the patients’ blood pressure was checked at 10:56 AM with a reading of 113/59 and was not checked until 12:58 PM, with a reading of 112/54, two hours and two minutes later, and then not checked until 1:46 PM with a reading of 109/55, 47 minutes later. During an interview on 10/09/24 at 12:29 PM, Certified Clinical Hemodialysis Technician (CCHT)6 confirmed the checks should occur every 30 minutes unless there are issues with the blood pressure in which the checks should occur more often. During an interview on 10/09/24 at 12:52 PM, the Nurse Manager (NM) reviewed the treatment sheets for P2, P6, and P10 and confirmed that they did not have the 30-minute monitoring. The CM stated, “The checks occur for patient safety. Make sure they are stable.” During an interview on 10/09/24 at 1:27 PM, the Administrator confirmed the treatments were not monitored per policy. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024 indicated, “Purpose: To obtain and document baseline and ongoing information about patient before, during and after dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and reviewing the patient’s response to the treatment and status prior to discharge. . . Intradialytic Data Collection/ Assessment. . . 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT [Patient Care Technician], or licensed nurse includes. . . iii Non-nocturnal treatments are completed at least every thirty (30) minutes. . .””