Davita Oshkosh West 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: 47413 Based on record review, observation and interview, the facility staff failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 2 of 2 patients (Patients #12, 13) observed holding access sites in a total universe of 16 observations of patient care. Findings Include: A review of the facility’s policy #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “... Patients and caregivers will be encouraged to... Perform hand hygiene after treatment before leaving treatment area...” During an observation on 09/10/2024 at 10:45 AM, Patient #13 was observed holding his/her dialysis access site with a glove, removed the glove, and did not perform hand hygiene prior to exiting the treatment area. During an observation on 09/10/2024 at 10:47 AM, Patient #12 was observed holding his/her dialysis access site with a glove, removed the glove, and did not perform hand hygiene prior to exiting the treatment area. During an interview on 09/11/2024 at 11:47 AM, the observation findings were discussed with Facility Administrator A who stated, “They should be performing hand hygiene upon exiting the facility.””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 47413 Based on observation, record review and interview, the facility staff failed to complete disinfection of all equipment in the dialysis station following completion of dialysis treatment for 2 of 2 patients (Patient #11, #14) observed in a total of 16 observations. Findings Include: A review of the facility’s policy #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “... At the end of each treatment, the dialysis station will be cleaned and disinfected... Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings... and frequently contacted by healthcare personnel...” During an observation on 09/10/2024 at 10:05 AM, Patient Care Technician E was observed cleaning the dialysis machine at Station #6, after Patient #11 was discharged, and did not clean the IV pole or the hooks on top of the IV pole. During an observation on 09/10/2024 at 10:13 AM, Patient Care Technician G was observed cleaning the dialysis machine at Station #2, after Patient #14 was discharged, and did not clean the IV pole or the hooks on top of the IV pole. During an interview on 09/11/2024 at 11:47 AM, the observation findings were discussed with Facility Administrator A who stated that staff should be cleaning the IV pole and hooks. 29963”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to ensure the administration of the pre-treatment Heparin bolus was at least 3 to 5 minutes prior to the initiation of dialysis, per facility policy, in 2 of 3 in-center hemodialysis patients (Patients #4, 5) with current active orders for Heparin boluses in a total universe of 7 medical records reviewed. Findings Include: A review of the facility’s policy #1-06-02 titled, “Anticoagulation” last revised April 2024 revealed, “... To anticoagulate the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least three (3) to five (5) minutes prior to the initiation of the hemodialysis treatment...” A review of Patient #4’s current in-center hemodialysis orders revealed an order for 2,000 units of Heparin bolus. A review of the treatment sheet dated 07/13/2024 revealed Patient #4’s dialysis was started at 5:08 PM. “Medications Administered” revealed the Heparin bolus was documented as given at 5:08 PM, the same time as initiation of dialysis. Treatment sheet dated 08/31/2024 revealed Patient #4’s dialysis was started at 6:52 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 6:56 AM, 4 minutes after the initiation of dialysis. A review of Patient #5’s current in-center hemodialysis orders revealed an order for 2,000 units of Heparin bolus. A review of the treatment sheet dated 08/31/2024 revealed Patient #5’s dialysis was started at 1:02 PM. “Medications Administered” revealed the Heparin bolus was documented as given at 3:32 PM, 152 minutes after the initiation of dialysis. During an interview on 09/11/2024 at 11:43 AM, the observation findings were discussed with Facility Administrator A who stated, “Yes, Heparin should be given 3-5 minutes prior to the start of dialysis.” 29963”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47413 Based on record review, observation and interview, the facility staff failed to change the gauze dressing used to hold access sites once bleeding had stopped for 3 of 3 patients (Patients #12, 13, 15) observed for discontinuation of dialysis with an AV Fistula/Graft in a total of 16 observations of patient care. Findings Include: A review of the facility’s policy #12-06-01 B titled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” last revised April 2023 revealed, “... Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect for any trauma and for hemostasis. Apply band-aid or sterile dressing over cannulation site...” During an observation on 09/10/2024 at 10:32 AM, Patient Care Technician E was observed discontinuing dialysis on Patient #13’s fistula/graft. Patient Care Technician E taped over the existing gauze dressing. The original gauze dressing was not removed to assess the site and the dressing was not changed prior to Patient #13’s discharge. During an observation on 09/10/2024 at 10:35 AM, Patient Care Technician E was observed discontinuing dialysis on Patient #15’s fistula/graft. Patient Care Technician E taped over the existing gauze dressing. The original gauze dressing was not removed to assess the site and the dressing was not changed prior to Patient #15’s discharge. During an observation on 09/10/2024 at 10:47 AM, Patient Care Technician E was observed discontinuing dialysis on Patient #12’s fistula/graft. Patient Care Technician E taped over the existing gauze dressing. The original gauze dressing was not removed to assess the site and the dressing was not changed prior to Patient #12’s discharge. During an interview on 09/11/2024 at 11:47 AM, the observation findings were discussed with Facility Administrator A who stated, “Yes the gauze should be changed.” 29963”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 29963 47413 Based on record review and interview the facility failed to ensure that all in-center dialysis patients were seen by a Physician, Registered Nurse, and Dietician once a month in 4 of 7 patients (Patients #2, 3, 4, 6) in a total universe of 7 medical records reviewed. Findings Include: A review of the facility’s policy #3-02-17 titled, “Progress Note Policy” last revised October 2023 revealed, “... Physician: The attending Nephrologist is required to record progress notes at least monthly... Nurse: Nurses are required to record patient progress notes at least monthly... Dietician: Dieticians are required to record patient progress notes at least monthly...” A review of Patient #2’s medical record revealed that there was no Registered Dietician documentation of seeing Patient #2 in June or August 2024. A review of Patient #3’s medical record revealed that there was no Registered Dietician documentation of seeing Patient #3 in June 2024. A review of Patient #4’s medical record revealed that there was no Registered Nurse documentation of seeing Patient #4 in June 2024, no Registered Dietician documentation of seeing Patient #4 in July 2024, and no Physician documentation of seeing Patient #4 in August 2024. A review of Patient #6’s medical record revealed there was no Registered Dietician documentation of seeing Patient #6 in July 2024. During an interview on 09/11/2024 at 10:39 AM, the following findings were discussed with Facility Administrator A who stated, “The notes should be monthly.””

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 29963 Based on record review and interview, the staff failed to document that education was completed with a patient when records of dialysis treatment in the home setting did not include a daily weight, blood pressure, pulse, and dextrose concentration used for treament for 1 of 2 patients (Patient #7) home peritoneal dialysis medical records reviewed in a total universe of 7 medical records reviewed. Finding include: A review of the facility’s policy #5-01-29 titled, “Daily Home Treatment Record (Flowsheet),” last revised September 2023 revealed, “To provide guidance for proper documentation of home peritoneal dialysis treatments and to collect data in assessing the patient’s response to peritoneal dialysis treatments. to provide definition of acceptable daily home treatment records (flowsheet) types and submission of these records... 1. Each peritoneal dialysis patient has agreed and been trained to complete documentation of each treatment procedure on the Daily Home Treatment Record, also referred to as a flowsheet... 3. As clinically applicable, all treatment data outlined on the Daily Home Treatment Record must be collected. Completed Daily Home Treatment Records must be reviewed to assist in the evaluating the patient’s progress and self-care decision-making process. This post-treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record per guidance below: ... a) The licensed nurse will review the patient’s data via the submitted Daily Home Treatment Records... d) The licensed nurse is responsible for end of month review for all Daily Home Treatment Records, and for obtaining a signed or verbal patient attestation that is appropriately documented within the patient’s medical record during the monthly clinic visit... 4. All Daily Treatment Records will be reviewed, attestation to, and maintained as a part of the patient’s medical record. In the absence of Daily Home Treatment Records, the licensed nurse will review with the patient the importance of Daily Home Treatment Records, and the patient’s responsibility to provide them and issue new paper flowsheets and provide instruction as applicable for electronic documentation. All of the above will be documented and attested to by the licensed nurse in the medical record...” A review of Patient #7’s medical record revealed on the treatment sheet for the month of July 2024, there was no blood pressure, weight, pulse rate, or dextrose concentration documented on the “Home Treatment Record” for the entire month. There was no treatment record for the month of June. There was no documentation in the Registered Nurses notes in July or August that education was completed with Patient #7 regarding not completing the information on the ‘Home Treatment Record” form. During an interview on 09/11/2024 at 11:30 AM, the medical record review findings were discussed with and confirmed by Facility Administrator A and Peritoneal Dialysis Nurse J who stated, “Education should be documented in the chart about treatment sheets not being fully completed.””

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to ensure data is being collected, analyzed, and trended to identify potential problems with patient infections for 1 of 1 monthly Infection Trackers reviewed in 1 of 1 dialysis Quality Program for a total of 2 dialysis services. Findings Include: A review of the facility’s policy #5-15-06 titled, “Continuous Quality Improvement Program” last revised April 2024 revealed, “... The facility will measure, analyze and track quality indicators... The program must include but not be limited to the following: ... Infection Control, including Incidence of infections...” A review of the facility’s “Infection Tracker” data from March 2024-August 2024 revealed missing documentation related to the type of infection, name of antibiotic, and if blood cultures were drawn. During an interview on 09/11/2024 at 2:30 PM, the following findings were discussed with Facility Administrator A who stated that there was missing documentation in the infection tracker and stated, “There could be more information in there.””

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 29963 Based on record review and interview the facility staff failed to ensure that a comprehensive Registered Nurse assessment was completed prior to initiation of the first treatment at the facility in 4 of 6 newly admitted patients (Patient #2, 17, 18, 19) reviewed in a total sample of 6 newly admitted patient medical records reviewed. Findings include: A review of facility policy #1-03-07 titled, “Initial Patient Nursing Assessment for New Patients,” last revised April 2024 revealed, “1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility.” A review of Patient #2’s medical record revealed Patient #2 was admitted for their first dialysis treatment on 06/15/2024. The first dialysis treatment was started on 06/15/2024 at 5:00 PM. Patient #2’s “Initial Assessment” was completed on 06/15/2024 at 5:39 PM (39 minutes after initiation of first dialysis treatment). A review of Patient #17’s medical record revealed Patient #17 was admitted for their first dialysis treatment on 07/30/2024. The first dialysis treatment was started on 07/30/2024 at 5:59 PM. Patient #17’s “Initial Assessment” was completed on 08/02/2024 at 6:44 PM (2 days and 45 minutes after initiation of first dialysis treatment). A review of Patient #18’s medical record revealed Patient #18 was admitted for their first dialysis treatment on 07/31/2024. The first dialysis treatment was started on 07/31/2024 at 3:05 PM. Patient #18’s “Initial Assessment” was completed on 07/31/2024 at 4:01 PM (54 minutes after initiation of first dialysis treatment). A review of Patient #19’s medical record revealed Patient #19 was admitted for their first dialysis treatment on 07/30/2024. The first dialysis treatment was started on 07/30/2024 at 11:49 AM. Patient #19’s “Initial Assessment” was completed on 07/30/2024 at 11:56 AM (7 minutes after initiation of first dialysis treatment). During an interview on 09/11/2024 at 10:32 AM, the observation findings were discussed with Facility Administrator A who stated, “Assessments should be completed prior to the first treatment.””