Davita Amery 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 perform glove changes and/or hand hygiene when moving from “dirty” to “clean” tasks while providing cares for 4 of 4 patients (Patients #3, 9, 14 &15) and 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 & 15) observed holding access sites in a total 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, “... All teammates... will perform hand hygiene a. upon entering and exiting the patient treatment area... g. before touching clean areas such as... chairside keyboard/mouse... Patients... will be encouraged to... perform hand hygiene after treatment before leaving treatment area.... Gloves should be changed: ... when going from a ‘dirty’ area or task to a ‘clean’ area or task...” On 09/25/2024 at 9:10 AM Patient #12 held access sites with his/her gloved hand, removed the glove, and left the treatment area without completing hand hygiene. During an observation on 9/25/2024 at 9:15 AM, Patient Care Technician F, with gloved hands, adjusted Patient #14’s blood pressure cuff, touched the dialysis machine and Patient #14’s chair then proceeded to remove fistula needle without first changing gloves. During an observation on 09/25/2024 at 9:24 AM, Patient Care Technician D initiated dialysis on Patient #9 and left Patient #9’s dialysis station and did not perform a glove change or hand hygiene. During an observation on 9/25/2024 at 9:37 AM, Patient #15 held access sites with his/her gloved hand. Patient Care Technician C assisted Patient #15 to remove “dirty” glove and escorted Patient #15 from treatment floor. No hand hygiene was offered to or performed by Patient #15 prior to exit from facility. During an observation on 09/25/2024 at 12:31 PM, Patient Care Technician D discontinued dialysis on Patient #9. Patient Care Technician D left the dialysis station with no glove change or hand hygiene, and went to grab Patient #9’s belongings outside of the dialysis station with the same “dirty” gloves. During an observation on 09/25/2024 at 11:55 AM, Patient Care Technician D initiated Patient #3’s dialysis, did not perform a glove change or hand hygiene and left Patient #3’s dialysis station to grab supplies outside of the dialysis station with the “dirty” gloves. During an interview on 9/25/2024 at 3:30 PM, the observations findings were discussed with Facility Administrator B who stated that hand hygiene and glove changes should be performed per policy. 43037”

“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 (Patients #11 & 12) observed and the facility staff failed to remove blood lines and fluid bags from the dialysis station prior to disinfecting of the station for 1 of 2 patients (Patient #10) observed in a total of 16 observations of patient care. Findings Include: Examples of failure to disinfect all equipment in the dialysis station: 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... 12...a. Prior to routine disinfection, remove all visible blood...” During an observation on 09/25/2024 at 9:25 AM, Registered Nurse E was observed cleaning the dialysis machine at Station #11, after Patient #12 was discharged, and did not clean the IV (intravenous) pole or the hooks on top of the IV pole. During an observation on 09/25/2024 at 9:35 AM, Patient Care Technician C was observed cleaning the dialysis machine at Station #3, after Patient #11 was discharged, and did not clean the IV pole or the hooks on top of the IV pole. During an interview on 09/25/2024 at 3:30 PM, the observation findings were discussed with Facility Administrator B who stated that all surfaces need to be cleaned. 43037 Example of non-removal of blood lines/fluid bag prior to station disinfection: During an observation on 9/25/2024 at 9:38 AM, Patient Care Technician F began cleaning station #6 to prepare for Patient #10’s arrival for treatment. Patient Care Technician F cleaned the chair while “dirty” blood lines and a fluid bag remained hanging on the IV pole and threaded into the machine adjacent to the chair. During an interview on 9/25/2024 at 3:30 PM, the observation findings were discussed with Facility Administrator B who, when asked if the blood lines should have been removed prior to any disinfection to avoid splashing of fluids or blood on the clean chair stated, “Yes.””

“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: 47413 Based on observation, record review and interview facility staff failed to cleanse the CVC (Central Venous Catheter) exit site prior to initiation of dialysis per facility policy for 2 of 2 patients observed (Patients #9 & 11) in a total sample of 2 observations of care of patients with a CVC. Findings Include: A review of the facility’s document titled, “Disinfection Timing” (no revision date) revealed, “... CVC; ChloraPrep; Insertion site; Wet contact time; 30 sec (seconds)...” During an observation on 9/25/2024 at 8:58 AM, Patient Care Technician C was observed performing CVC exit site care for Patient #11. Patient Care Technician C was observed cleansing the area around the CVC exit site for 7 seconds with ChloraPrep, 23 seconds less than facility policy. During an observation on 09/25/2024 at 9:15 AM, Patient Care Technician D was observed performing CVC exit site care for Patient #9. Patient Care Technician D was observed cleansing the area around the CVC exit site for 9 seconds with ChloraPrep, 21 seconds less than facility policy. During an interview on 09/25/2024 at 3:30 PM, the observation findings were discussed with Facility Administrator B who stated that the CVC site should be scrubbed for 30 seconds. 43037”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 47413 Based on observation, record review and interview the facility failed to ensure a safe environment for storage of supplies per facility policy in 3 of 4 areas (hallway, storage room, medication room) observed out of a total universe of 4 supply storage areas. Findings Include: A review of the facility’s policy #8-04-01 titled, “Physical Environment” last revised April 2018 revealed, “... Supplies will not be stored directly on the floor but stored on shelves or pallets...” During observation on 09/25/2024 beginning at 8:40 AM the following was observed: - 2 cardboard boxes containing various supplies on the floor in the hallway leading to the treatment area. -2 cardboard boxes containing various supplies on the floor in the storage room. -4 cardboard boxes containing various supplies on the floor in the medication room. During an interview on 09/25/2024 at 3:30 PM, the observation findings were discussed with Facility Administrator B who confirmed the boxes should be off the ground and stored on a pallet. 43037”

“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 (anticoagulation medication) bolus was at least 3 to 5 minutes prior to the initiation of dialysis, per facility policy, in 7 of 7 in-center hemodialysis patients (Patients #1, 2, 3, 4, 6, 8 & 9) with current active orders for Heparin boluses in a total universe of 10 medical records reviewed. Findings Include: A review of facility policy 1-04-01E titled, “AV Fistula or Graft Cannulation With Nipro or Medisystems Safety Fistula Needles (SFN) And Administration of Heparin Loading Dose” last revised October 2022 revealed, “...29. Do not initiate dialysis for a minimum of three (3) to five (5) minutes after administering heparin loading dose...” A review of Patient #1’s current in-center hemodialysis orders revealed an order for 1,000 units of Heparin bolus. A review of treatment sheet dated 9/12/2024 revealed Patient #1’s dialysis was started at 11:35 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 11:36 AM, 1 minute after the initiation of dialysis. Treatment sheet dated 9/21/2024 revealed dialysis was started at 11:54 AM and the Heparin bolus was documented as given at 11:58 AM, 4 minutes after the initiation of dialysis. A review of Patient #2’s current in-center hemodialysis orders revealed an order for 800 units of Heparin bolus. A review of the treatment sheet dated 09/25/2024 revealed Patient #2’s dialysis was started at 10:26 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 10:25 AM, 1 minute before the initiation of dialysis. A review of Patient #3’s current in-center hemodialysis orders revealed an order for 1,500 units of Heparin bolus. A review of the treatment sheet dated 09/11/2024 revealed Patient #3’s dialysis was started at 11:22 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 11:21 AM, 1 minute before the initiation of dialysis. Treatment sheet dated 09/13/2024 revealed dialysis was started at 11:37 AM. and the Heparin bolus was documented as given at 11:35 AM, 2 minutes before the initiation of dialysis. A review of Patient #4’s current in-center hemodialysis orders revealed an order for 2,600 units of Heparin bolus. A review of treatment sheet dated 9/11/2024 revealed Patient #4’s dialysis was started at 7:27 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 7:25 AM, 2 minutes before the initiation of dialysis. Treatment sheet dated 9/16/2024 revealed dialysis was started at 7:19 AM and the Heparin bolus was documented as given at 7:18 AM, 1 minute before the initiation of dialysis. A review of Patient #6’s current in-center hemodialysis orders revealed an order for 1,500 units of Heparin bolus. A review of treatment sheet dated 9/2/2024 revealed Patient #6’s dialysis was started at 9:02 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 9:00 AM, 2 minutes before the initiation of dialysis. A review of Patient #8’s current in-center hemodialysis orders revealed an order for 1,000 units of Heparin bolus. A review of treatment sheet dated 9/16/2024 revealed Patient #8’s dialysis was started at 10:46 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 10:44 AM, 2 minutes before the initiation of dialysis. Treatment sheet dated 9/18/2024 revealed dialysis was started at 10:47 AM and the Heparin bolus was documented as given at 10:45 AM, 2 minutes before the initiation of dialysis. Treatment sheet dated 9/20/2024 revealed dialysis was started at 10:44 AM and the Heparin bolus was documented as given at 10:42 AM, 2 minutes before the initiation of dialysis. A review of Patient #9’s current in-center hemodialysis orders revealed an order for 1,000 units of Heparin bolus. A review of the treatment sheet dated 09/20/2024 revealed Patient #9’s dialysis was started at 9:48 AM. “Medications Administered” revealed the Heparin bolus was documented as given at 9:52 AM, 4 minutes after the initiation of dialysis. During an interview on 09/26/2024 at 8:00 AM, the medical record review findings were discussed with Facility Administrator B who stated, “Heparin should be given 3-5 minutes prior to the start of treatment.” 43037”

“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 perform skin antisepsis prior to cannulation per policy for 2 of 2 patients (Patients #3, 15) observed for initiation of dialysis with an AV (Arteriovenous) Fistula/Graft in a total of 16 observations of patient care. Findings Include: A review of the facility’s document titled, “Disinfection Timing” (no revision date) revealed, “... AVF AVG Skin Antisepsis; Betadine; Wet contact time; 30 sec...” A review of the facility’s policy 1-04-01E titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) And Administration of Heparin Loading Dose” last revised October, 2022 revealed, “...13. Do not palpate insertion site once area has been prepped...” During an observation on 09/25/2024 at 10:10 AM Patient Care Technician D used Betadine to cleanse Patient #15’s arm access sites prior to cannulation for a total of 5 seconds, 25 seconds less than per policy. At 10:13 AM, Patient Care Technician D touched Patient #15’s access sites after they had been cleansed with Betadine and proceeded to cannulate Patient #15’s fistula without re-cleaning the access sites. During an observation on 09/25/2024 at 11:40 AM, Patient Care Technician D used Betadine to cleanse Patient #3’s arm access sites prior to cannulation for a total of 3 seconds, 27 seconds less than per policy. During an interview on 09/25/2024 at 3:30 PM, the observation findings were discussed with Manager of Clinical Services H who stated that the sites should be scrubbed for 30 seconds with Betadine and once cleaned they should not be contaminated by touching.”