Davita Mequon Road 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: 29963 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 2 of 9 patients (Patients #9, 10); failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 1 of 2 patients (Patient #12) observed holding access sites; and failed to wear gloves when touching the dialysis machine for 4 of 9 patients (Patients #9, 12, 13, 14) 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 ... b. prior to gloving and immediately after removal of gloves, ... after patient and dialysis delivery system contact ... before touching clean areas such as supplies, supply cart, and chairside keyboard/mouse ...7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station... a. Gloves should be changed when: ii. When going from a ‘dirty’ area or task to a ‘clean’ area or task... iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” A review of the facility’s policy #1-04-01B titled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” last revised April 2023 revealed, “... When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed...” A review of facility’s policy #1-04-02B titled, “Central Venous Catheter (CVC) ... Procedure” last reviewed April 2025 revealed, “ ... Aseptically disconnect arterial blood line from arterial CVC limb ... Remove gloves and discard, perform hand hygiene ...” Examples of staff failing to complete hand hygiene: During an observation on 09/29/2025 at 9:50 AM, Patient Care Technician F was initiating dialysis on Patient #10’s fistula. Patient Care Technician F cleaned Patient #10’s access, removed glove from right hand and walked over to the supply cart and grabbed a package of iodine wipes, returned to the dialysis station and put a new glove on the right hand and did not complete hand hygiene. During an observation on 09/29/2025 at 10:10 AM, Patient Care Technician E was discontinuing dialysis on Patient #9. Patient Care Technician E disconnected the blood lines from Patient #9’s CVC, removed gloves and then began documenting on computer and did not complete hand hygiene. Examples of staff failing to ensure patients completed hand hygiene after glove removal after holding dialysis access sites: During an observation on 09/29/2025 at 9:15 AM, Patient #12 was observed holding dialysis access site with a gloved hand. Patient #12 removed the glove, walked over to the scale and touched the grab bar. Patient #12 did not perform hand hygiene prior to exiting the treatment area. Examples of staff touching the dialysis machines with a glove wrapped around the finger: During an observation on 09/29/2025 at 9:14 AM, Patient Care Technician D touched Patient #12’s dialysis machine using a glove wrapped around the finger. During an observation on 09/29/2025 at 9:40 AM, Patient Care Technician F touched Patient #14’s dialysis machine using a glove wrapped around the finger. During an observation on 09/29/2025 at 9:50 AM, Patient Care Technician E touched Patient #13’s dialysis machine using a glove wrapped around the finger. During an observation on 09/29/2025 at 10:10 AM, Patient Care Technician E touched Patient #9’s dialysis machine using a glove wrapped around the finger. During an interview on 09/30/2025 at 12:44 PM, the observation findings were discussed with Facility Administrator A who stated the expectation is that staff perform hand hygiene with glove removal and that staff should be offering hand gel to every patient at the completion of dialysis. Facility Administrator A stated the staff are expected to put the glove completely on the hand prior to touching the dialysis machine.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 29963 Based on record review, observation and interview, facility staff failed to ensure that non-disposable items taken into the patient station (thermometer) were disinfected following use for 4 of 4 patients observed (Patients #8, 9, 12, 13) for discontinuation of dialysis 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, “... Non-disposable items are to be disinfected after each patient use, prior to removal from treatment/area station and if contaminated between uses.” During an observation on 09/29/2025 at 9:00 AM, Patient Care Technician D was observed using a thermometer on Patient #12 at the completion of dialysis. Patient Care Technician D then returned the thermometer to the computer cart on wheels without disinfecting the thermometer. During an observation on 09/29/2025 at 9:30 AM, Patient Care Technician F was observed using a thermometer on Patient #8 at the completion of dialysis. Patient Care Technician D then returned the thermometer to the computer cart on wheels without disinfecting the thermometer. During an observation on 09/29/2025 at 9:50 AM, Patient Care Technician E was observed using a thermometer on Patient #13 at the completion of dialysis. Patient Care Technician E then returned the thermometer to the computer cart on wheels without disinfecting the thermometer. During an observation on 09/29/2025 at 10:10 AM, Patient Care Technician E was observed using a thermometer on Patient #9 at the completion of dialysis. Patient Care Technician E then returned the thermometer to the computer cart on wheels without disinfecting the thermometer. During an interview on 09/30/2025 at 12:45 PM, the observation findings were discussed with Manager of Clinical Services G who stated thermometers should be cleaned with a bleach wipe between patients when taken into the dialysis station.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 29963 Based on record review, observation and interview the facility staff failed to ensure that supplies were not past expiration dates in 1 of 1 patient treatment areas (in-center treatment area) observed in a total of 1 patient treatment areas observed. Findings include: A review of the facility’s policy 1-06-01, titled “Medication Policy” last revised October 2023, revealed, “All medications in the facility are checked monthly ... Medications are ordered and replaced prior to expiration ...” During an observation on 09/29/2025 at 8:49 AM found (3) boxes of triple antibiotic ointment (144 packets in each box) with an expiration date of 07/20205. During an interview on 09/30/2025 at 12:32 PM, Facility Administrator A stated the staff should be removing supplies from the supply cart when they are expired.”

“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: 29963 Based on record review, observation and interview, the facility staff failed to complete disinfection of all equipment in the dialysis station for 2 of 2 dialysis stations (Patient #12, 13) observed being cleaned 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, “... 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 09/29/2025 at 9:20 AM, Patient Care Technician E was observed cleaning dialysis station after Patient #13 completed dialysis. Patient Care Technician E did not wipe down the IV (intravenous) pole, hooks or blood pressure basket on the side of the dialysis machine. During an observation on 09/29/2025 at 9:27 AM, Patient Care Technician D was observed cleaning dialysis station after Patient #12 completed dialysis. Patient Care Technician D did not wipe down the IV pole hooks. During an interview on 09/29/2025 at 12:50 PM, the observation findings were discussed with Facility Administrator A who stated that staff should be wiping down everything on the IV pole and on the dialysis machine.”

“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: 29963 Based on record review, observation and interview, the facility staff failed to ensure aseptic technique was maintained when working with central venous catheter (CVC), per facility policy for 1 of 4 patients observed (Patients #7) in a total sample of 6 observations of care of patients with a CVC. Findings Include: A review of the facility’s policy #1-04-02 B titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps and Tegaderm CHG Dressing Procedure” last revised April 2025 revealed, “... Verify patient’s clothing is secured away from the exit site/work area...” During an observation on 09/29/2025 at 11:00 AM, Patient Care Technician E was observed performing CVC exit site care for Patient #7. Patient #7 was observed to be wearing a button-down shirt. Patient Care Technician E was observed moving the collar of the button-down away from Patient #7’s exit site but did not secure the shirt away from the site. Upon completion of exit site cleansing, Patient #7’s shirt was observed to be touching the right side of the exit site. The shirt continued to touch the exposed site while Patient Care Technician E performed other tasks until Patient Care Technician E placed a new dressing over the exit site without repeat cleansing. During an interview on 09/30/2025 at 12:44 PM, the observation findings were discussed with Facility Administrator A who stated, “The shirt should be taped back so there is a 2-3 inch clearance away from the catheter insertion site.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to complete documentation of why physician orders were not followed for prescribed blood flow rates and/or dialysate flow rates for 3 of 5 in-center medical records reviewed (Patients #2, 3, 4) in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 revealed, “ ...Intradialytic Data Collection/Assessment ...At a minimum, obtain and document the following ...Blood and dialysate flows ...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ...” A review of Patient #2’s medical record revealed a physician order for the blood flow rate (BFR) of 400 mL/min (milliliters per minute) and a dialysate flow rate (DFR) of 600 mL/min. The treatment sheet dated 09/19/2025 revealed the DFR was set at 500 mL/min for the entire treatment. There was no documentation in the medical record for the reason the DFR was lower than the ordered rate. The treatment sheets dated 09/22/2025 and 09/26/2025 revealed the BFR was set at 350 mL/min for the entire treatment. Treatment sheet dated 09/24/2025 revealed the BFR was turned down to 350 mL/min mid treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. A review of Patient #3’s medical record revealed a physician order for the BFR of 350 mL/min and DFR of 800 mL/min. The treatment sheets dated 09/18/2025 and 09/23/2025 revealed the DFR was set at 500 mL/min for the entire treatment. There was no documentation in the medical record for the reason the DFR was lower than the ordered rate. The treatment sheet dated 09/25/2025 revealed the BFR was set at 300 mL/min for the entire treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. A review of Patient #4’s medical record revealed a physician order for the BFR of 450 mL/min. The treatment sheets dated 09/20/2025, 09/25/2025, and 09/27/2025 revealed the BFR was set at 400 mL/min for the entire treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. During an interview on 09/30/2025 at 1:05 PM, the medical record findings were discussed with and confirmed by Facility Administrator A who stated facility staff were expected to document a reason for not meeting prescribed blood and dialysate flow rates.”