Davita Harbor View 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 wear gloves when touching the dialysis machine for 3 of 8 patients (Patients #2, 19, 26), facility staff failed to perform glove changes when moving between patient stations while providing cares for 2 of 8 patients (Patients #2, 28), and facility staff failed to ensure patients performed hand hygiene after glove removal and holding dialysis access sites in 1 of 2 patients (Patient #27) holding dialysis 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, “... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station... Gloves should be changed when: iv. After touching one patient and 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...” last revised April 2023 revealed, “... When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed...” Examples of staff touching the dialysis machine without gloves: During an observation on 12/16/2025 at 9:35 AM, Patient Care Technician K touched Patient #19’s dialysis machine with a glove wrapped around her finger. During an observation on 12/16/2025 at 10:30 AM, Patient Care Technician M touched Patient #2’s dialysis machine with a glove wrapped around her finger. During an observation on 12/17/2025 at 9:35 AM, Patient Care Technician Q touched Patient #26’s dialysis machine with a glove wrapped around her finger. Example of staff failing to perform gloves changes: During an observation on 12/16/2025 at 10:34 AM, Patient Care Technician J was observed moving between 2 dialysis station and touching the patient’s dialysis stations (Patients #2, 28) without a glove change. Examples of staff failing to ensure patients completed hand hygiene after glove removal after holding dialysis access site: During an observation on 12/16/2025 at 10:05 AM, Patient #27 was observed holding dialysis site with a glove, removed the glove and did not perform hand hygiene. During an interview on 12/17/2025 at 2:30 PM with Manager of Clinical Services B, she stated that staff need to wear gloves when touching the dialysis machines, that gloves need to be changed when moving between patient stations, and that patients should be offered hand hygiene after holding their access site.”

“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: 47413 Based on record review, observation and interview, facility staff failed to ensure that non-disposable items taken into the patient station (stethoscope) were cleaned and disinfected following use for 1 of 1 patients observed (Patient #25) 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, “... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station...” During an observation on 12/17/2025 at 9:52 AM Patient Care Technician N was observed evaluating Patient #25’s fistula using a stethoscope. After access was evaluated, Patient Care Technician N returned the stethoscope to the nurse’s station without disinfecting the stethoscope. During an interview on 12/17/2025 at 2:40 PM, Manager of Clinical Services B stated that items need to be disinfected prior to removal from the station.”

“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 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 (Stations #16, 24) 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, “... 13. 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... and frequently contacted by healthcare personnel...” During an observation on 12/16/2025 at 9:46 AM, Patient Care Technician J was observed cleaning Station #24 and did not wipe down the hooks on the IV pole. During an observation on 12/17/2025 at 9:00 AM, Patient Care Technician P was observed cleaning Station #16 and did not wipe down the IV pole or hooks. During an interview on 12/17/2025 at 2:40 PM, Manager of Clinical Services B confirmed that all surfaces need to be disinfected.”

“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 record review, observation and interview, the facility staff failed to perform central venous catheter exit site care using aseptic technique for 1 of 2 patients (Patient #17) in a total sample of 2 observations of care of patients with a CVC. Findings Include: A review of the facility’s policy #1-04-02B titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” last revised April 2025 revealed, “... Verify patient’s clothing is secured away from the exit site/work area...” During an observation on 12/16/2025 at 11:06 AM, Patient Care Technician K was observed performing CVC exit site care for Patient #17. Patient #17 was observed to be wearing a short sleeve shirt. Patient Care Technician K was observed moving the shirt away from Patient #17’s exit site but did not secure the shirt away from the site. Upon completion of exit site cleansing, Patient #17’s shirt was observed to be touching the right side of the exit site. Patient Care Technician K moved the shirt away with a gloved hand and placed a new dressing over the exit site without repeat cleansing. On 12/17/2025 at 2:25 PM Manager of Clinical Services B stated that clothing should be secured away from the site or repeat cleansing is needed.”

“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 5 of 6 in-center hemodialysis patients (Patients #1, 2, 5, 6, 9) with current active orders for Heparin boluses in a total universe of 15 medical records reviewed. Findings Include: A review of the facility’s policy #1-04-01D titled, “AV Fistula or Graft Cannulation...” last revised April 2025 revealed, “...28. 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 2,600 units of Heparin bolus. A review of the treatment sheet dated 12/06/2025 revealed Patient #1’s dialysis was started at 6:57 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 6:56 AM, 1 minute before 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 12/02/2025 revealed Patient #2’s dialysis was started at 6:45 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 6:43 AM, 2 minutes before the initiation of dialysis.. A review of Patient #5’s current in-center hemodialysis orders revealed an order for 1,000 units of Heparin bolus. A review of the treatment sheet dated 12/05/2025 revealed Patient #5’s dialysis was started at 10:55 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 10:54 AM, 1 minute before the initiation of dialysis. A review of Patient #6’s current in-center hemodialysis orders revealed an order for 800 units of Heparin bolus. A review of the treatment sheet dated 12/04/2025 revealed Patient #6’s dialysis was started at 7:27 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 7:35 AM, 8 minutes after the initiation of dialysis. Review of the treatment sheet dated 12/02/2025 revealed Patient #6’s dialysis was started at 7:18 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 7:20 AM, 2 minutes after 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 12/06/2025 revealed Patient #9’s dialysis was started at 9:40 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 9:40 AM, same time as initiation of dialysis. Review of the treatment sheet dated 12/02/2025 revealed Patient #9’s dialysis was started at 9:56 AM. “Loading Dose” revealed the Heparin bolus was documented as given at 9:54 AM, 2 minutes before the initiation of dialysis. During an interview on 12/17/2025 at 2:47 PM, the medical record review findings were discussed with and confirmed by Manager of Clinical Services B who stated that Heparin boluses should be administered 3 to 5 minutes prior to the initiation of dialysis.”

“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: 47413 Based on record review and interview, the facility staff failed to ensure intradialytic monitoring was completed per facility policy in 5 of 10 in-center medical records reviewed (Patients #2, 5, 6, 9, 10) in a total universe of 15 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, “... iii. Non-nocturnal treatments are completed at least every thirty (30) minutes... v. Vascular access visible and line connections intact...” A review of Patient #2’s medical record revealed on the treatment sheet dated 12/11/2025, an intradialytic monitoring (AV- access visualized, FV- face visualized) was documented at 9:03 AM and then again at 10:05 AM (58 minutes later). A review of Patient #5’s medical record revealed on the treatment sheet dated 12/10/2025, an intradialytic monitoring (AV, FV) was documented at 11:34 AM and then again at 1:02 PM (88 minutes later). A review of Patient #6’s medical record revealed on the treatment sheet dated 12/06/2025, an intradialytic monitoring (AV, FV) was documented at 9:30 AM and then again at 10:40 AM (70 minutes later). A review of Patient #9’s medical record revealed on the treatment sheet dated 12/04/2025, an intradialytic monitoring (AV, FV) was documented at 9:40 AM and then again at 11:01 AM (81 minutes later). A review of Patient #10’s medical record revealed on the treatment sheet dated 12/13/2025, an intradialytic monitoring (AV, FV) was documented at 12:00 PM and then again at 1:00 PM (60 minutes later). Review of the treatment sheet dated 12/11/2025 revealed an intradialytic monitoring (AV, FV) was documented at 2:00 PM and then again at 3:30 PM (90 minutes later). Review of the treatment sheet dated 12/06/2025 revealed an intradialytic monitoring (AV, FV) was documented at 2:30 PM and then again at 3:30 PM (60 minutes later). During an interview on 12/17/2025 at 2:38 PM the medical record review findings were discussed with Manager of Clinical Services B who stated that monitoring should be every 30 minutes.”

“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 1 of 2 patients (Patient #9) observed for initiation of dialysis with an AV Fistula/Graft in a total of 16 observations of care. Findings Include: A review of the facility’s policy #1-04-01D titled, “AV Fistula or Graft Cannulation..., “ last revised April 2025 revealed, “... Do not palpate insertion site once area has been prepped...” During an observation on 12/16/2025 at 9:34 AM, Patient Care Technician J was observed cleansing Patient #9’s insertion site and palpated the site again before cannulation. During an interview on 12/17/2025 at 2:35 PM, Manager of Clinical Services B stated that the site should not be palpated once cleansed.”