Davita Marshfield 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: 43037 Based on observation, record review 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 5 of 6 patients (Patient #s 1, 2, 8, 13 &19) in a total sample of 13 observations of patient care and failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 1 of 6 patients (Patient #3) in a total sample of 13 observations of patient care. Findings: A review of facility policy 1-05-01, “Infection Control for Dialysis Facilities” last revised 4/2023 revealed, “...1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine), f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...” A review of facility policy 1-04-01B, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” last revised 4/2023 revealed, “...9. The patient will be encouraged to hold their own sites if their condition permits. When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed...” Examples of staff not performing hand hygiene: An observation of patient care was conducted on 1/16/2024 at 10:30 AM. Patient Care Technician (PCT) F was beginning to de-access Patient #1’s Central Venous Catheter after termination of treatment. PCT F changed gloves prior after reinfusing the extracorporeal circuit but did not perform hand hygiene after removal of “dirty” gloves and prior to donning “clean” gloves. An observation of patient care was conducted on 1/16/2024 at 10:41 AM. Registered Nurse (RN) C removed gloves after providing patient care to Patient #19 and immediately placed hands on keyboard to document without first performing hand hygiene. An observation of patient care was conducted on 1/16/2024 at 10:44 AM. PCT D put on clean gloves after using the keyboard to document at station #10 for Patient #2 but did not perform hand hygiene before donning the gloves. An observation of patient care was conducted on 1/17/2024 at 10:17 AM. PCT D put on clean gloves on after using the keyboard to document at station #4 for Patient #13 but did not perform hand hygiene before donning the gloves. An observation of patient care was conducted on 1/17/2024 at 11:57 AM. PCT E was beginning to access Patient #8’s Central Venous Catheter for treatment. PCT E changed gloves prior to beginning procedure but did not perform hand hygiene after removal of “dirty” gloves and donning “clean” gloves. Example of Patients not performing hand hygiene: An observation of patient care was conducted on 1/16/2024 at 11:41 AM. RN C assisted Patient #3 to remove a glove after holding access sites. No offer or reminder of hand hygiene was performed and Patient #3 left the facility without performing hand hygiene. During an interview on 1/17/2024 at 1:55 PM, the observation findings were discussed with Registered Nurse C who agreed that hand hygiene should have been performed.”

“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: 43037 Based on record review and interview, the facility staff failed to ensure that nursing assessment documentation addressed patients leaving above or below 1 kilogram (kg) of their target weight in 2 of 5 patients (Patient #s 1 & 5) in-center medical records reviewed in a total sample of 7 medical records reviewed. Findings: A review of facility policy 1-03-08, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised 10/2023 revealed, “...Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Fluid Status:..Post-Treatment: If a patient is above or below 1 kg from the target weight...” A review of Patient #1’s medical record revealed a physician order for a target weight of 153 kg. Treatment sheet dated 1/2/2023 revealed a post-treatment weight of 154.6 kg. (1.6 kg. above target weight). Treatment sheet dated 1/9/2023 revealed a post-treatment weight of 154.3 kg. (1.3 kg. above target weight). Treatment sheet dated 1/11/2023 revealed a post-treatment weight of 154.5 kg. (1.5 kg. above target weight). Treatment sheet dated 1/13/2023 revealed a post-treatment weight of 154.5 kg. (1.5 kg. above target weight). A review of Patient #5’s medical record revealed a physician order for a target weight of 66.5 kg. Treatment sheet dated 1/15/2023 revealed a post-treatment weight of 68.6 kg. (2.1 kg. above target weight). There were no documented notes as to why post-treatment weights were not attained or documented. During an interview on 1/17/2024 at 1:55 PM, the findings were discussed with Registered Nurse C who stated that there should have been documentation about target weights not being met.”

“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: 43037 Based on record review and interview, the facility staff failed to complete an “Against Medical Advice (AMA)” form, per policy, for 2 of 5 in-center hemodialysis patients (Patient #s 5 &7) with shortened treatment times in a total sample of 7 medical records reviewed. Findings: A review of facility policy 1-01-09, “Prescribed Treatment Time Not Met” last revised 10/2023 revealed, “...A. Completion of the Early Termination of Treatment Against Medical Advice form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time...B. Prescribed Treatment Time Not Met 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs...” A review of Patient #5’s medical record revealed a physician order for a treatment time duration of 210 minutes. Treatment sheet dated 1/15/2024 revealed a treatment of 166 minutes (44 minutes less than prescribed duration). No documentation was found in the medical record that the physician was notified and no AMA form was found for Patient #5 on 1/15/2024. A review of Patient #7’s medical record revealed a physician order for a treatment time duration of 210 minutes. Treatment sheet dated 1/3/2024 revealed a treatment of 176 minutes (34 minutes less than prescribed duration). No documentation was found in the medical record that the physician was notified and no AMA form was found for Patient #7 on 1/3/2024. During an interview on 1/17/2024 at 1:55 PM, the observation findings were discussed with Registered Nurse C who stated that there should have been documentation and an AMA form for the early termination of treatments.”