Davita Wisconsin Rapids 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 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 13 patients (Patients #4, 9, 10, 16), the facility staff failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 1 of 1 patients (Patient #15) observed holding access sites, and the facility staff failed to wear gloves when touching the dialysis machine for 1 of 13 patients (Patients #4) in a total of 15 observations of patient care. Findings Include: A review of the facility’s policy #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised 04/2023 revealed, “... All teammates... will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves... g. 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...” A review of the facility’s policy #1-04-01B titled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” last revised 04/2023 revealed, “... When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed...” During an observation on 04/01/2025 at 9:35 AM, Patient Care Technician G touched Patient #9’s dialysis machine and then disconnected blood lines from CVC (central venous catheter) without changing gloves and performing hand hygiene. During an observation on 04/01/2025 at 10:20 AM, Patient Care Technician F was setting up the dialysis machine to initiate dialysis on Patient #10. Patient Care Technician F touched the keyboard on the computer and then put on gloves and set up the dialysis machine without completing hand hygiene. During an observation on 04/01/2025 at 10:33 AM, Patient Care Technician G touched Patient #4’s dialysis machine without gloves. During an observation on 04/01/2025 at 10:35 AM, Patient Care Technician G cleansed Patient #4’s CVC exit site, removed her gloves, and left the dialysis station without performing hand hygiene. During an observation on 04/01/2025 at 10:38 AM, Patient #15 was observed holding 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 04/02/2025 at 9:26 AM, Patient Care Technician H initiated dialysis on Patient #16. Patient Care Technician H removed her gloves and did not perform hand hygiene prior to exiting Patient #16’s dialysis station. During an interview on 04/02/2025 at 10:52 AM, the observation findings were discussed with Facility Administrator A who stated that hand hygiene needs to be performed when going from a dirty to clean task, that staff cannot touch the dialysis machine without gloves, and that patients need to perform hand hygiene after holding their access sites.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 29963 Based on observation, record review and interview, facility staff failed to remove gown when exiting the treatment area and entering the waiting room for 1 of 1 staff observed (Patient Care Technician F) in the patient waiting room in a total of 15 observations of care. Findings include: A review of facility’s policy 1-05-01 titled, “Infection Control for Dialysis Facilities” dated 04/2023 revealed “PPE (Personal Protective Equipment) (i.e., gown, gloves, eye protection, face shield) 5. a. Removed prior to leaving the treatment area ... c. PPE is not to be worn in the non-treatment areas ...” During an observation on 04/01/2025 at 10:20 AM, Patient Care Technician F exited the treatment area and entered the patient waiting area to gather Patient #10’s personal belongings out of a storage area without removing gown. During an interview on 04/01/2025 at 10:50 AM, Facility Administrator A stated PPE should be removed when leaving the patient treatment area.”

“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 ensure that patients vacated the dialysis station prior to disinfection of the dialysis station in 1 of 1 patients (Patient #12), and the facility staff failed to complete disinfection of all equipment in the dialysis station for 2 of 2 dialysis stations (Stations #7, 13) observed being cleaned in a total of 15 observations of patient care. Findings Include: A review of the facility’s policy #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised 04/2023 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... Dialysis station must be completely vacated by the previous patient before teammates can being to bring disinfection supplies to the station, clean or disinfect the station...” During an observation on 04/01/2025 at 9:08 AM, Patient Care Technician G was observed cleaning Station #7 and did not wipe down the IV pole hooks or priming bucket. During an observation on 04/01/2025 at 9:20 AM, Patient Care Technician F started cleaning dialysis Station #13 while Patient #12 remained in the dialysis chair following dialysis treatment. During an observation on 04/01/2025 at 9:50 AM, Patient Care Technician F was observed cleaning Station #13 and did not wipe down the IV pole hooks or priming bucket. During an interview on 04/02/2025 at 10:59 AM, the observation findings were discussed with Facility Administrator A who stated that staff should not be cleaning the dialysis stations until the patient has vacated the station and that staff should wipe down all surfaces 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 47413 Based on record review, observation and interview, the facility staff failed to ensure aseptic technique was maintained when working with central venous catheters (CVC), per facility policy for 1 of 4 patients with a CVC observed (Patient #11) in a total sample of 4 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 10/2024 revealed, “... Upon Completion of Dialysis: Teammate and patient will wear masks covering the nose and mouth during this procedure...” During an observation on 04/01/2025 at 9:02 AM, Patient Care Technician G was observed discontinuing dialysis on Patient #11 who had a CVC. Patient Care Technician G and Patient #11 were not wearing masks. During an interview on 04/02/2025 at 10:51 AM, the observation findings were discussed with Facility Administrator A who stated that it is the expectation that both the teammate and patient wear a mask when working with a CVC.”

“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 blood pressure monitoring was completed per facility policy in 1 of 7 patients (Patient #2) in-center medical records in a total universe of 7 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 04/2024 revealed, “... Intradialytic Data Collection/Assessment: Vital signs and treatment monitoring: ... iii: Non-nocturnal treatments are completed at least every thirty (30) minutes... At a minimum, obtain and document the following: i. Blood pressure...” A review of Patient #2’s medical record revealed on the treatment sheet dated 03/05/2025, an intradialytic blood pressure was documented at 3:31 PM and then again at 4:30 PM (59 minutes later) and on the treatment sheet dated 03/12/2025, an intradialytic blood pressure was documented at 4:35 PM and then again at 5:30 PM (55 minutes later). During an interview on 04/02/2025 at 8:54 AM, the medical record findings were reviewed with and confirmed by Facility Administrator A who stated that blood pressure checks should be documented 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: 29963 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 #10) observed for initiation of dialysis with an AV Fistula/Graft and staff failed to check for a bruit or thrill after the application of clamps, per policy, for 3 of 3 patients (Patients #8, 12, 15) observed for discontinuation of dialysis with an AV Fistula/Graft in a total of 15 observations of patient care. Findings Include: A review of the facility’s policy #1-04-01D titled, “AV Fistula or Graft Cannulation..., “ last revised 04/2025 revealed, “Skin Antiseptic ...Povidone Iodine...Effective contact time: 30 seconds ...While maintaining aseptic technique, cleanse the sites by applying skin antiseptic using a circular motion, moving from the center out and allow to dry...” A review of the facility’s policy #1-04-08 A titled, “Utilizing Vascular Access Clamp Procedure” last revised 04/2023 revealed, “... After placement of clamp, check for thrill and bruit above and below clamp...” During an observation on 04/01/2025 at 9:16 AM and 9:32 AM, following discontinuation of dialysis, Patient Care Technician F applied a clamp to Patient #8’s fistula/graft access site and did not check for bruit and thrill as per policy. During an observation on 04/01/2025 at 9:50 AM, following discontinuation of dialysis, Registered Nurse E applied a clamp to Patient #12’s fistula/graft access site and did not check for bruit and thrill as per policy. During an observation on 04/01/2025 at 10:20 AM, Patient Care Technician F used Povidone Iodine to cleanse Patient #10’s arm access sites prior to cannulation for a total of 15 seconds, 15 seconds less than per policy. During an observation on 04/01/2025 at 10:38 AM, following discontinuation of dialysis, Patient Care Technician F applied a clamp to Patient #15’s fistula/graft access site and did not check for bruit and thrill as per policy. During an interview on 04/02/2025 at 10:58 AM, the observation findings were discussed with Facility Administrator A who stated that staff need to check for a bruit and thrill after clamp application.”

“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: 47413 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 1 of 1 newly admitted patients (Patient #4) reviewed in a total sample of 1 newly admitted patient medical record reviewed. Findings include: A review of the facility’s policy #1-03-07 titled, “Initial Patient Nursing Assessment for New Patients” last revised April 2024 revealed, “... 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 #4’s medical record revealed Patient #4 was admitted for their first dialysis treatment on 03/25/2025. The first dialysis treatment was started on 03/25/2025 at 10:38 AM. Patient #4’s “Initial Assessment” was completed on 03/25/2025 at 11:12 AM (34 minutes after initiation of first dialysis treatment). During an interview on 04/02/2025 at 8:58 AM, the medical record review findings were reviewed with and confirmed by with Facility Administrator A who stated, “The expectation is that the note is completed before the start of the first treatment.””