Davita Capitol Court 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: 35561 Based on observations, interviews, and policy review, the facility failed to ensure two of five Patient Care Technicians (Patient Care Technician (PCT) 1) and PCT7) who were observed during care delivery, implemented proper infection control measures when PCTs had artificial nails longer than one quarter inch. Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients, staff, and others to blood-borne pathogens. This deficient practice had the potential to affect all 81 patients receiving treatment in the hemodialysis unit. Findings include: On 11/13/24 at 1:00 PM, PCT1 was observed initiating dialysis for Patient 2 at Station 16. PCT1 was noted to have artificial fingernails on which extended past the fingertips at least one-half inch or more. The artificial nails also had multiple nail art decals on the surface on the nails, increasing the potential risk of bacterial growth in cracks and crevices. During an interview on 11/13/24 at 1:00 PM, when asked if the facility’s policy allowed nails of this type and length, PCT1 stated “yes, they’re okay.” On 11/15/24 at 9:00 AM, PCT7 was observed disinfecting Station 2 after a treatment had been discontinued. PCT7 was noted to have artificial fingernails on which extended past the fingertips at least one-half inch or more. During an interview on 11/15/24 at 1:30 PM, PCT7 was questioned about the facility’s fingernail policy, to which PCT7 replied “They told me I wasn’t supposed to have long nails because they carry bacteria. I know it’s not okay to have them.” Review of the facility’s policy titled “Infection Control for Dialysis Facilities,” dated April 23, indicated “It is a requirement for all teammates whose primary location is working in a facility to have only natural nails, and fingernail length should not extend more than ¼ inch.” During an interview on 11/15/24 at 11:30 AM, and review of the above findings, the Facility Administrator stated, “These observations do not meet the requirements of our infection control policy. The PCT’s have all been instructed about our fingernail policy and have been counseled about this topic before.” The Facility Administrator acknowledged that this practice presented a risk for cross contamination and stated, “we all need to do better with that.””

“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: 35561 Based on observations, interviews, and policy review the facility failed to ensure that cleaning and disinfection of contaminated equipment taken into the dialysis station was cleaned and disinfected according to facility policy for five of five dialysis stations (Station #16, #9, #14, #10, and #2) disinfected post dialysis treatment by five of five Patient Care Technicians (Patient Care Technician (PCT)1, PCT2, PCT3, PCT4, and PCT7). Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients, staff, and others to blood-borne pathogens. This deficient practice had the potential to affect all patients receiving treatment in the dialysis unit. Findings include: 1. On 11/13/24 at 12:30 PM: PCT1 was observed disinfecting Station #16 after the completion of dialysis treatment. During the disinfection procedure, PCT1 was observed to wipe the hemostats (blue plastic blood line clamps used during the dialysis treatment) with a cleaning rag used for disinfection of this station before replacing the hemostats on the clean machine. During an interview on 11/13/24 at 12:30 PM, When asked how the clamps were disinfected, PCT1 stated “We wipe them off.” 2. On 11/14/24 at 9:20 AM: PCT4 was observed disinfecting treatment station 9 after an unidentified patient had left the area. During the disinfection procedure, PCT4 was observed to wipe the hemostats with a cleaning rag used for disinfection of this station before replacing the hemostats on the clean machine. 3. On 11/14/24 at 10:00 AM: PCT2 was observed disinfecting Station #14 after the completion of dialysis treatment. During the disinfection procedure, PCT2 failed to clean or remove the hemostats from the dialysis machine. The hemostats remained in place during the machine set up for the next patient. During an interview on 11/14/24 at 10:00 AM, when asked if the hemostats were cleaned in between patients, PCT2 stated “Yes, I guess I missed it.” 4. On 11/15/24 at 8:50 AM: PCT3 was observed disinfecting Station #10 after the completion of dialysis treatment. During the disinfection procedure, PCT3 was observed to wipe the hemostats with a cleaning rag used for disinfection of this station before replacing the hemostats on the clean machine. During an interview on 11/15/24 at 8:50 AM, when asked about disinfecting the hemostats, PCT3 stated “we use bleach, or soap and water to wipe them down after each patient.” 5. On 11/15/24 at 9:10 AM: PCT7 was observed disinfecting Station #2 after the completion of dialysis treatment. During the disinfection procedure, PCT7 failed to clean or remove the hemostats from the dialysis machine. The hemostats remained in place during the machine set up for the next patient. During an interview on 11/15/24 at 9:10 AM, when asked why the hemostats were not disinfected, PCT7 stated “I thought I did.” Review of the facility’s policy titled “Infection Control for Dialysis Facilities,” dated April 23, revealed “Non-disposable items are to be disinfected after each patient use. If an item cannot be cleaned and disinfected it will be dedicated for use on a single patient. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution.” During an interview on 11/15/24 at 12:40 PM, the Facility Administrator confirmed that the PCT’s had been instructed to wipe the hemostats instead of submerging and soaking the clamps in a disinfectant solution. The Facility Administrator stated, “I was not aware of that requirement.””

“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: 35561 Based on observations, an interview, and policy review, the facility failed to ensure that a cart designated for clean supplies was clearly separated from a designated dirty sink area where there was potential for contamination with blood or body fluids for three of the three survey days. The failure to separate clean areas from dirty areas had the potential for contamination of clean supplies and could affect 81 in-center patients. Findings include: During an observation on the dialysis Treatment floor on 11/13/24 from 11:30 AM to 1:30 PM revealed a large three shelf cart on wheels with multiple boxes clean supplies located adjacent to the dirty sink across from Station #8. During an observation on the dialysis Treatment floor on 11/14/24 from 8:30 AM to 12:30 PM revealed the same large three shelf cart on wheels with multiple boxes clean supplies located adjacent to the dirty sink across from Station #8. During an observation on the dialysis Treatment floor on 11/15/24 from 8:30 AM to 10:00 AM the same large three shelf cart on wheels with multiple boxes clean supplies was located next to the dirty sink across from Station #8. PCT1, PCT 2, PCT3 and PCT4 were observed multiple times from 11/13/24 through 11/15/24 during observations on dialysis treatment floor using the dirty sink for disposal of contaminated solutions post dialysis treatments with the clean supply carts adjacent to the dirty sinks. During an interview on 11/15/24 at 1:00 PM the Facility Administrator acknowledged that as observed, the dirty sink area for contaminated solutions and equipment had not been separated from clean supplies to prevent cross contamination of the clean supplies. The Facility Administrator also acknowledged the facility’s infection control policy prohibited clean supplies from being stored in the same area as the “dirty sink.” Review of the facility policy’s titled, “Infection Control for Dialysis Facilities,” dated April 23, indicated, “If a common cart is used to store clean supplies in the patient treatment area, this cart is to remain in a designated area at a sufficient distance to avoid contamination. Clean supplies or equipment will not be placed adjacent to a sink.””

“RO-MEETS AAMI/MONITORED, RECORDED ON LOG CFR(s): 494.40(a) 5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2. 5.2.7 Reverse osmosis Users should carefully follow the manufacturer’s instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters. 6.2.7 Reverse osmosis All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review. This Standard is not met as evidenced by: 35561 Based on observation, interview and review of facility’s water treatment documents, the facility failed to ensure that all results of reverse osmosis (RO) disinfection and follow up residual chemical testing prior to use was recorded weekly in an operating log that permits trending and historical review. The failure to complete required disinfection and residual chemical testing of the RO system could lead to acute and chronic complications of hemodialysis therapy, which could potentially affect all 81 patients receiving in-center hemodialysis. Findings include: During an observational tour of the water treatment room on 11/13/24 at 2:00 PM with the Bio-Medical Technician (BMT) and a review of the facility’s RO water purification system was discussed. Documentation of the monitoring and disinfection process of the RO system was requested for the past six months and reviewed. Review of the “RO Machine Logs,” dated from 08/05/24 through 11/02/24, under the “RO weekly disinfection” revealed the following: For the week of 08/05/24 to 08/10/24: no RO chemical disinfection was documented; no residual chemical testing was documented as being performed. For the week of 08/19/24 to 08/24/24: no RO chemical disinfection was documented; no residual chemical testing was documented as being performed. For the week of 08/26/24 to 08/31/24: no RO chemical disinfection was documented; no residual chemical testing was documented as being performed. For the week of 10/28/24 to 11/02/24: no RO chemical disinfection was documented; no residual chemical testing was documented as being performed. During an interview on 11/13/24 at 2:00 PM the BMT stated, “I don’t know what happened those weeks. It’s impossible to know if the RO disinfection or residual chemical testing was done or not. I need to check these logs more closely.” Review of the facility’s policy titled “Water Treatment System Disinfection,” dated October 2021, revealed “The RO distribution system is disinfected at least weekly using peracetic acid solution. Facility teammates are to perform independent residual chemical testing prior to the beginning of the daily activities on the first treatment day following a water treatment system or membrane chemical disinfection.” During an interview on 11/13/24 at 5:00 PM, the Facility Administrator confirmed these findings and stated, “The disinfection and residual testing wasn’t documented, so we can’t be sure if it was completed as required.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 35561 Based on observation, staff interview, and review of manufacturer’s instructions for use, the facility failed to ensure that laboratory blood specimen collection vacutainers available for use were not expired. Expired lab tubes, such as blood collection tubes, should be discarded because the vacuum may not be strong enough to fill the tube completely which can lead to an incomplete sample that is not suitable for testing. Failure to ensure that all equipment is maintained in accordance with the manufacturer’s recommendations had the potential to adversely affect laboratory results for all 81 current patients receiving hemodialysis treatments. Findings include: During an initial flash tour conducted with the Facility Administrator at 8:30 AM on 11/13/24. While touring the treatment floor laboratory processing room inside the laboratory supply cabinet, a box of “BD Vacutainer” was observed and contained 100 blood specimen tubes that had expired on 10/31/24. During an interview on 11/13/24 at 8:30 AM, the Facility Administrator confirmed the 100 expired vacutainer tubes and stated, “we must have missed that box.” Review of the BD Vacutainer Serum Tubes manufacturer’s instructions titled, “Intended Use” dated 03/2024, revealed, “Do not use tubes after their expiration date.””

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 35561 Based on medical record review and interview, the facility failed to ensure the necessary monitoring and social work interventions were implemented as needed for one of one patient (Patient (P) 4) undergoing a significant behavioral and psychosocial issue on an acute basis. A lack of social work intervention in times of crisis presents the potential failure to resolve patient concerns. This deficient practice had the potential to affect all 81 current patients and all future patients receiving treatment at this dialysis clinic. Findings include: Medical record review revealed P4 was admitted on 06/07/24 at 6:02 PM at with a diagnosis of end stage renal disease and was receiving dialysis three times per week. On a “Patient Note,” dated 09/25/24, Registered Nurse (Registered Nurse (RN)1 documented “Treatment ended early today due to disruptive behavior 15 minutes after starting treatment. Patient (4) requested PCT (patient care technician) to move trash can closer to him/her so he/she can throw some stuff, PCT obliged and moved trash can near him/her. After moving trash can near him/her, patient (4) called PCT a “bitch.” Patient (4) then started berating PCT with “bitch, a tacky bitch, a bitch, a bald head bitch.” This RN then stated to patient that this behavior was inappropriate. Patient (4) refused to stop and screamed to have someone “come and beat your ass and kill you.” Patient (4) also continued to berate PCT by calling him/her a “bitch,” “cunt,” and “tacky hoe.” PCT then called 911 ... Police came and escorted (P4) out of clinic.” On a “Patient Note,” dated 09/30/24 at 1:56 PM, the Facility Administrator documented “Pt (P4) called clinic multiple times this morning asking staff if he/she could come back to the clinic today. Facility Administrator called pt (P4) and informed him/her that yes, he/she could come back to the clinic today at his/her normal time. Informed pt (P4) we would be meeting with him/her prior to his/her treatment. Pt (P4) was brought back to MSW (Medical Social Worker) office and MSW and Facility Administrator met with pt (P4). Reviewed with him/her letter of concern and pt standard of conduct.” On a “Patient Note,” dated 09/30/24 at 1:56 PM, the MSW documented “Pt (P4) given First Letter of Concern and Rules of Conduct. Pt (P4) became increasingly upset indicating that he/she felt the clinic was attacking him/her. SW and Facility Administrator both indicated that this meeting was not to attack the pt (P4) and rather just remind the pt (P4) of what policies must be followed at the clinic. Pt (P4) requested at transfer to FMC (Fresenius Medical Clinic). SW called and put a request through. As of 11/15/24, no further documentation was found in P4’s medical record of further contact or communication regarding the transfer that the patient (P4) had requested. During an interview on 11/15/24 at 1:30 PM, the MSW stated “No, I haven’t done any follow up on this request for transfer, I was waiting for the patient (P4) to let me know what FMC decided.” There was no evidence that the MSW provided follow up on the request for transfer or further counseling in an attempt to help P4 cope with the current dialysis treatment plan in this facility. During an interview on 11/15/24 at 4:10 PM, these findings were discussed with the Facility Administrator who responded, “I wasn’t aware that this patient (P4) hadn’t been given an answer about the transfer request yet. Six weeks is a long time to wait.” The Facility Administrator was asked if the Midwest Kidney Network was notified of the above occurrences with P4, and he/she stated, “no, we did not notify them, but that is a really good suggestion.””