Davita New Martinsville Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 43434 Based on policy review and staff interview, it was determined the facility failed to comply with 494.20, by failing to follow their “Requesting Surveyor Access to Protected Health Information” policy and Federal, State, and local laws and regulations regarding access to patient records. The facility failed to provide appropriate access to patients medical records in a sufficient and reasonable time frame. Findings include: The policy titled “Requesting Surveyor Access to Protected Health Information” states “1. DaVita will provide Surveyors access to medical and patient records in order to full fill their survey responsibilities or as otherwise required or permitted by law...” An interview was conducted on 10/23/24 at 10:32 a.m. with Staff #1. Staff #1 confirmed that medical record access was not immediate and was delayed until the second day of the survey causing a delay and impeding the survey process.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 38282 Based on observation, document review, and staff interview, it was determined the facility failed to comply with 494.30 by failing to follow their infection control policies regarding the sanitary discontinuation of dialysis and hand sanitizing prior to donning gloves observed in three (3) patients (Patient #3, Patient #8, and Patient #10). (Refer to V0111). Findings include: The policy titled, “Infection Control for Dialysis Facilities;” revised 04/2023; was reviewed and states, in part, “Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene...b. Prior to gloving and immediately after removal of gloves...7. a. Gloves should be changed when:...ii. When going from a “dirty” area or task to a “clean” area or task. iii. When moving from a contaminated body site to a clean body site of the same patient...” The color handout provided by the facility titled, “Cannulating an AVF [arteriovenous fistula]or AVG [arteriovenous graft],” based upon policy and procedure 1-04-01 and 1-04-01E; was reviewed and stated, in part,”...No hanging tape - facilities being cited as hanging tape can catch on items like lab coats, underside of tables.” And the process for placing a barrier piece of tape on the barrier and stacking tape for use was described. The policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Loading Dose” revised 10/2022, was reviewed and stated, in part: “...Place a clean barrier under access extremity...” An observation was conducted on 10/21/24 at 12:05 p.m. of the discontinuation of dialysis and post dialysis access care of a fistula for Patient #10 by Staff #3. Patient #10 was noted to have three (3) cannulation tubing’s coming from the fistula on the left upper arm, two (2) of which were attached to the machine, and a third one with a syringe attached, but not in use. It was explained that the third access was not usable and was left in place throughout the dialysis treatment because of the closeness to the other cannulation and the risk of bleeding during the dialysis treatment. Without using a barrier, Staff #3 removed the syringe from the tubing and laid the extra tubing on the Patient’s shirt prior to removing the needle from the fistula. Staff #3 walked around to the opposite side of the chair and retrieved a cap and a barrier. The cap was placed on the third line and the barrier was placed under the Patient’s arm in preparation for removal. A roll of tape was noted to be hanging off the side of the table on the left side of the chair. Staff #3 was tearing off pieces of tape from another roll lying on the barrier one at a time. They would stick the tape to their glove and use it with gauze for a pressure dressing after discontinuing each of the cannulation needles. An observation was conducted on 10/21/24 at 12:54 p.m. of the discontinuation of dialysis with central venous catheter (CVC) in the right subclavian (SC) for Patient #8 by Staff #3. During the process of discontinuation, Staff #3 had sanitized their hands and applied clean gloves. They adjusted the Patient’s chair and opened supplies and placed them on a fresh barrier on the chairside tray. A barrier was placed under the CVC tubing. Without sanitizing their hands and changing gloves again, Staff #3 disconnected the tubing, connected the tubing together, and hung it on the machine. They returned to the Patient, disinfected the ports, administered Heparin, capped the hubs, and wrapped them in tape-wrapped gauze. An observation was conducted of a medication pass on 10/21/24 at 3:03 p.m. for Patient #3 by Staff #1. Staff #1 prepared the intravenous (IV) medication according to protocol and brought it to the computer at the Patient’s station. While holding the medication without gloves, Staff #1 documented in the computer, then donned gloves without first sanitizing their hands, and administered the medication. An interview was conducted on 10/22/24, at 11:30 a.m. with Staff #2. Staff #2 confirmed that Staff #3 had not followed procedures and protocols with barrier placement and the use of tape with Patient #10; or sanitized their hands and changed gloves while moving from dirty to clean areas with Patient #8. Staff #2 stated, “They must have been nervous; they will be re-trained.” An interview was conducted on 10/22/24 at 8:30 a.m. with Staff #1. Staff #1 confirmed that the laptop keyboards in the dialysis area were to be used to document Patient treatments, assessments, and medications as they were being administered, and that gloves were not to be worn when documenting. Staff #1 then confirmed that hands were to be sanitized and gloves donned prior to providing patient care or administering medications.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 38282 Based on observation, document review, Patient electronic medical record (EMR) record review, and staff interview, it was determined the facility failed to comply with 494.80(a)(1) by failing to follow their policy to perform pre-treatment nursing assessments prior to, or within 60 minutes of, the initiation of dialysis for three (3) out of three (3) Patients observed (Patient #1, Patient #2, and Patient #7). (Refer to V0502). Findings include: The policy titled: “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment;” revised: 04/2024; was reviewed and stated in part: “The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN)...vi. A physical assessment of the patient which includes: 1. Apical heart rate and rhythm 2. Auscultation of the lungs 3. Evaluation of volume status including edema 4. Bruising or bleeding ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment ...” Regarding post assessment, the policy stated in part: “15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings ...” An observation was conducted on 10/21/24 from 11:45 a.m. to 3:30 p.m. of the dialysis treatment area. Initiation of treatment was observed with Patient #1 at 2:30 p.m.; Patient #2 at 1:30 p.m. and #7 at 1:40 p.m. At no time during the observation was the RN on duty observed assessing the patients. A review of Patient #1’s EMR revealed that in-center hemodialysis was ordered “three times a week for three (3) hours (180 min).” A pre-treatment nursing assessment was completed by Staff #1 on 10/21/24 at 5:05 p.m. and a post-treatment assessment was completed at 5:17 p.m.; and treatment was observed to be initiated at 2:30 p.m. There was an “Early Termination of Treatment Against Medical Advice” signed by the Patient and cosigned by Staff #1. The document was dated 10/21/24, but not timed, that stated, “Prescribed treatment time 180 minutes (total); Shortened Treatment by (minutes) 84. Pt [Patient] put on machine late, wants to go home, time crunch d/t [due to] family pick up.” A review of Patient #2’s EMR revealed that in-center hemodialysis was ordered “three times a week for 3 hours 30 min (210 min). A pre-treatment nursing assessment was completed by Staff #1 on 10/21/24 at 4:37 p.m. and a post-treatment assessment was completed at 6:05 p.m.; and treatment was observed to be initiated at 1:30 p.m. A review of Patient #7’s EMR revealed that in-center hemodialysis was ordered “three times a week for three (3) hours (180 min).” A pre-treatment nursing assessment was completed by Staff #1 on 10/21/24 at 4:42 p.m. and a post-treatment assessment was completed at 5:57 p.m.; and treatment was observed to be initiated at 1:40 p.m. There was an “Early Termination of Treatment Against Medical Advice” signed by the Patient and cosigned by Staff #1. The document was dated 10/21/24, but not timed, and stated: “Prescribed treatment time 180 minutes (total); Shortened Treatment by (minutes) 87. Refused to stay despite education, RN aware.” An interview was conducted on 10/22/24 at 11:15 a.m. with Staff #2 regarding the pre-treatment nursing assessments. Staff #2 stated, “We are open on Monday, Wednesday, and Friday; and serve three (3) shifts of patients. I am the only regular RN for the facility. I try to assess all of my patients prior to the initiation of their treatments; especially those on the third shift, as they are some of our sicker Patients. At most, I will assess them within thirty (30) minutes of initiation, even though we have up to an hour to complete it. I will also complete a post-treatment assessment and document it on the computer. The PCT can also do the post-treatment documentation according to policy, but I prefer to do it myself. I was not there yesterday, so I cannot speak to that.” An interview was conducted on 10/22/24 at 12:03 p.m. with Staff #1 who stated, “[Staff #2] is our regular RN, but [they] were off yesterday. I was covering and helping out as best as I could, but I was busy doing other things and did not get to the pre-treatment assessments.” Staff #1 then concurred that the pre-treatment assessments were not completed prior to or within an hour of the initiation of dialysis per facility policy on 10/21/24; and that two (2) Patients had left against medical advice because their appointments were running late.”