Davita 2010 surveys - infection control

DAVITA

Alameda Dialysis - Oakland

Complaint investigation - 5/6/10 - Patient Rights (not understanding staff language)

Berkeley

Recertification - 2/25/10

V122 -Infection Control - Disinfecting equipment used for/in dialysis treatment

V126 -Infection Control - Hepatitis (HBV) Vaccinate Patients/Staff

V132 -Infection Control - Training/Education of Staff

V142 -Infection Control - Implement policies - biohazard

V147 -Infection Control - Staff Education - Catheter Care

**Patients hospitalized with septicemia (infection in blood stream) 2006-2008 was 10% -> 2% under national average

**2009 -> total 23 deaths - 26.1% were due to infection Note: increase in %

2008 18 5.6%

2007 13 15.4%

2006 20 10%

Montclair Dialysis

Recertification 01/4/10 (last survey not identified in CMS data)

V110 - CONDITION NOT MET FOR INFECTION CONTROL

V111 - Sanitary Environment

V112 - Not following CDC recommendations

V113 - Gloves/Hand Hygiene

V115 - Gowns/Shields/Masks

V116 - Disinfecting Items used for or in dialysis treatments

V117 - Clean/Dirty areas/medication area

2006-2008 - 4%/5% over state/national averages

2009 - 18 deaths - 16.7% due to infection

2008 - 24 deaths - 33.3% due to infection

2007 - 18 deaths - 11.1% due to infection

2008 - 26 deaths - 30.8% due to infection

** unlabeled medications prepared by one staff, administered by another

Reuse - informed consent

* Patient death rate versus expected death rate for 2006-2009 - 30% worse than expected

First year death rate versus expected death rate 2006-2008 - 84% worse than expected

North Hollywood Dialysis

Complaint 1/7/10 (last survey 2003)

V114 - Sinks available for washing hands

V117 - Medication Preparation

2009 - 15 deaths - 20% due to infection

2008 - 24 deaths - 16.7% due to infection

2007 - 37 deaths - 5.4% due to infection

2006 - 19 deaths - 15.8% due to infection

San Diego South Gateway

Recertification - 4/27/10 -- (last survey 2003)

V122 - Infection Control - Disinfect Surfaces/Equipment used in/for dialysis

** 2009 - 20 deaths - 15% due to infection

2008 - 21 deaths - 9.5% due to infection

2007 - 10 deaths - 10% due to infection

2006 - 18 deaths 5.6% due to infection

Recertification 8/5/10 (last survey 2007)

V113 Infection Control - gloves/hand hygiene

V126 Infection Control - pts not vaccinated

V127 Infection Control - Hepatitis Testing

V142 Infection Control - monitoring / implementing policies

V146 Infection Control - Catheters (not implementing facility procedures)

2009 - 8 deaths - 25% due to infection

2008 - 7 deaths 14.3% due to infection

Complaint -- 1/6 and 6/24/10 wrong dialzyer - patient received another patients dialzyer

Complaint -5/28/10 - wrong dialzyer - patient received another patients dialzyer

Recertification 7/22/10 ( last survey 2007)

V122 - Infection Control - Disinfect Surfaces/Equipment

V147 - Infection Control - Staff Education/Catheter Care

2009 - 12 deaths - 33.3% due to infection