Davita Florence 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: 49894 Based on observations, review of facility policy, and staff interviews, it was determined the facility failed to ensure staff performed hand hygiene after removing gloves. This affected Patient Identifier (PI) # 10 in one of two observations of discontinuation of dialysis with an Arteriovenous Fistula or Graft and PI # 9 in one of two observations of discontinuation of dialysis with a Central Venous Catheter and had the potential to negatively affect all 50 patients dialyzing at the facility, staff, and visitors. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Origination Date: 9/07 ...Hand Hygiene All Teammates, Physicians and Non-Physician (NPP) will perform hand hygiene...prior to gloving and immediately after removal of gloves...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse... 1. An observation was conducted on 10/16/24 at 9:45 AM with EI # 2 providing care for PI #10 at station 6. After rinse back of the patient’s blood, EI # 2 removed his/her gloves, and without performing hand hygiene began typing on the chairside keyboard. An interview was conducted on 10/17/24 at 3:30 PM with EI # 1, Facility Administrator, who confirmed hand hygiene was not performed per policy. 2. An observation was conducted on 10/16/24 at 11:51 AM with EI # 3, Registered Nurse, discontinuing dialysis for EI # 9 at station 15. After rinse back of the patient’s blood, EI # 3 failed to remove his/her gloves and perform hand hygiene. An interview was conducted on 10/17/24 at 3:45 PM with EI # 1, who confirmed hand hygiene was not performed per policy.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 49894 Based on review of facility policy and procedure, observation, and staff interview, it was determined the facility failed to ensure staff tested the final dialysate of the dialysis machine per facility policy. This affected Patient Identifier (PI) # 8 in one of three observations of preparation of the hemodialysis machine and had the potential to negatively affect all 50 patients dialyzing at the facility. Findings include: Facility Policy: Testing Potential of Hydrogen (pH) of Citric Acid Base Balance Using RPC E-Z Check K100-0117CT 6.8-8.5 Test Strips Policy Number: 1-21-09 Originiation Date: 11/19 Procedure: ...Remove strip from vial... ...Using a new syringe, obtain dialysate sample from sample port, allow fluid to flow over the pad for one second. ...shake off excess dialysate. Within 20-25 seconds, compare the color reaction on strip to the color chart on bottle to determine the closest match. An observation was conducted on 10/16/24 at 10:06 AM of Employee Identifier (EI) # 5, Patient Care Technician, testing the pH of the dialysate at station 9. Using a new syringe, EI # 5 drew the sample to be tested from the arterial blood line hanging from the dialysis machine. An interview was conducted on 10/17/24 with EI #1, Facility Administrator, who confirmed the sample for pH testing was not pulled from the correct port.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 49894 Based on review of medical records (MR), facility policy, Tazicef Manufacturer’s Directions for Use (Package Insert), and staff interview it was determined the facility failed to administer antibiotics per the physician’s order and/or manufacturer’s directions for use. This affected Patient Identifier (PI) # 5 in one of five in-center MRs reviewed and had the potential to negatively affect all patients receiving antibiotics at this facility. Findings include: Facility Policy: Medication Policy Policy Number: 1-06-01 Origination Date: 9/07 ...Medications are administered as prescribed and then documented in the patient’s medical record. ...All medication errors are reported to the Facility Administrator/designee. She/he will the notify the patient’s physician of the event...Examples of medication errors include: ...a prescribed medication not administered to the patient. Tazicef (Ceftazidine) For Intravenous (IV) or Intramuscular Use Package Insert Hospira LAB-1131-0 Revised: 3/22 Dosage and Administration: Impaired Renal Function: Intravenous Administration: For direct IV administration...slowly inject...over a period of three to five minutes Compatibility and Stability Intravenous: Vancomycin solution inhibits a physical incompatibility when mixed with...ceftazidime. It is therefore recommended...that they be given separately. PI # 5 was admitted to the facility on 9/19/18 with a diagnosis of End Stage Renal Disease. Review of the Patient Summary Report (PSR) revealed the patient had a Arteriovenous Graft (AVG) and a Central Venous Catheter (CVC). Further review of the PSR revealed an order dated 10/9/24 for Vancomycin 400 milligrams every dialysis treatment. Further review of the PSR revealed an order dated 10/11/24 for Tazicef One Gram every dialysis treatment. Review of the Treatment Details Report (TDR) dated 10/9/24 revealed the Vancomycin was not given due to clotted access. Documentation by the patient care technician on the Intradialytic Vitals Stat Line on the TDR dated 10/9/24 revealed the treatment ended due to an infiltrated venous needle. Further review of the TDR revealed the CVC was not accessed and used to administer the antibiotics as ordered. Review of the TDR dated 10/11/24 revealed the Vancomycin and Tazicef were both administered at 12:32 PM. Review of the TDR dated 10/14/24 revealed the Vancomycin was administered at 3:49 PM and the Tazicef was administered at 3:50 PM. An interview was conducted on 10/17/24 at 3:00 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed the antibiotics were not administered per physician’s order or per the manufacturer’s directions for use.”

“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: 49894 Based on review of medical records (MR), facility policy and procedure, and staff interview, it was determined the facility failed to ensure staff documented post weights per facility policy. This affected Patient Identifier (PI) # 1 and PI # 5 in two of five in-center MRs reviewed and had the potential to negatively affect all 50 patients dializing in the facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Origination Date: 9/07 Policy: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes...patient weight. Post Treatment Data Collection/Assessment The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 1. PI # 1 was admitted to the facility on 5/17/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the patient’s Treatment Details Reports (TDR) revealed on dates 9/25/24, 9/27/24, 9/30/24, 10/10/24, and 10/11/24 (five of six TDRs reviewed) the post weight was calculated by the system and not collected and documented by the PCT or licensed nurse per facility policy. An interview was conducted on 10/17/24 at 3:00 PM with Employee Identifier (EI) #1, Facility Administrator, who confirmed the post weights were not obtained and documented per the facility policy. 2. PI # 5 was admitted to the facility on 9/19/18 with a diagnosis of ESRD. Review of the patient’s TDRs dated 10/2/24, 10/9/24, 10/11/24, and 10/14/24 (four of six TDRs reviewed) revealed the post weight was calculated by the system and not collected and documented by the PCT or licensed nurse per facility policy. An interview was conducted on 10/17/24 at 3:00 PM with EI # 1, who confirmed the post weights were not obtained and documented per the facility policy.”

“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: 47295 49603 49894 Based on review of medical records (MR), faciity policies and procedures, and staff interview, it was determined the facility failed to ensure: 1. Staff followed the physician’s order for Blood Flow Rate (BFR). 2. Staff administered the post-treatment Central Venous Catheter (CVC) Intra-catheter Heparin Locking Solution (heplock) at the end of the patient’s treatment. This affected Patient Identifiers (PI) # 1, PI # 4 and PI # 5 in four of five in-center MRs reviewed, and had the potential to negatively affect all 50 patients dialyzing at this facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Origination Date: 9/07 Policy: ...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain the prescribed blood flow rate) the reason will be documented... ...All findings, interventions, and patient response will be documented in the patient’s medical record. Facility Policy: CVC Locking Solutions Policy Number: 1-06-03 Origination Date:9/07 Policy: Catheter locking solutions are utilized between dialysis treatment to maintain patency. Locking solutions are used to fill the catheter limbs between treatments to prevent blood migration into the limbs and susequent clotting. ...Post installation, the following is documented on the treatment record...date and time instilled Facility Policy: Medication Policy Policy Number: 1-06-01 Origination Date: 9/07 Policy: ...Medications are administered as prescribed and then documented in the patient’s medical record. 1. PI # 1 was admitted to the facility on 5/17/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Treatment Details Report (TDR) dated 9/23/24 revealed the patient’s treatment ended at 2:28 PM. The heplock was documented administered at 2:06 PM, which is twenty-two minutes before the end of the patient’s treatment. Review of the TDR dated 9/25/24 revealed the BFR was 270 from 12:35 PM to 1:05 PM, and 300 from 1:35 PM to 2:09 PM, and not the prescribed 350. There was no documentation of why the BFR was not as prescribed. Review of the TDR dated 9/27/24 revealed the BFR was 300 from 12:39 PM to 2:39 PM, and 250 from 2:39 PM to 3:09 PM, and not the prescribed 350. There was no documentation of why the BFR was not as prescribed. Further review of the TDR dated 9/27/24 revealed the treatment ended at 3:09 PM and the heplock was administered at 3:47 PM, which is thirty-eight minutes after the patient’s treatment ended. Review of the TDR dated 10/10/24 revealed the BFR was 270 from 11:37 AM to 3:06 PM, and not the prescribed 350 with no documentation why the BFR was not as prescribed. Further review of the TDR dated 10/10/24 revealed the the treatment ended at 3:06 PM and the heplock was documented administered at 4:31 PM, which is one hour and twenty-five minutes after the patient’s treatment ended. An interview was conducted on 10/17/24 at 3:00 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed the BFR and the heplock administration were not documented per facility policy. 2. PI # 4 was admitted on 8/27/21 with a diagnosis of End Stage Renal Disease. On treatment date 10/07/24, the BFR was 200 from 8:32 AM to 9:32 AM. There was no documentation why the BFR was 200 and not the ordered rate of 350. On treatment date 10/11/24, the BFR was 300 from 6:55 AM to 9:54 AM. There was no documentation why the BFR was 300 and not the ordered rate of 350. An interview was conducted on 10/17/24 at 3:27 PM with EI # 1, who confirmed there was no documentation why the BFR was not the ordered rate of 350. 3. PI # 5 was admitted to the facility on 9/19/18 with a diagnosis of ESRD. Review of the TDR dated 10/2/24 revealed the BFR was 300 from 1:32 PM to 3:49 PM, and not the prescribed 350, with no documentation of why the BFR was not as prescribed. An interview was conducted on 10/17/24 at 3:00 PM with EI # 1, who confirmed the BFR was not documented per facility policy.”

“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: 49894 Based on observation, review of facility policy, and staff interview, it was determined the facilty failed to ensure staff performed Arteriovenous Fistula/Graft (AVF/AVG) site preparation for cannulation per policy in one of two observations of Access of AVF or AVG for initiation of dialysis. This affected Patient Identifier (PI) # 8 and had the potential to negatively affect all patients with an AVF/AVG. Findings include: Facility Policy: AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose Policy Number: 1-04-01 Origination Date: 10/24 Procedure: ...Perform inspection, auscultation, and palpation on entire length of access... ...Do not palpate insertion site once area has been prepped. An observation was conducted on 10/16/24 at 10:45 AM with Employee Identifier (EI) # 4, CCHT, initiating dialysis for PI # 8 at station 9. EI # 4 failed to auscultate the access for a bruit/thrill before palpating. After skin antisepsis was performed, EI # 4 touched the skin on the arterial access without re-cleaning it before cannulation. An interview was conducted on 10/17/24 at 3:30 PM with EI # 1, Facility Administrator, who confirmed AVF/AVG site preparation for cannulation was not per the facility policy.”