Davita Center Point Dialysis

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49894 Based on observation, review of facility policy and procedure, Potter-Perry Fundamentals of Nursing, and staff interview, it was determined the facility failed to ensure staff did not leave prepared medications unattended and distributed medication to the patient station in an aseptic manner. This deficient practice affected Patient Identifier (PI) # 6 in one of four observations of medication administration and had the potential to affect all patients prescribed medications dialyzing at the facility. Findings include: Facility Policy: Medication Policy Policy Number: 1-06-01 Revision Date: 10/23 ...8. All teammates administering medications must utilize aseptic technique. Facility Procedure: Preparation and Administration of Parenteral Medications Procedure Number: 1-06-01A Revision Date: 4/24 ...17. Distribute the medication to the patient station in an aseptic manner. For example, place patient’s syringes in a reclosable plastic bag if medication is not administered immediately. Potter-Perry Fundamentals of Nursing 6th Edition Copyright Date: 2001 Chapter 34 Unit VI Medication Administration Page 907 Bullets 11-12 The six rights of medication administration are the right medication, right dose, right client, right route, right time, and right documentation. Nurses administer only medications they prepare and prepared medications are never left unattended. 1. An observation was conducted on 5/21/25 at 10:05 AM with Employee Identifier (EI) # 6, Registered Nurse, administering heparin for PI # 6 at station 3. EI # 6 entered the patient station with the patient’s heparin syringes in his/her hand, placed one syringe on the hourly heparin port on the hemodialysis machine and the other on the side table of the patient’s chair. EI # 6 then left the patient station. After the patient’s access was cannulated by the Certified Clinical Hemodialysis Technician, EI # 6 re-entered the patient’s station, retrieved the heparin syringe from the patient’s chairside table, and administered it. An interview was conducted on 5/22/25 at 2:30 PM with EI # 1, Facility Administrator, who confirmed staff left prepared medications unattended and failed to administer medications in an aseptic manner.”

“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 staff interview, it was determined the facility failed to ensure: 1. Staff reported post weights above or below one kilogram (kg) from the patient’s target weight to the physician. 2. Staff followed physician orders for Ultrafiltration Rate (UFR). This affected Patient Identifiers (PI) # 4, PI # 1, and PI # 5 in three of five MR reviewed and had the potential to affect all 35 patients dialyzing at the facility. Findings include: Facility Policy: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy Number: 1-03-08 Revision Date: 4/24 Policy: 1. Patient data will be obtained and documented... a. data collection includes... iv. patient weight ...3. Patient identity, prescription, and machine settings are verified by teammate prior to the initiation of treatment... Prescription components include but are not limited to: ...c. Target weight d. UFR and Max UFR Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 16. If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. 17. Licensed nurse will...determine if any clinical interventions or notification of physician...is necessary prior to discharge... Abnormal Findings ...Fluid Status: Post-treatment: If patient is above or below one kg from the target weight. 1. PI # 4 was admitted to the facility on 10/27/23 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the Patient Summary Report (PSR) revealed hemodialysis treatment orders dated 3/18/25 which included a prescribed target weight of 66 kg and a Max UFR of 20 milligrams/kilogram/hr (ml/kg/hr) or 1320 ml/hr. Further review of the PSR revealed on 5/7/25, 5/9/25, 5/12/25, 5/14/25, 5/16/25, and 5/19/25 revealed the UFR was not at the prescribed 20 ml/kg/hr. Review of the Treatment Details Reports (TDR) dated 5/7/25, 5/9/25, 5/12/25, 5/14/25, 5/16/25, and 5/19/25 revealed the patient’s post-treatment weight was more than 1 kg above the prescribed target weight and was not reported to the physician. An interview was conducted on 5/22/25 at 2:30 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed staff failed to follow the patient’s prescribed UFR and report post-treatment weights more than one kg above the prescribed target weight to the physician. 49797 2. PI # 1 was admitted to the facility on 2/12/25 with a primary diagnosis of ESRD. A review of the PSR dated 5/20/25 revealed an order for a UFR of 13 ml/kg/hr to equal 793 ml/hr. A review of the TDR dated 3/26/25 revealed the UFR was not at the prescribed rate. An interview was conducted on 5/22/25 at 2:17 PM with EI # 2, Clinical Service Manager, who confirmed staff failed to follow the prescription for UFR. 3. PI # 5 was admitted to the facility on 6/10/19 with a primary diagnosis of ESRD. A review of the PSR dated 5/20/25 revealed an order for a target weight of 54.5 kg and UFR of 13 mL/kg/hr to equal 708.5 ml/hr. A review of the TDR dated 5/12/25 revealed the post treatment weight was 56.8 kg. A review of the TDR dated 5/14/25 revealed the UFR was not at the prescribed rate. An interview was conducted with EI # 2, who confirmed the staff failed to notify the physician for the post treatment weight greater than 1 kg above the prescribed target weight and follow the prescription for UFR.”

“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: 49894 Based on observations, facility procedure, and staff interviews, it was determined the facility failed to ensure: 1. Staff waited three to five minutes after the heparin loading dose was administered (allows heparin to circulate systemically) to initiate dialysis. 2. Staff obtained Early Termination or Late Arrival (Against Medical Advice or AMA) forms signed by the patient for treatment times less than prescribed. This affected Patient Identifier (PI) # 6 in one of three observations of access of an Arteriovenous Fistula/Arteriovenous Graft (AVF/AVG) for initiation of dialysis and PI # 4, PI # 5, and PI # 3 in three of five MR reviewed, and had the potential to negatively affect all patients dialyzing with an AVF/AVG at the facility. Findings include: Facility Procedure: AVF/AVG Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose Procedure Number: 1-04-01E Revision Date: 4/22 Procedure ...29. Do not initiate dialysis for three to five minutes after administering heparin loading dose. Rationale Allows heparin to circulate systemically...allows the heparin to interupt the coagulation cascade (anticoagulates). Facility Policy: Prescribed Treatment Time Not Met Policy Number: 1-01-09 Revision Date: April 2024 Purpose: Provide requirements for teammates to follow when a patient’s treatment time is terminated early or extended. Policy: Completion of the Early Termination of Treatment Against Medical Advice (AMA) Form. 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treament. If unable to obtain the patient’s signature prior to the rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s depature from the facility. B. Prescribed Treatment Time Not Met 1. If the shortended/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss appropriate intervention... 1. An observation was conducted on 5/21/25 at 10:05 AM with Employee Identifier (EI) # 7, Certified Clinical Hemodialysis Technician, accessing the AVF/AVG and initiating dialysis for PI # 6 at station 3. After the heparin loading dose was administered by the Registered Nurse, EI # 7 failed to wait three to five minutes before connecting the hemodialysis blood lines and initiating treatment. An interview was conducted on 5/22/25 at 2:30 PM with EI # 1, Facility Administrator, who confirmed staff failed to follow the policy for the administration of the heparin loading dose. 2. PI # 4 was admitted to the facility on 10/27/23 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the Patient Summary Report (PSR) revealed hemodialysis orders that included a treatment time of three hours and thirty minutes. Review of the Treatment Details Reports (TDR) dated 5/12/25, 5/16/25, and 5/19/25 the treatment time was less than prescribed and the staff failed to obtain an AMA form signed by the patient. An interview was conducted on 5/22/25 at 2:30 PM with EI # 1, Facility Administrator, who confirmed staff failed to obtain AMA forms for treatment times less than prescribed. 49797 3. PI # 5 was admitted to the facility on 6/10/19 with a primary diagnosis of ESRD. A review of the PSR dated 5/20/25 revealed an ordered treatment time of three hours and fifteen minutes. A review of the TDR dated 5/16/25 revealed a treatment time of one hour and fifty four minutes and no documentation of a signed AMA form. An interview was conducted on 5/22/25 at 2:12 PM with EI # 2, Cinical Service Manager, who confirmed the staff failed to obtain an AMA form signed by the patient for treatment time less than prescribed. 4. PI # 3 was admitted to the facility on 11/5/21 with a diagnosis of ESRD. A review of the PSR dated 5/20/25 revealed hemodialysis orders that included a treatment time of three hours and fifteen minutes. A review of the TDR dated 5/16/25 revealed a treatment time of two hours and nineteen minutes, and no documentation of a signed AMA form. An interview was conducted on 5/22/25 at 2:15 PM with EI # 2, Clinical Service Manager, who confirmed the staff failed to follow the facility policy and have the patient sign an AMA form.”

“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: 49894 Based on medical record (MR) review, facility policy, and staff interview, it was determined the facility failed to ensure the Registered Nurse (RN) performed an initial pre-treatment nursing assessment of all patients prior to the initiation of the first treatment at the facility. This affected Patient Identifier (PI) # 2 in one of two MR reviewed for new admissions less than 90 days and had the potential to affect all new patients admitted to the facility. Findings include: Facility Policy: Initial Patient Nursing Assessment for New Patients Policy Number: 1-03-07 Revision Date: 4/24 Policy: 1. An RN...will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility. 1. PI # 2 was admitted to the facility on 2/7/25 with a primary diagnosis of End Stage Renal Disease. Review of the MR revealed the initial nursing assessment was not completed until 2/21/25. An interview was conducted on 5/22/25 at 2:08 PM with Employee Identifier # 1, Facility Administrator, who confirmed staff failed to perform an initial pre-treatment nursing assessment prior to the initiation of the treatment at the facility.”