Davita Osceola Dialysis

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 37145 Based on observation and interview, the facility failed to ensure that the integrity of all physical surfaces were intact, clean, and free from damage. The failed practice promoted the spread of infection and had the likelihood to affect all 33 patients on census and all staff. The findings were: A. On 01/13/25 from 11:40 AM through 12:50 PM, the following observations were made on tour of the facility: 1) The lab area and medication area showed: a) The clean sink had a white buildup on the faucet, and a rust colored buildup in the drain. b) There were storage bins with dirt and grime buildup on the outside of the drawers. c) There were holes in the wall behind the centrifuge and some peeling paint behind the sink. d) There was peeling tape and label residue on the storage cabinets. 2) The stock and storage room observations showed: a) Several boxes of patient supplies and empty boxes stored directly on the floor. b) The storage shelves floors had dirt and grime buildup underneath them and some rust colored buildup on the screws that held the shelves together. 3) The Treatment area observation showed: a) Throughout the treatment area, there was a buildup of dust, grime, and rust colored residue. b) Throughout the treatment area, the floors had cracked tiles and various colored stain buildup. c) Throughout the treatment area, the sinks had a white residue on the faucets, rust color residue on and around the drains, and dirt and grime build up on the drains below the sinks. d) Behind Station 6 there were several holes in the wall. e) The clean sink by Station 5 had a hole with exposed wires below the sink to the left of the drain pipe. f) The walls throughout the treatment area had dirt and grime buildup. g) The storage drawers were labeled as to content of the drawer with sticky labels that were peeling, and areas of tape residue was on the front of the drawers. 4) The Water/Storage room showed: a) There was a rust-colored substance on the pipes build up in multiple areas throughout the water treatment system. b) There were multiple leaks throughout the water treatment system. c) The water pipes from the water heater had torn and discolored insulation. d) There was a thick white buildup on the lines coming from the bicarbonate tank. e) There was a black substance on the walls behind the RO (Reverse Osmosis) system and in the floor drains by the RO. f) The bolts holding the booster pump in place had a thick rust colored coating. g) There were areas on the RO and Bicarbonate tanks that had partially removed sticky labels and tape residue. B. During an interview on 01/13/25 at 11:40 AM, the findings in A were verified with the Administrator.”

“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: 37145 Based on observation, policy and procedure review and interview, it was determined 12 of 12 (Stations #1-#12) blood pressure (BP) cuffs were not maintained in that there was a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection. The failed practice promoted the spread of infection from cross contamination. The failed practice had the likelihood to affect all 33 in-center hemodialysis patients on census and staff. The findings included: A. Review of policy titled, “Infection Control For Dialysis Facilities,” revision date April 2023, showed, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. “At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings. (dialysis chair, tray table, blood pressure cuffs) and frequently contacted by healthcare personnel (control panel, top, front, and sides of dialysis machine; touchscreens, countertops). Use an appropriate Disinfectant such as a 1:100 (One to one hundred) bleach solution for routine disinfection of environmental surfaces.” B. Observation of shift change on 01/15/25 from 8:10 AM to 10:15 AM showed BP cuffs at Station #1-#12 had a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection between patients. C. During an interview on 01/15/25 at 10:45 AM, the LPN (Licensed Practical Nurse) confirmed the findings in A.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 37145 Based on clinical record review, policy review, and interview, it was determined the Registered Nurse (RN) failed to assess, treat, and/or notify Physician of the blood pressure (BP) and heart rate for three (#1, #3 and #5) of five (#1-#5) in-center hemodialysis patients. The failed practice placed patients at risk for complications related to un-managed blood pressure. The failed practice had the likelihood to affect all 33 in-center hemodialysis patients. The findings were: A. Review of the facility Abnormal Findings Job Aid: ICHD (in center hemodialysis) with revision date 04/01/2024 showed, 1. Purpose: Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre, intra, or post treatment data collection will be documented and immediately reported to the licensed nurse. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders, and the patient response. 2. Pre-treatment: Inform the nurse of any abnormal findings per policy. Nurse will complete patient assessment before treatment is initiated if the patient presents with: Blood pressure: systolic greater than 180 mm/Hg (millimeters of mercury) or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Heart Rate/Pulse less than 60 or greater than 100 beats per minute &/or an irregular heartbeat. 3. Intradialytic: Blood Pressure Systolic greater than 180 mm/Hg or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Heart Rate/Pulse less than 60 or greater than 100 beats per minute and/or an irregular heartbeat. 4. Post Treatment: If the patient can stand Standing systolic BP (blood pressure) greater than 140 mm/Hg or less than 90 mm/Hg. Standing Diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Sitting BP for patients that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Signs and symptoms of hypotension may include nausea, vomiting, cold & clammy skin, restlessness, rapid shallow respirations, excessive yawning, diaphoretic, dizziness, feeling faint. B. Review of the facility policy for Hypotension with a revision date of October 2023 showed, “Special consideration should be taken to prevent hypotensive events from occurring. Per Physician order as appropriate, special considerations may include but are not limited: Accurate pre and post weight documentation, frequent evaluation of Target weight, evaluation of hypertensive medications, ultrafiltration profiling, decrease in dialysate temperature, and encouraging adherence to fluid and sodium restrictions. Take vital signs. Place patient in a flat supine position. Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient’s condition. Administer normal saline bolus of 100-200ml (milliliters) for severe hypotensive symptoms. Patient Care Technicians (PCT), LPN/LVN (Licensed Practical or Vocational Nurse) may only administer saline under the direction of a Registered Nurse. For less severe signs of hypotension give oral fluids. If patient continues to show signs and symptoms of hypotension, the licensed nurse will notify physician and follow physician orders.” C. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be <140/90 and post-treatment was to be BP < 130/80. D. During an interview on 01/15/25 at 2:35 PM, the Administrator confirmed findings in A and B. E. Patient # 1 1) Review of six TFS (treatment flow sheets), six of six treatments, 12/30/24-01/10/25, showed no evidence the RN (Registered Nurse) assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. a) 12/30/24 - Pretreatment 148/92, Intradialytic169/84, Post treatment standing 140/92. PCT (Patient Care Technician) # 1 documented “Patient blood pressure is elevated.” There were no entries on the TFS that indicated the RN had assessed the patient. b) 01/01/25 - Pretreatment 172/90, Intradialytic 94/51, 84/51, 97/27 c) 01/03/25 - Pretreatment 157/107, Intradialytic 157/79, and Post treatment 164/88. d) 01/06/25 - Pretreatment 174/112, Intradialytic 166/95, 96/65 e) 01/08/25 - Pretreatment 158/102 f) 01/10/25 - Pretreatment 170/98, Intradialytic 79/43, 75/41. 2. Review of the Physician orders for Patient # 1 showed, “Clonidine give 0.1 mg (milligram) Tablets for systolic BP over or equal to 170 and or diastolic over or equal to 100. Recheck in 60 minutes if no response can give up to 3 doses, then notify MD.” 3. During the interview, on 01/15/25 at 2:45 PM, the Administrator confirmed the findings in E. F. Patient #3 1) Review of six TFS (treatment flow sheets), six of six treatments, 12/30/24 - 01/10/25, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 12/30/24 - Pretreatment 202/60, Intradialytic 168/63, 176/123, heart rate 59, 49, 50, 51. b) 01/01/25 - Pretreatment 196/81, Intradialytic, 174/66, heart rate 54, 55, 56 and Post treatment 161/63. c) 01/03/25 - Pretreatment 190/62, Intradialytic 171/44, heart rate 54, 56, 57 and Post treatment 153/68. d) 01/06/25 - Pretreatment 188/65, Intradialytic 156/65 heart rate 50, 53, 54, and Post treatment 153/56 e) 01/08/25 - Pretreatment 190/69, Intradialytic 170/65, 95/80 f) 01/10/25 - Pretreatment 190/74, Intradialytic 163/59, 160/62, and Post treatment 156/57. 2) Review of the Physician orders for Patient # 3 showed, “Clonidine give 0.1 mg (milligram) Tablets for systolic BP over or equal to 170 and or diastolic over or equal to 100. Recheck in 60 minutes if no response can give up to 3 doses, then notify MD.” 3) During the interview, on 01/15/25 at 2:50 PM, the Administrator confirmed the findings in F. G. Patient # 5 1) Review of six TFS, six of six treatments, 12/30/24 - 01/10/25, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 12/30/24 - Pretreatment 97/84 heart rate 49, Intradialytic 88/33, 93/48, 87/61, 84/30, 80/60, and Post treatment 97/42 b) 01/01/25 - Pretreatment 122/99, Intradialytic 87/57, 88/55, 85/57, 81/49 and Post treatment 109/57. c) 01/03/25 - Pretreatment 96/42, Intradialytic 97/39, 95/42, 86/44, 73/55, 88/30, 86/56. d) 01/06/25 - Pretreatment 92/72, Intradialytic 89/58, 91/58, 95/69. e) 01/08/25 - Pretreatment 93/45, Intradialytic 100/37, 101/48, 107/43, 96/33 Post treatment 107/45. f) 01/10/25 - Pretreatment 96/41, Intradialytic 97/54, Post Treatment 104/47. 3) Review of the Physician orders for Patient # 5 showed, “Normal Saline 0.9% for symptomatic in 100 ml increments up to 1 liter.” There was no evidence Physician orders were followed. 2) During the interview, on 01/15/25 at 2:50 PM, the Administrator confirmed the findings in G.”

“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: 37145 Based on clinical record review, policy review, and interview, it was determined the Interdisciplinary Team (IDT) failed to modify the patient’s plan of care (POC) for three (#1, #3 and #5) of Five (#1-#5) patients when the patients’ blood pressure was outside established parameters. The failed practice placed patients at risk for complications related to un-managed blood pressure and fluid volume. The failed practice had the likelihood to affect all 33 in-center hemodialysis. The findings were: A. Review of the facility Abnormal Findings Job Aid: ICHD (in center hemodialysis) with revision date 04/01/2024 showed, 1. Purpose: Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre, intra, or post treatment data collection will be documented and immediately reported to the licensed nurse. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders, and the patient response. 2. Pre-treatment: Inform the nurse of any abnormal findings per policy. Nurse will complete patient assessment before treatment is initiated if the patient presents with: Blood pressure: systolic greater than 180 mm/Hg (millimeters of mercury) or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Heart Rate/Pulse less than 60 or greater than 100 beats per minute &/or an irregular heartbeat. 3. Intradialytic: Blood Pressure Systolic greater than 180 mm/Hg or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Heart Rate/Pulse less than 60 or greater than 100 beats per minute &/or an irregular heartbeat. 4. Post Treatment If the patient can stand Standing systolic BP (blood pressure) greater than 140 mm/Hg or less than 90 mm/Hg. Standing Diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Sitting BP for patients that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Signs and symptoms of hypotension may include nausea, vomiting, cold & clammy skin, restlessness, rapid shallow respirations, excessive yawning, diaphoretic, dizziness, feeling faint. B. Review of the facility policy for Hypotension with a revision date of October 2023 showed, “Special consideration should be taken to prevent hypotensive events from occurring. Per Physician order as appropriate, special considerations may include but are not limited: Accurate pre and post weight documentation, frequent evaluation of Target weight, evaluation of hypertensive medications, ultrafiltration profiling, decrease in dialysate temperature, and encouraging adherence to fluid and sodium restrictions. Take vital signs. Place patient in a flat supine position. Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient’s condition. Administer normal saline bolus of 100-200ml (milliliters) for severe hypotensive symptoms. Patient Care Technicians (PCT), LPN/LVN (Licensed Practical or Vocational Nurse) may only administer saline under the direction of a Registered Nurse. For less severe signs of hypotension give oral fluids. If patient continues to show signs and symptoms of hypotension, the licensed nurse will notify physician and follow physician orders.” C. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be <140/90 and post-treatment was to be BP < 130/80. D. During an interview on 01/15/25 at 2:35 PM, the Administrator confirmed findings in A and B. E. Patient # 1 1) Review of six TFS (treatment flow sheets), six of six treatments, 12/30/24-01/10/25, showed the following BP examples: a) 12/30/24 - Pretreatment 148/92, Intradialytic169/84, Post treatment standing 140/92. PCT (Patient Care Technician) # 1 documented “Patient blood pressure is elevated.” There were no entries on the TFS that indicated the RN had assessed the patient. b) 01/01/25 - Pretreatment 172/90, Intradialytic 94/51, 84/51, 97/27 c) 01/03/25 - Pretreatment 157/107, Intradialytic 157/79, and Post treatment 164/88. d) 01/06/25 - Pretreatment 174/112, Intradialytic 166/95, 96/65 e) 01/08/25 - Pretreatment 158/102 f) 01/10/25 - Pretreatment 170/98, Intradialytic 79/43, 75/41. 2. There was no evidence that the IDT modified the POC related to the patient’s BPs outside of established parameters. 3. During the interview, on 01/15/25 at 2:45 PM, the Administrator confirmed the findings in E. F. Patient #3 1) Review of six TFS (treatment flow sheets), six of six treatments, 12/30/24 - 01/10/25, showed the following BP examples: a) 12/30/24 - Pretreatment 202/60, Intradialytic 168/63, 176/123, heart rate 59, 49,50,51 b) 01/01/25 - Pretreatment 196/81, Intradialytic, 174/66, heart rate 54, 55, 56 and Post treatment 161/63 c) 01/03/25 - Pretreatment 190/62, Intradialytic 171/44, heart rate 54, 56, 57 and Post treatment 153/68. d) 01/06/25 - Pretreatment 188/65, Intradialytic 156/65 heart rate 50, 53, 54, and Post treatment 153/56 e) 01/08/25 - Pretreatment 190/69, Intradialytic 170/65, 95/80 f) 01/10/25 - Pretreatment 190/74, Intradialytic 163/59, 160/62, and Post treatment 156/57. 2) There was no evidence that the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview, on 01/15/25 at 2:50 PM, the Administrator confirmed the findings in F. G. Patient # 5 1) Review of six TFS, six of six treatments,12/30/24 - 01/10/25, showed the following BP examples: a) 12/30/24 - Pretreatment 97/84 heart rate 49, Intradialytic 88/33, 93/48, 87/61, 84/30, 80/60, and Post treatment 97/42 b) 01/01/25 - Pretreatment 122/99, Intradialytic 87/57, 88/55,85/57, 81/49 and Post treatment 109/57. c) 01/03/25 - Pretreatment 96/42, Intradialytic 97/39, 95/42, 86/44, 73/55, 88/30, 86/56. d) 01/06/25 - Pretreatment 92/72 Intradialytic 89/58, 91/58, 95/69 e) 01/08/25 - Pretreatment 93/45, Intradialytic 100/37, 101/48, 107/43, 96/33 Post treatment 107/45. f) 01/10/25 - Pretreatment 96/41, Intradialytic 97/54, Post Treatment 104/47. 2) There was no evidence that the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview, on 01/15/25 at 2:50 PM, the Administrator confirmed the findings in G.”