Van Buren Dialysis Center

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37145 Based on review of personnel records and interview, it was determined there was no evidence the Medical Director received emergency preparedness training. The failed practice did not assure the staff were knowledgeable of what to do in the event of an emergency. The failed practice had the likelihood to affect all 84 patients on census and staff. The findings were: A. Review of the personnel records for the Medical Director showed there was no evidence they received emergency preparedness training. B. During an interview on 12/19/23 at 3:30 PM, Clinic Director # 1 and Clinical Director # 2 confirmed the findings in A.”

“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 the safety, functionality, cleanliness, and integrity of all surfaces and maintain the physical environment in a clean storage room in that there was a brown rust colored substance and black build-up on three of three sink drains in the clean storage room. The failed practice promoted the spread of infection and had the likelihood to affect all 84 in-center hemodialysis patients on census and all staff. The findings follow: A. Observation on 12/18/2023, at 11:30 AM, showed three of three sink drains in the clean storage room had brown rust colored substance and black build-up. B. During observation on 12/18/2023, at 11:30 AM, the Clinic Manager 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 the blood pressure (BP) for seven of seven (#1-#7) 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 84 in-center hemodialysis patients. The findings were: A. Review of policy titled, “Fluid Management and Hypertension (HTN),” revised 07/27/21, showed the following: 1). The Dialysis Center’s Interdisciplinary Team (IDT) will provide the necessary care and services to manage the patient’s volume status. Goal: Euvolemic with blood pressure (BP) 140/90 pre-treatment and BP 130/80 post treatment. 2). Patient’s blood pressures must be monitored pre, during, and post treatment. A Registered Nurse (RN) will notify physician if the patient has a systolic blood pressure (BP) trend (6 treatments) less than 100 or greater than 140/ or diastolic BP trend (6 treatments) of less than 40 or greater than 90. Any trends identified (6 or more treatments) must be addressed/documented in the Plan of Care (POC). The comprehensive assessment includes evaluation of the patient’s BP pre/post and during and related symptoms (hypertension, hypotension, and muscular cramping. The actions taken per these policies must be documented on the treatment flowsheet. B. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre- BP was to be <140/90 and post BP < 130/80 C. During an interview on 12/19/23 at 1:30 PM, Clinical Director # 1 confirmed findings in A and B. D. Patient #1 1) Review of six treatment flow sheets (TFS), six of six treatments, 12/05/23-12/16/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 12/05/23 - Pretreatment 164/7, Intradialytic 192/92, Post Treatment 178/85 b) 12/08/23 - Pretreatment 157/76, Intradialytic 186/86, Post treatment 173/89 c) 12/09/23 - Pretreatment 159/79, Intradialytic 185/81, Post treatment 192/101 d) 12/12/93-Intradialytic 174/92, e) 12/14/23 - Pretreatment 162/83, Intradialytic 175/76, Post treatment 177/85 f) 12/16/23 -Intradialytic 167/80, post treatment 166/86 2) There was no evidence of an RN assessment for HTN (Hypertension). 3) During interview on 12/19/23 at 1:55 PM, Clinic Director # 1 confirmed the findings in D. E. Patient #2 1) Review of six TFS, four of six treatments, 10/17/23-10/28/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment systolic BP. BP Examples: a) 12/07/23 - Pretreatment 162/72 intradialytic, 161/72 and post treatment 170/74 b) 12/09/23 - Pretreatment 171/59, intradialytic 173/69, and post treatment 192/74 c) 12/12/23 - Pretreatment 175/73 intradialytic 162/127 and/or post treatment 182/79 d) 12/14/23 - Pretreatment 191/74 intradialytic 185/75 and post treatment 173/70 e) 12/15/23-Pretreatment 163/65, post treatment 170/73 f/ 12/18/23- Pretreatment 167/75, post treatment 157/72 2) There was no evidence of an RN assessment for HTN. 3) During interview, on 12/19/23 at 2:00 PM, Clinic Director # 1 confirmed the findings in E. F. Patient #3 1) Review of six TFS, four of six treatments, 12/05/23-12/16/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 12/05/23 - Pretreatment 163/50 b) 12/07/23 - Pretreatment 163/72, post treatment 150/71 c) 12/12/23 - Pretreatment 150/67, intradialytic 189/107, and post treatment 198/113 d) 12/14/23 - Post treatment 155/78 2) There was no evidence of an RN assessment for HTN. 3) During interview, on 12/19/23 at 2:05 PM, Clinic Director # 1 confirmed the findings in F. G. Patient #4 1) Review of six TFS, five of six treatments, 12/06/23-12/18/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment systolic BP. BP Examples: a) 12/06/23 - Pretreatment 154/87, post treatment 141/77 b) 12/08/23 - Pretreatment 155/79, post treatment 140/65 c) 12/13/23 - Pretreatment 149/71 d) 12/15/23 Pretreatment-141/68, post treatment 149/89 e) 12/18/23 - Post treatment 154/80 2) There was no evidence of an RN assessment for HTN. 3) During interview on 12/19/23 at 2:07 PM, Clinic Director # 1 confirmed the findings in G. H. Patient #5 1) Review of six TFS, six of six treatments, 12/07/23-12/19/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 12/07/23- Pretreatment 141/71 and post treatment 148/72 b) 12/09/23- Intradialytic 158/76 c) 12/12/23- Pretreatment 155/72 d) 12/14/23- Pretreatment 154/72 e) 12/16/23- Pretreatment 149/76 f) 12/19/23 Pretreatment 135/102 2) There was no evidence of an RN assessment for HTN. 3) During interview on 12/19/23 at 2:10 PM, Clinic Director # 2 confirmed the findings in H. I. Patient #6 1) Review of six TFS, three of six treatments, 12/06/23-12/18/23, showed no evidence the Registered Nurse (RN) assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 12/06/23-Intradialytic 74/40, 69/38 and Post treatment 123/107 b) 12/11/23- Pretreatment 140/53, intradialytic 91/44, and 83/71, and post treatment 161/103 c) 12/18/23-Post treatment 148/92 2) There was no evidence of an RN assessment for HTN or Hypotension for review. 3) During interview on 12/19/23 at 2:12 PM, Clinic Director # 1 confirmed the findings in I. J. Patient #7 1) Review of six TFS, six of six treatments, 12/06/23-12/18/23, showed no evidence the RN assessed the patient’s Pretreatment, intradialytic, and/or post treatment BP. BP Examples: a) 12/06/23- Pretreatment162/92, intradialytic 89/54 b)12/08/23- Pretreatment 159/94, intradialytic 86/34, and post treatment 170/77 c) 12/11/23- Pretreatment 144/102, intradialytic 97/72,78/58,152/111, 142/120, and post treatment 181/98 d) 12/13/23- Pretreatment 152/108, intradialytic 50/34,and 80/61, and post treatment 152/50, e) 12/15/23-ntradialytic 77/68,78/52, 88/43, and post treatment 169/112 f) 12/18/23 Pretreatment 163/90, intradialytic,63/49 75/58t 2) There was no evidence of an RN assessment for HTN for review. 3) During interview on 12/19/23 at 2:15 P M, Clinic Manager # 1 confirmed the findings in J.”

“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 for seven of seven (#1-#7) 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 84 in-center hemodialysis. The findings were: A. Review of policy titled, “Fluid Management and Hypertension (HTN),” revised 07/27/21, showed the following: 1). The Dialysis Center’s Interdisciplinary Team (IDT) will provide the necessary care and services to manage the patient’s volume status. Goal: Euvolemic with blood pressure (BP) 140/90 pre-treatment and blood pressure (BP) 130/80 post treatment. 2). Patient’s blood pressures must be monitored pre, during, and post treatment. A Registered Nurse (RN) will notify physician if the patient has a systolic blood pressure (BP) trend (6 treatments) less than 100 or greater than 140/ or diastolic BP trend (6 treatments) of less than 40 or greater than 90. Any trends identified (6 or more treatments) must be addressed/documented in the Plan of Care (POC). The comprehensive assessment includes evaluation of the patient’s BP pre/post and during and related symptoms (hypertension, hypotension, and muscular cramping). The actions taken per these policies must be documented on the treatment flowsheet. B. Review of MAT (Measures Assessment Tool) shows the Euvolemic and pre- BP was to be <140/90 and post BP < 130/80 C. During an interview on 12/19/23 at 1:30 PM, the Clinical Director confirmed findings in A and B. D. Patient #1 1) Review of six treatment flow sheets (TFS), six of six treatments, 12/05/23-12/16/23, showed BP examples: a) 12/05/23 - Pretreatment 164/7, Intradialytic 192/92, Post Treatment 178/85 b) 12/08/23 - Pretreatment 157/76, Intradialytic 186/86, Post treatment 173/89 c) 12/09/23 - Pretreatment 159/79, Intradialytic 185/81, Post treatment 192/101 d) 12/12/93 - Intradialytic 174/92, e) 12/14/23 - Pretreatment 162/83, Intradialytic 175/76, Post treatment 177/85 f) 12/16/23 - Intradialytic 167/80, post treatment 166/86 2) There was no evidence the IDT modified the POC (Plan of Care) related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 1:55 PM, Clinic Director #1 confirmed the findings in D. E. Patient #2 1) Review of six TFS, four of six treatments, 10/17/23-10/28/23, showed BP Examples: a) 12/07/23 - Pretreatment 162/72 intradialytic, 161/72 and post treatment 170/74 b) 12/09/23 - Pretreatment 171/59, intradialytic 173/69, and post treatment 192/74 c) 12/12/23 - Pretreatment 175/73 intradialytic 162/127 and/or post treatment 182/79 d) 12/14/23 - Pretreatment 191/74 intradialytic 185/75 and post treatment 173/70 e) 12/15/23-Pretreatment 163/65, post treatment 170/73 f/ 12/18/23- Pretreatment 167/75, post treatment 157/72 2) There was no evidence the IDT modified the POC related to the patient’s BP’s outside of established parameters. 3) During interview on 12/19/23 at 2:00 PM, Clinic Director #1 confirmed the findings in E. F. Patient #3 1) Review of six TFS, four of six treatments, 12/05/23-12/16/23, showed BP Examples: a) 12/05/23 - Pretreatment 163/50 b) 12/07/23 - Pretreatment 163/72, post treatment 150/71 c) 12/12/23 - Pretreatment 150/67, intradialytic 189/107, and post treatment 198/113 d) 12/14/23 - Post treatment 155/78 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 2:05 PM, Clinic Director # 1 confirmed the findings in F. G. Patient #4 1) Review of six TFS, five of six treatments, 12/06/23-12/18/23, showed BP Examples: a) 12/06/23 - Pretreatment 154/87, post treatment 141/77 b) 12/08/23 - Pretreatment 155/79, post treatment 140/65 c) 12/13/23 - Pretreatment 149/71 d) 12/15/23 Pretreatment-141/68, post treatment 149/89 e) 12/18/23 - Post treatment 154/80 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 2:07 PM, Clinic Director #1 confirmed the findings in G. H. Patient #5 1) Review of six TFS, six of six treatments, 12/07/23-12/19/23, showed BP Examples: a) 12/07/23- Pretreatment 141/71and post treatment 148/72 b) 12/09/23- Intradialytic 158/76 c) 12/12/23- Pretreatment 155/72 d) 12/14/23- Pretreatment 154/72 e) 12/16/23- Pretreatment 149/76 f) 12/19/23 Pretreatment 135/102 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 2:10 PM, Clinic Director # 1 confirmed the findings in H. I. Patient #6 1) Review of six TFS, three of six treatments, 12/06/23-12/18/23, showed BP Examples: a) 12/06/23-Intradialytic 74/40 and 69/38 and Post treatment 123/107 b) 12/11/23- Pretreatment 140/53, intradialytic 91/44 and 83/71, and post treatment 161/103 c) 12/18/23-Post treatment 148/92 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 2:12 PM, Nurse Manager confirmed the findings in I. J. Patient #7 1) Review of six TFS, six of six treatments, 12/06/23-12/18/23, showed BP Examples: a) 12/06/23- Pretreatment162/92, intradialytic 89/54 b)12/08/23- Pretreatment 159/94, intradialytic 86/34, and post treatment 170/77 c) 12/11/23- Pretreatment 144/102, intradialytic 97/72,78/58,152/111, 142/120, and post treatment 181/98 d) 12/13/23- Pretreatment 152/108, intradialytic 50/34 and 80/61, and post treatment 152/50 e) 12/15/23-ntradialytic 77/68,78/52, 88/43, and post treatment 169/112 f) 12/18/23 Pretreatment 163/90, intradialytic,63/49 75/58 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During interview on 12/19/23 at 2:15 P M, Nurse Manager confirmed the findings in J.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 37145 Based on observation and interview, it was determined the facility failed to ensure three (#4, #5,and #8) of seven patient’s blood was rinsed back to a salmon color to prevent a drop in hemoglobin. The failed practice promoted a decrease in patient’s hemoglobin. The failed practice had the liklihood to affect all 84 hemodialysis patients on census. The findings were: A. Review of the policy and procedure “Termination of Dialysis Treatment Policy, revised 04/29/21,” showed “Rinse the blood back with 250-300 ml (milliliters) normal saline or until blood lines are clear., then turn off the blood pump.” B. Observation of termination of dialysis on 12/20/23 from 10:48 AM to 12:04 PM showed the blood was not rinsed back to a clear or salmon color for Patients #4, #5 and, #8. The blood was rinsed back to the color of medium to a medium-dark red. C. During interview on 12/20/23 from 10:48 AM to 12:04 PM, Clinic Director #1 confirmed A-B.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 37145 Based on review of Facility Quality Management Meetings and interview, it was determined in five of five (July, August, September, October, and November 2023) months, there was no evidence the Interdisciplinary Team (IDT) selected Blood Pressure (BP) and Fluid management for development of measures, performance of root cause analysis and implementation of an action plan to improve outcomes for in-center hemodialysis. The failed practice did not assure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 84 In-Center hemodialysis patients. The findings were: A. Review of the Facility Quality Management Meetings from July 2023 to November 2023 showed there was no evidence the IDT selected BP and Fluid management for development of measures, performance of root cause analysis and implementation of an action plan to improve outcomes for in-center hemodialysis. B. In an interview with the Clinical Director on 12/20/23 at 1:30 PM, the findings in A were confirmed.”