Davita Tuba City Dialysis

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, the facility failed to ensure the Emergency Preparedness Plan (EPP) documented the development of an all hazards based facility and/or community risk assessment. This failure had the potential to affect the current 101 patients receiving care in the facility and any outpatients that receiving care in the facility. Findings include: Review of the facility’s EPP on 09/10/24 at 2:30 PM, with the Facility Administrator, revealed that the EPP did not identify all the possible hazards that could affect the facility or community. Review of the facility policy titled “Facility Emergency Management Plan (ICHD [In Center Hemodialysis], Home), reviewed April 2024, showed: “ ...Facility Hazard Vulnerability Assessment- The Facility Hazard Vulnerability Assessment (HVA) provides a systematic approach to recognizing hazards that may affect the community and facility’s ability to provide dialysis services and meet the health and safety needs of the patient population. . .regarding the plan, and the facility’s. . .4. A hazard noted with a probability rating of ‘1’, ‘2’, or ‘3’, a plan is required to be included in the facility EMP. . . .” Review of the facility HVA showed no identified risks for any of the following categories on the “Facility Hazard Vulnerability Analysis Tool - 2023” Flood, external Tornado Winter/Ice Storm Earthquake Landslide Wildfire Supply Shortage Civil Disorder Biological agents Nuclear Terrorist Attack Active Shooter During an interview on 09/10/24 at 2:50 PM the Facility Administrator stated he was surprised there was no active shooter as there had been an incident in the past year and cyber threat was not something he had thought of.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Management Plan, the facility failed to ensure the Emergency Preparedness Plan (EPP) policies identified the patient population that would be at risk during an emergent event, the services the facility could provide or how the facility would continue operations during an emergency. This failure had the potential to affect the current 101 in-center the facility and any outpatients that receiving care in the facility. Findings include: Review of the facility’s EPP on 09/10/24 at 2:30 PM, with the Facility Administrator revealed that the EPP did not identify the patient population that would be at risk in the event of an emergency event, the services the facility would be able to provide during an emergency, or how the facility planned to continue operations during an emergency. During an interview on 09/10/24 at 3:00 PM while reviewing the EPP, the Facility Administrator stated “The patient population is implied but not specific.” At 3:10 PM regarding the services or operations continuity, the Facility Administrator stated “As far as the emergency plan, how we care for patient during and post event it might depend on the emergency.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 28154 Based on medical record review, staff interview, and review of the facility’s policy, the facility failed to ensure a physician’s order was implemented as prescribed for two of 12 sampled patients (Patients (P) 9 and P11) hemodialysis treatments (the mechanical removal of toxins when kidneys fail). Failure to follow the physician’s dialysis prescription could negatively impact the effectiveness of the dialysis treatment for all 101 in-center hemodialysis patients receiving treatment at this facility Findings include: 1. Review of nine of P9’s hemodialysis treatment records from 08/20/24 through 09/06/24 showed a prescribed blood flow rate (BFR) of 550 milliliters /minute (mL/min) and on 09/04/24 the BFR was run at 500 mL/min from 1:10 PM to 2:01 PM without documentation. On 08/23/24, P9 had a prescribed BFR of 500 mL/min; the treatment sheet showed from 11:54 AM through 2:54 PM the BFR was 300 mL/min. The nurse verified the treatment settings at 12:55 PM without documenting a reason for the decreased BFR. On 08/28/24, P9’s treatment sheet showed the treatment started at 2:32 PM at 550 mL/min BFR. At 3:02 PM the BFR was dropped to 500 mL/min where it stayed until 4:03 PM. At 3:22 PM, the Patient Care Technician (PCT) noted the ultrafiltration was off and the nurse was aware, but nothing noted about the BFR decrease. 2. Review of nine of P11’s hemodialysis treatment records from 08/13/24 through 09/05/24 showed a prescribed BFR of 500 mL/min. The 08/15/24 treatment record showed a BFR at 400 mL/min from 11:54 AM thought 2:33 PM without documentation of a reason for the decreased rate. During an interview on 09/11/24 at 4:28 PM, Registered Nurse (RN) 1 stated if a blood flow rate was not at prescription, there should be a documented reason why and the nurse should be notified. During an interview on 09/11/24 at 6:26 PM, the Facility Administrator stated an expectation that the BFR would be at the prescribed rate or addressed to the nurse and documented. A review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge .... 3. Patient identity, prescription and machine settings ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by law .... Intradialytic Data Collection/Assessment ... 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: ... b. At a minimum, obtain and document the following: ...iii. Blood and dialysate flows ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed flood flow rate) the reason will be documented and the licensed nurse informed. . . .””

“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: 28154 Based on interview and record review, the facility failed to ensure the staff reported and documented occurrence of blood pressure and/or heart rate variances during a hemodialysis (the mechanical removal of toxins when kidneys fail) treatment for five of 12 sample patients, (Patient [P] 2, P4, P5, P11, and P12). The policy and procedure for monitoring and reporting hypertensive (high blood pressure), hypotensive (low blood pressures), or heart rate during treatment was not followed. Failure to report and document these variant episodes had the potential to adversely affect any of the 101 current patients cardiovascular status and health. Findings include: A review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: ...ii Measurement of patient Blood Pressure (BP) Intradialytic Data Collection/Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: . . .b. At a minimum, obtain and document the following: i. Blood Pressure . . . 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record .... Blood Pressure: Pre-dialysis -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 Blood Pressure-Intradialytic: -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 Blood Pressure Post Treatment: -If the patient can stand: - - Standing systolic [first number] BP greater than 140 mm/Hg [millimeters of mercury] or less than 90 mm/Hg - - Standing diastolic [second number] BP greater than 90 mm/Hg or less than 50 mm/Hg ... -Sitting BP for patient’s 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 ... Heart or Pulse Rate Pre/Intra/Post: -Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat” 1. Review of nine of P2’s hemodialysis treatment records showed the following heart rates: On 08/12/24: 12:28 PM, 99 BPM 12:58 PM, 102 BPM 1:29 PM, 102 BPM 2:28 PM, 104 BPM 2:58 PM, 107 BPM 3:28 PM, 129 BPM 4:14 PM, 160 BPM with a note that the nurse was aware. On 09/02/24: 11:34 AM, 102 beats per minute (BPM) at the start of treatment 12:04 PM, 104 BPM 1:31 PM, 106 BPM 2:03 PM, 110 BPM There was no further documentation that the nurse was notified of elevated heart rate. 2. Review of P4’s hemodialysis treatment records showed the following BP: On 08/29/24: 2:43 PM, 184/100 3:18 PM, 183/102 On 09/07/24: 1:26 PM, 165/100 2:27 PM, 180/101 2:57 PM, 173/106 3:00 PM, 175/104 There was no documentation that thenurse was notified regarding high BP. 3. Review of P5’s hemodialysis treatment records showed the following BP: On 08/17/24: 9:25 AM, 207/120 10:24 AM, 167/106 On 08/22/24: 9:00 AM, 181/108 9:30 AM, 172/102 There was no documentation that the nurse was notified regarding high BP. 4. Review of P11’s hemodialysis treatment records showed the following BP: On 08/20/24: 1:39 PM, 205/35 2:26 PM, 197/33 2:44 PM, 198/72 On 08/27/24: 12:57 PM, 194/45 at the start of the treatment 1:31 PM, 185/24 with a heart rate of 104 There was no documentation that the nurse was notified regarding high blood pressures. 5. Review of P12’s dialysis treatment records showed the following BP: On 09/04/24: 12:34 PM, 123/105 12:35 PM, 157/115 2:04 PM, 206/89 2:06 PM, 209/89 2:20 PM, 192/91 3:45 PM, 206/108 4:39 PM, 207/114 On 09/06/24: 1:28 PM, 201/83 2:02 PM, 196/94 2:59 PM, 196/108 There was no documentation that the nurse was notified regarding high blood pressures. During an interview on 09/11/24 at 3:35 PM, Patient Care Technician (PCT)1 stated, the nurse should be notified of low or high BP and that BP were to be monitored every 30 minutes, but if low or high BP the nurse may have us do it every 15 minutes. During an interview on 09/11/24 at 4:05 PM Registered Nurse (RN) 1 stated, PCT’s should notify the nurse of BP over 180 systolic, a heart rate greater than 100, a diastolic below 70 or greater than 100, or a heart rate below 60. During an interview on 09/11/24 at 6:26 PM, the Facility Administrator (FA) stated high or low blood pressures or heart rates need to be addressed, documented, and relayed. When asked to clarify, the FA stated from the PCT to the RN to the nephrologist and back if there are orders.”

“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: 28154 Based on interview and record review, the facility failed to ensure patients were monitored per policy for three of 12 patients reviewed (Patient [P] 2, P3 and P11). In addition, the facility failed to ensure the charge nurse and/or physician were notified regarding not achieving a post hemodialysis (the mechanical removal of toxins when kidneys fail) treatment weight goal of at least one kilogram (kg) for five of 12 patients (P1, P4, P5, P6, and P9) reviewed. This failure had the potential to affect the efficacy and safety of treatment for any of the 101 patients receiving hemodialysis treatment in the facility. Findings include: A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, indicated, “Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. . . .Intradialytic Data Collection/Assessment ...2. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vital signs and treatment monitoring ... iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. 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(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP [non-physician practitioner] as applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record .... Fluid Status: ...Post-treatment:If patient is above or below 1 kg [kilogram] from the target weight.” 1. 2. Review of P2’s hemodialysis treatment records showed on 08/26/24, P2 was monitored at 1:57 PM and the next time was at 2:46 PM. 2. Review of P3’s hemodialysis treatment records showed on 09/06/24 P3 was monitored at 9:55 AM then next at 10:43 AM. 3. Review of P11’s hemodialysis treatment records showed on 08/27/24 P11 was monitored at 1:31 PM and the next time was at 2:32 PM. 4. Review of P1’s hemodialysis treatment records showed on 08/29/24, a prescribed target dry weight of 81 kg. The actual post treatment weight was 82.3 kg (1.3 kg above the prescribed weight) with no documentation the nurse or physician was notified of the post weight being over one kg above the target weight (TW). 5. Review of P4’s hemodialysis treatment showed on 09/03/24 a prescribed target dry weight of 81.5 kg and a post treatment weight of 87.5 kg (six kg above the prescribed TW) and on 09/07/24 a post treatment weight of 88.6 kg (7.1 kg above the prescribed TW). There was no documentation found the nurse or physician being notified of the post weight being over one kg above prescribed dry weight. 6. Review of P5’s hemodialysis treatment records showed on 09/03/24 a prescribed target dry weight of 73 kg with a post treatment weight of 75.7 kg (2.7 kg above the prescribed TW) and on 09/07/24 a post treatment weight of 74.6 kg (1.6 kg above the prescribed TW). There was no documentation found the nurse or physician being notified of the post weight being over one kg above prescribed dry weight. 7. Review of P6’s hemodialysis treatment records showed on 08/13/24 a prescribed target dry weight of 83 kg with the following post treatment weight: On 08/13/24, 87.3 kg (4.3 kg above the prescribed TW), On 08/15/24, 84.3 kg (1.3 kg above the prescribed TW), On 08/20/24, 88.1 kg (5.1 kg above the prescribed TW), On 08/22/24, 87 kg (4 kg above the prescribed TW) and On 09/04/24, 88.4 kg (5.4 kg above the prescribed TW). There was no documentation found the nurse or physician being notified of the post weight being over one kg above prescription. 8. Review of P9’s hemodialysis treatment records showed on 08/20/24 a prescribed target dry weight of 88 kg with the following post treatment weight: On 08/20/24, 90.5 kg (2.5 kg above the prescribed TW), On 08/21/24, 89.6 kg (1.6 kg above the prescribed TW), On 08/23/24, 90.3 kg (2.3 kg above the prescribed TW), On 08/28/24, 92.7 kg (4.7 kg above the prescribed TW), On 09/02/24, 91.9 kg (3.9 kg above the prescribed TW) and On 09/04/24, 94.7 kg (5.1 kg above the prescribed TW). There was no documentation found the nurse or physician being notified of the post weight being over one kg above prescription. During an interview on 09/11/24 at 4:05 PM, Clinical Coordinator Registered Nurse (RN) 1 stated patients were to be monitored during treatment every 30 minutes or more [often] if needed depending on their acuity and post weights greater than one kg from target should be advised and the patient educated and offered an extra treatment.”