Davita Nogales Dialysis

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 37489 Based on review of facility policy/procedure, medical records and interviews, it was determined the facility failed to require staff reassess and update and/or develop a plan of care for (1) of (1) unstable patient (Patient #1) every 30 days. Unstable patients require additional, more frequent monitoring from the interdisciplinary team (IDT) in order to effectively meet the needs of the patient. Failure to assess the patient’s status every 30 days poses the potential risk that the IDT is unable to treat or respond to significant changes that addresses the issues documented which deemed the patient to be unstable. Findings include: Facility policy, “Development of Patient Care Plans” requires: “...The multidisciplinary team and the patient develop the Patient Plan of Care. The plan is reviewed and updated...at least every 30 days for a patient whose medical condition is not stable...Criteria for classifying patients as unstable...Marked deterioration in health status would be specifically identified and documented by the IDT...Significant changes in psychosocial needs...Deterioration in mental or functional status....” Patient #7 A Patient Plan of Care was completed and patient was deemed unstable by the IDT on 11/19/2024. The medical record did not contain any updated care plans for the patient after being deemed unstable in November 2024 and prior to her transfer from the facility on 03/26/2025. Employees #1 , #2, and #20 confirmed on 04/15/2025 that Patient #7 did not have an updated plan of care after being deemed unstable in November 2024 as required.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 50568 Based on observation, review of policies and procedures, and staff interview, it was determined that the facility failed to ensure that staff thoroughly cleaned and disinfected the dialysis machine and station between patients which poses a potential risk of infection and cross contamination between patients. Findings include: The facility policy titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” requires: “...At the end of each treatment, the dialysis station/training 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 (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops)...Non-disposable items are to be disinfected after each patient use...If item cannot be cleaned and disinfected it will be dedicated for use on a single patient....” Observation on 04/08/2024 revealed Employee #11 cleaning and disinfecting station #15. Employee #11 failed to thoroughly clean and disinfect all surfaces of the dialysis chair, leaving dried blood on the leg rest of the chair. Observation on 04/08/2024 revealed Employee #12 cleaning and disinfecting station #8. Employee #12failed to thoroughly clean and disinfect all surfaces of the dialysis machines including the face of the dialysis machine, the mobile computer workstation, and the pole of the television. During an interview on April 10, 2024, facility administrator confirmed that Employee #11 and Employee #12 failed to thoroughly clean and disinfect surfaces as required in facility policy.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49430 Based on review of facility policies and procedures, observations and staff interviews, it was determined that the facility failed to require staff dispose of expired supplies and medications, which has the potential risk of infection by using outdated items that may have lost their intended effectiveness for patients receiving hemodialysis treatments; Findings include: Facility policy, “Expiration Dates of Sterile Supplies” revealed: “...Sterile items will be checked before use to ensure that they have not expired...Appropriately dispose of sterile items that have reached the expiration date...” Observation on 04/08/2024 revealed the following expired supplies were found in the patient care area: Seventy-nine (79) BD Eclipse 3ml 22G x 1 ½ injection needle with luer-lok syringe expired 11/30/2023 Four (4) BD Vacutainer safety-lok blood collection set 23G x ¾ ’’ x 12’’ expired 2/28/23 Four (4) BD Eclipse Needle 22G x 1 ½ expired 1/31/2022 Two (2) Saline 0.85% Solution Tube 3.0 ml expired 1/2024 Five (5) BD Vacutiner Trace Elements K2 EDTA 10.8 mg tube expired 11/30/2023 Twenty-five (25) Serim Gaurdian Blood Leak strips expired 03/31/2024 Ninety-one (91) Covidien Monoject Filter Needle expired 4/1/2024 Employee #11 confirmed the expiration dates of supplies and that policy was not followed in the removal and disposal of these items.”

“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: 50568 Based on review of facility policy, medical records, and interview with staff it was determined that the facility failed to ensure: 1. registered nurse notify the patient’s nephrologist when the patient’s weight deviated one (1) or more kilograms from the estimated dry weight (EDW). 2. staff administer clonidine based on physician’s orders. 1. The lack of reporting EDW not achieved and neglecting to assess and respond to hypertension increases the risk for inadequate treatments, fluid overload, dehydration, hospitalizations, stroke and death. 2. The lack of administration of a prescribed antihypertensive medication increases the risk for inadequate treatment, hospitalization, stroke, disruption of blood prefusion to vital organs, and death. Findings include: 1. The facility policy titled “Pre-intra-post Treatment Data Collection, Monitoring, and Nursing Assessment” requires: “...Intradialytic treatment monitoring and data collection ... vital signs and treatment monitoring ... non-nocturnal treatments are completed at least every thirty (30) minutes ...” and “ ... Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ...”. The policy also states: “Abnormal findings ... the following are considered abnormal findings and should be reported to the licensed nurse ... Fluid status, post-treatment: If patient is above or below 1 kg from the target weight ... 1. Patient #2’s medical records reveal (2) of (6) treatments where patients weight was greater than 1 KG over the estimated dry weight without documentation of physician notification. 2. Patient #1’s treatment sheet dated 04/06/24, reveals continuous elevated blood pressure prior to treatment, during treatment, and post treatment. Treatment dated 04/06/2024 at 10:55 revealed a BP of 188/98 with elevated blood pressure readings continued until 14:25. The BP readings for the treatment were as followed: 11:01 201/102 11:31 189/101 12:01 196/103 12:31 197/100 13:01 212/97 13:31 194/92 14:02 187/96 14:25 200/97 Patient #1’s ordered revealed that patient had an active order for Clonidine, but it was not dispensed prior treatment, during treatment, or after treatment. An interview with facility administrator was conducted on 4/9/2024 confirming the BP was outside of parameters set forth in the titled “Pre-intra-post Treatment Data Collection, Monitoring, and Nursing Assessment” and that no intervention was initiated as directed per facility policy. During an interview on April 10, 2024, facility administrator confirmed that there was no RN or MD notifiction of deviated EDW and no documentation of intervention for elevated blood pressure as directed in patient orders and required per facility policy.”

“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: 50568 Based on a review of facility policy, and medical records, it was determined that the facility failed to require that staff: 1. Clinical staff to notify the nurse and the nurse provide a documented intervention for 3 out of 5 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) was out of range per the facility policy. 2. Clinical staff failed to ensure staff performed safety checks every 30 minutes per facility guidelines for (3) of (5) patients (Patients #1, #3, and #2). These findings poses the potential risk of cardiovascular compromise and hospitalization and the risk that the necessary interventions are not taking which could also lead to hospitalization Findings include: 1.The facility policy titled “Pre-intra-post Treatment Data Collection, Monitoring, and Nursing Assessment” requires: “...Intradialytic treatment monitoring and data collection ... vital signs and treatment monitoring ... non-nocturnal treatments are completed at least every thirty (30) minutes ...” and “ ... Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ...”. The policy also states: “Abnormal findings ... the following are considered abnormal findings and should be reported to the licensed nurse ... Fluid status, post-treatment: If patient is above or below 1 kg from the target weight ... blood pressure pre-dialysis: systolic greater than 180mm.Hg or less than 90mm/Hg. Diastolic greater than or equal to 100mg/Hg or less than 50 mm/Hg .... Blood pressure-intradialytic: Systolic greater than 180mg/Hg or less than 90mm/Hg. Diastolic greater than or equal to 100mm/Hg or less than 50 mm/Hg ... Blood pressure post treatment; Standing systolic BP 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 ... Heart or Pulse Rae Pre/intra/post: less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat ...” Patient #1 Patient #1’s treatment sheet reports, with dates ranging from March 26, 2024 to April 2, 2024, revealed an elevated blood pressure post dialytic treatment was not reported to the RN or MD. Patient #3 Patient #3’s treatment sheet reports, revealed treatment sheet dated April 3, 2024 at the 14:01 timestamp indicated that the BFR range prescribed rate, 300, was increased to 400, with a HR of 52 during the increase BFR with no notification to the RN. Patient #2 Patient #2’s treatment sheet reports, with dates ranging from March 25, 2024 to April 5, 2024, revealed an elevated blood pressure post dialytic treatment was not reported to the RN or MD. The treatment sheets revealed that the patient’s heart rate was greater than 100 without notification to nursing staff as follows: 4/5/24 at 13:31 4/1/24 at 10:31 4/1/24 at 10:01 3/29/24 at 11:46 3/29/24 at 11:16 3/27/24 at 13:07 3/27/24 at 12:31 3/27/24 at 12:01 3/27/24 at 10:31 3/27/24 at 9:31 3/25/24 at 13:23 3/25/24 at 12:01 3/25/24 at 11:01 3/25/24 at 10:31 3/25/24 at 10:01 3/25/24 at 9:31 During an interview on April 10, 2024, facility administrator confirmed that there was no RN or MD notifiction of deviated EDW and no documentation of intervention for elevated blood pressure as directed in patient orders and required per facility policy.”