Davita Desert Dunes Dialysis

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 45999 Based on a review of facility policy, Centers for Disease Control (CDC) recommendations, observation, and staff interview, it was determined that the facility failed to ensure that unused patient supplies and medications were stored in “clean” areas and not stored in drawers at the “dirty” sinks, which poses the potential risk of cross-contamination and infection in the dialysis patient. Findings Include: Facility policy titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” published April 2023, revealed: “...To minimize the spread of infections or bloodborne pathogens in the dialysis environment ...Supplies will be stored in a manner that maintains their integrity ...Measures will be taken to prevent cross-contamination....” CDC “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients” dated 4/27/01 revealed: “...Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment....” Observation on tour on December 20, 2023, revealed: The first sink labeled “dirty” contained: Clean clamps and Hemostats, and also pre-made patient packs. The second sink labeled “dirty” contained: Clean clamps, Hemostats, and premade patient packs as well as glucose testing strips, and control solutions. Employee #1 verified in an interview conducted on December 20, 2023, that supplies were not stored per 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 document review, observation, and staff interview, it was determined that the facility failed to ensure staff discarded expired Oral/IV/IM patient medications. Failure to discard expired medications and secure medications when not in use has the potential risk patient will receive unstable, ineffective, contaminated, and/or tampered with medications and supplies. Findings include: The facility policy titled “Medication Policy “requires: “...All medications are checked monthly for expiration dates...Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations....” Observation on 12/20/2023 revealed the following. 25 bottles, Gentamycin 80 mg, Oral, expired 11/30/23 35 individual packaged doses, Tazicef 1 Gram, IV, expired 10/30/23 4 individual packaged doses, Daptomycin 500 mg, IV, expired 10/30/23 All aforementioned medications were discovered in the main nurse medication station. Employee #3 confirmed on 12/20/2023 that the above listed medications were expired and not removed from the patient care area or labeled and/or stored appropriately.”

“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: 45999 Based on document review and interview, it was determined that the facility failed to ensure dialysis delivery systems were cleaned and disinfected daily which poses a potential risk of cross-contamination and infection to patients receiving dialysis treatment if machines are not disinfected as required. Findings include: The facility policy titled “NIPRO SURDIAL DX DIALYSIS DELIVERY SYSTEM CLEANING AND DISINFECTION POLICY” requires: “...PROCEDURE..50% Citric Acid/Thermal Disinfection...EACH TREATMENT DAY...after patient use, end of day...Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log...Cleaning and disinfection of dialysis delivery systems will be documented on this log...At a minimum, the facility-specific log must include the following elements...Identification number...Date procedure provided...Type of procedure provided...Post chemical rinse residual test...Verification of negative chemical residual test just prior to next use...Status of equipment...Teammate initials...Signature/initial legend...Completed logs will be filed...and maintained for the entire time the equipment is owned by DaVita....” A review of the “Nipro SDX Dialysis Delivery System Clean and Disinfect Log” revealed the following days machines were not filled out with that date that machines were disinfected as required. On the following days, the machine logs were not dated to indicate when they had been disinfected as required: September 20, 2023 September 22, 2023 September 23, 2023 October 2, 2023 October 4, 2023 October 7, 2023 October 13, 2023 November 3, 2023 November 4, 2023 November 7, 2023 November 8, 2023 November 12, 2023 November 18, 2023 November 20, 2023 November 21, 2023 November 22, 2023 December 5, 2023 December 7, 2023 Employee #12 verified in an interview on December 20, 2023, that staff was not filling out the machine disinfection log book as indicated by policy and procedure.”

“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: 49430 Based on review of facility policy, medical records and interview, it was determined that the facility failed to ensure that staff followed the attending physicians prescribed hemodialysis (HD) order for blood flow rate for patients #2, 3, 4 and 6. Failure to follow physician orders poses the potential risk of inadequate dialysis, decreased clearances and hospitalizations. Findings Include: Patient #2 Treatment Sheet 12/19/23: Blood Flow Rate (BFR) ordered 350 ml/min. BFR charted 450 ml/min at 17:30-1830 without any charted reason for deviation from physician order. BFR charted 0 ml/min at 18:37 without any charted reason for deviation from physician order. Treatment Sheet 12/16/23: Blood Flow Rate (BFR) ordered 350 ml/min. BFR charted 400 ml/min at 10:44 without any charted reason for deviation from physician order. BFR charted 250 ml/min at 13:07 without any charted reason for deviation from physician order. BFR charted 400 ml/min at 13:18 without any charted reason for deviation from physician order. Treatment Sheet 11/14/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 10:52 without any charted reason for deviation from physician order. Treatments Sheet 11/11/23: BFR ordered 350 ml/min. BFR charted 400 at 13:00-14:00 without any charted reason for deviation from physician order. Treatment Sheet 11/9/23: BFR ordered 350 ml/min. BFR charted 300 ml/min at 10:37-14:31 without any charted reason for deviation from physician order. Patient # 3 Treatment Sheet 12/19/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 05:40 without any charted reason for deviation from physician order. Treatment Sheet 12/9/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 05:31-06:00 without any charted reason for deviation from physician order. Patient #4 Treatment Sheet 12/15/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 15:10-18:18 without any charted reason for deviation from physician order. Treatment Sheet 12/11/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 15:06-17:03 without any charted reason for deviation from physician order. Treatment Sheet 12/8/23: BFR ordered 350 ml/min. BFR charted 400 ml/min at 14:47-15:31 without any charted reason for deviation from physician order. Patient #6 Treatment Sheet 12/18/23: BFR ordered 450 ml/min. BFR charted 350 ml/min at 12:28-13:32 without any charted reason for deviation from physician order. Treatment Sheet 12/15/23: BFR ordered 450 ml/min. BFR charted 400 ml/min at 13:32 without any charted reason for deviation from physician order. Treatment Sheet 12/6/23: BFR ordered 450 ml/min. BFR charted 400 ml/min at 13:32-14:52 without any charted reason for deviation from physician order. Employee #2 confirmed on 12/20/2023 that staff did not follow patients prescribed blood flow rates as ordered by the nephrologist as required.”

“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: 49430 Based on review of facility policy and procedure, medical records, and interview it was determined that the facility failed to ensure RNs and PCTs monitored, assessed, and documented abnormal findings for (6) of (6) patients during treatment (Patients #1, 2, 3, 4, 5 and 6). This deficient practice limits the interdisciplinary team (IDT) in addressing blood pressure, heart rate, and fluid management issues in the patient’s plan of care if treatment data is not documented, assessed, and addressed in the patient’s medical record. Findings include: The facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” requires: “...Patient data will be obtained and documented...Data collection includes...Measurement of Blood Pressure...Intradialytic Data Collection/Assessment...Vital signs and treatment monitoring...At a minimum, obtain and document...Blood pressure...Abnormal findings...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. The licensed nurse notifies the physician...as needed of changes in patient status...Abnormal Findings...Blood pressure: Pre-dialysis ...Systolic greater than 180 mm Hg ...Diastolic greater than or equal to 100 mm Hg ...Blood Pressure-Intradialytic...Difference of 20 mm/Hg increase or decrease from patient’s last intradialytic treatment BP reading ...Post Treatment ...Standing systolic BP greater than 140 mm Hg ...Standing diastolic BP greater than 90 mm Hg ...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute....” Review of Patient Treatment Sheets reveals: Patient #1 Treatment Sheet 12/19/23: 10:31-11:01 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 11:01-11:31 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/16/23: 09:42-10:00 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 10:30-11:00 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 11:30-12:00 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 09:42 BP 187/64. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/12/23: 11:30-12:00 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/9/23: 09:32-10:02 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 10:31-11:01 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 11:01-11:31 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Patient #2 Treatment Sheet 12/19/23: 16:00-16:18 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 17:00-17:30 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 17:30-18:00 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:00-18:30 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/16/23: 11:01-11:34 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 12:01-12:31 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 13:18-13:31 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 13:31-14:01 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 14:01-14:31 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 11/9/23: 13:01-13:31 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Patient #3 Treatment Sheet 12/19/23: 07:36-08:06 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:40 BP 229/106. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:06 BP 184/92. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:36 BP 189/88. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 07:06 BP 184/98. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/16/23: 05:26 BP 228/116. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:33 BP 224/107. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:03 BP 183/90. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/14/23: 08:03-08:30 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:31 BP 216/105. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:33 BP 212/99. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:03 BP 184/90. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/12/23: 08:02-08:32 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:35 BP 192/105. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:02 BP 185/93. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:32 BP 190/100. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/9/23: 05:32-06:02 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 06:32-07:02 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 05:31 BP 204/96. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Patient #4 Treatment Sheet 12/15/23: 17:31 BP 188/91. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 16:01-16:33 Vital signs interval greater than 30 minutes Treatment Sheet 12/13/23: 15:31-16:01 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:01-18:03 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:31-18:38 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/11/23: 15:06-15:32 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/8/23: 16:00-16:30 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:02 HR 53. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:17 HR 59. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/4/23: 17:02 BP 188/97. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 17:32 BP 190/106. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:00 BP 182/114. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 18:02 BP 191/105. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Patient #5 Treatment Sheet 12/1/23: 15:02-15:35 Vital signs interval greater than 30 minutes. Treatment Sheet 11/296/23: 16:31-17:01 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 11/27/23: 15:31-16:04 Vital signs interval greater than 30 minutes. Patient #6 Treatment Sheet: 10:32-11:02 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 11:32-12:10 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 12:44-13:02 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/15/23: 11:31-12:03 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 13:06-13:32 BP increased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/13/23: 12:01-12:39 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 12:01-12:32 Vital signs interval greater than 30 minutes. Treatment Sheet 12/11/23: 10:34-11:02 BP decreased more than 20 MM/Hg. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. Treatment Sheet 12/8/23: 13:01-13:32 Vital signs interval greater than 30 minutes. 15:32 - Blood Pressure (BP) 184/100. No Registered Nurse (RN) notified by PCT or RN note/assessment charted. 16:01-16:32 Vital Signs greater than 30 min apart. Employee #1 confirmed on 12/19/2023 that staff failed to ensure RNs and PCTs monitored, assessed, and documented abnormal findings for the aforementioned patients and medical records.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 37489 Based on review of facility policy, medical records and interview, it was determined that the facility failed to ensure AMAs (against medical advice) forms were completed for treatment times not met for (4) of (5) patients (Patients #2, 3, 4, 5 and 7) with early termination of treatment which has the potential risk of adverse events related to inadequate dialysis. Findings include: The facility policy titled “Prescribed Treatment Time Not Met” requires: “...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....4. A copy of the Early termination of Treatment Against Medical Advice form signed by the patient, if shortened voluntarily by the patient, will be kept in the patient’s health record....” Patient #2 Treatment records dated 11/07/2023 through 12/19/2023 revealed (6) of (6) treatments were terminated early. The medical record did not contain AMA documentation for (4) of the (6) early terminated treatments. Patient #3 Treatment records dated 12/7/2023 through 12/19/2023 revealed (4) of (6) treatments were terminated early. The medical record did not contain AMA documentation for (4) of the (4) early terminated treatments. Patient #4 Treatment records dated 12/4/2023 through 12/15/2023 revealed (2) of (6) treatments were terminated early. The medical record did not contain AMA documentation for (2) of the (2) early terminated treatments. Patient #5 Treatment records dated 11/27/2023 through 12/15/2023 revealed (3) of (6) treatments were terminated early. The medical record did not contain AMA documentation for (3) of the (3) early terminated treatments. Patient #6 Treatment records dated 12/6/2023 through 12/18/2023 revealed (2) of (6) treatments were terminated early. The medical record did not contain AMA documentation for (2) of the (2) early terminated treatments. Employees #1 and 2 confirmed on 12/18/2023 that AMA forms were not completed for the aforementioned patients as required by facility policy.”