Davita Usc Kidney Center

“PA-ASSESS HD ADEQ Q MO;PD ADEQ Q 4 MO CFR(s): 494.80(c) The adequacy of the patient’s dialysis prescription, as described in §494.90(a)(1), must be assessed on an ongoing basis as follows: (1) Hemodialysis patients. At least monthly by calculating delivered Kt/V or an equivalent measure. (2) Peritoneal dialysis patients. At least every 4 months by calculating delivered weekly Kt/V or an equivalent measure. This Standard is not met as evidenced by: 51860 Based on interview and record review, the facility failed to implement the proper laboratory testing collection method for two of three sampled patients (Patient 1 and Patient 3) in accordance with the facility’s policy and procedure (P&P). This deficient practice had the potential to result in Patient 1 and Patient 3 not receiving correct laboratory results and the potential for physicians to make adjustments to Patient 1 and Patient 3’s dialysis treatment orders based on incorrect laboratory results. Findings: During a concurrent interview and record review on 12/10/2025 at 9:24 a.m. with Registered Nuse (RN) 1, Patient 1’s dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) adequacy (a measure of how effective a dialysis treatment is at cleaning the blood, also called a Kt/V) laboratory result, dated 8/25/2025, was reviewed. RN 1 stated for Patient 1, the “Total Volume of EFFL/Dial” [the fluid removed plus the spent dialysate (waste product)] inputted (data entered into a computer) entry amount result was edited from 8000 milliliters (mL, a unit of liquid measure) entered on 8/25/2025 to 15141 mL entered on an edit on 8/28/2025. RN 1 stated based on the edited result, Patient 1’s adequacy laboratory result from sample collected 8/25/2025 changed from a Kt/V of 1.15 (result prior to the edit), indicating inadequate dialysis, to a Kt/V of 1.97 (result after the edit), indicating adequate dialysis. RN 1 stated the “Total Volume of EFFL/Dial” was referred to as “Total Dialysate Volume Out” in the facility’s P&P. During an interview on 12/10/2025 at 9:47 a.m. with Facility Administrator (FA) 1, FA 1 stated the nurses would, on occasion, enter a temporary “Total Dialysate Volume Out” value for a Kt/V sample to be sent out. FA 1 stated the practice of entering temporary values was previously believed to be inconsequential. FA 1 stated the nurses had been in-serviced to postpone a Kt/V test if all the values in the “APD Adequacy Worksheet” were not available, in particular the “Total Dialysate Volume Out” value. During a concurrent interview and record review on 12/10/2025 at 10:44 a.m. with RN 1, Patient 3’s dialysis adequacy laboratory result dated 8/18/2025 was reviewed. RN 1 stated for Patient 3, the “Total Volume of EFFL/Dial” value entered on 8/18/2025 at 3:49 p.m. was 6000ml. An edit dated the same day 8/18/2025 at 4:21 p.m. indicated the “Total Volume of EFFL/Dial” value was edited with the new value 5628ml. During a review of the facility’s P&P titled, “Adequacy of Peritoneal Dialysis,” revised 10/2025, the P&P indicated, “Patients who do not meet the adequacy standard goal of Kt/V >/= 1.7 will receive ongoing evaluation of their status, including kinetic (changes in activity level in response to a specific action) modeling and intervention to ensure that an optimal outcome is achieved.” During a review of the facility’s P&P addendum titled, “APD Adequacy Worksheet,” revised 09/2016, the P&P addendum worksheet indicated the patient’s “Total Dialysate Volume Out” [the fluid removed plus the spent dialysate (waste product)] was required to submit for Kt/V calculation.”