Davita Creekside Dialysis Center

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 17991 Based on observation, interview and policy review, staff failed to encourage patients to wash hands and/or access sites upon entering and/or leaving the dialysis treatment floor. 1.) Two of two patients (Patient (P) P3, P8) failed to wash hands and access sites prior to initiation of dialysis; and, 2.) Two of two patients (P5, P9) failed to remove gloves and sanitize hands after holding needle access sites and before leaving the treatment floor. These failed infection control practices place all 54 in-center patients, staff, and community at risk for transmission of blood-borne pathogens and/or other microorganisms. Findings include: 1. Observation on 11/15/23 at 8:45 AM, revealed P8 entering the dialysis treatment floor. P8 obtained weight and proceeded to Station 11. Staff failed to encourage P8 to wash hands or access site before initiation of dialysis. Observation on 11/15/23 at 9 AM, revealed P3 in a wheelchair entering the dialysis treatment floor with assistance from staff. Staff placed P3 on the scales to obtain weight, then proceeded to Station 3 to initiate dialysis. Staff failed to encourage P3 to wash and/or sanitize hands and failed to assist P3 with washing access site or hands. During an interview on 11/17/23 at 10:56 AM, when asked if staff encourage him/her to wash access and hands, P3 replied, “Not so much,” but said he/she washed hands when he/she returned home. 2. On 11/15/23 at 9:15 AM, P5 was observed holding an access site with one gloved hand. Staff failed to encourage P5 to remove the used glove and sanitize hands after hemostasis (blood is clotted). P5 was packing up personal items, putting the cap on his/her water bottle, and obtaining weight. P5 left the treatment floor without removing the glove and sanitizing and/or washing hands. On 11/16/12 at 12:01 PM, P9 was observed holding an access site with one gloved hand. P9 removed the glove after hemostasis then handed it to Certified Clinical Hemodialysis Technician (CCHT) 1 to throw it away. CCHT 1 failed to offer P9 hand sanitizer or encourage P9 to wash hands before leaving the treatment floor. During an interview on 11/17/23 at 10:33 AM, Registered Nurse (RN) 1 confirmed the staff could do a better job encouraging patients to wash hands and access sites. During an interview on 11/17/23 at 11:18 AM, CCHT1 confirmed he/she could do a better job encouraging patients to practice good hand hygiene and to wash access sites. CCHT1 said they used wipes to wash the Patients’ access. CCHT1 recalled the interaction with P9 on 11/16/12 at 12:01 PM, as referenced above and said, “You got me on that one.” Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” dated 04/23, indicated ...”Purpose: To minimize the spread of infections of blood-borne pathogens in the dialysis facility environment ...2. Patients and caregivers will be encouraged to, a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis ...b. Perform hand hygiene after treatment before leaving treatment area.””

“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: 17991 Based on record review, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription, as determined by the medical provider, for three of seven sampled patients (Patient (P) 2, P4, P7). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 54 patients receiving dialysis at this facility. Findings include: 1. Review of an, “IDT (Interdisciplinary Team) Rounding Worksheet,” indicated P2 was admitted to the facility on 05/24/18. Review of, “Active Treatment Orders,” dated 11/03/23, 11/06/23, and 11/10/23, indicated P2’s blood flow rate (BFR) should be set at 400 mL/min (milliliters per minute.) a. Review of a, “Treatment Details Report,” dated 11/03/23, indicated P2’s treatment was initiated at 10:47 AM, with a BFR set at 300 mL/min and remained there until the treatment was terminated at 3 PM. The Registered Nurse (RN) verified the prescription was correct on 11/03/23 at 10:50 AM. There was no documented explanation as to why the physician’s prescription was not followed. b. Review of a, “Treatment Details Report,” dated 11/06/23, indicated P2’s treatment was initiated at 11:03 AM, with a BFR set at 350 mL/min, then at 11:30 AM, the BFR was set at 355 mL/min and remained there until 1:02 PM, at which time the BFR was set at 350 mL/min and remained at 350 mL/min until the treatment was terminated at 3:03 PM. The RN verified the prescription was correct on 11/06/23 at 11:05 AM. There was no documented explanation as to why the physician’s prescription was not followed. c. Review of a, “Treatment Details Report,” dated 11/10/23, indicated P2’s treatment was initiated at 3:30 PM, with a BFR set at 350 mL/min and remained there until the treatment was terminated at 7:12 PM. The RN verified the prescription was correct on 11/10/23 at 4:04 PM. There was no documented explanation as to why the physician’s prescription was not followed. 2. Review of an, “IDT Rounding Worksheet,” indicated P4 was admitted to the facility on 05/18/23. Review of, “Active Treatment Orders,” dated 11/11/23, indicated P2’s dialysate flow rate (DFR) should be set at 600 mL/min (milliliters per minute). There was no documented explanation as to why the physician’s prescription was not followed. Review of a, “Treatment Details Report,” dated 11/11/23, indicated P4’s treatment was initiated at 7:17 AM, with a DFR set at 300 mL/min and it remained there until the treatment was terminated at 10:41 AM. The RN verified the prescription on 11/11/23 at 7:56 AM. There was no documented explanation as to why the physician’s prescription was not followed. 3. Review of an, “IDT Rounding Worksheet,” indicated P7 was admitted to the facility on 09/05/16. Review of, “Active Treatment Orders,” dated 10/30/23, indicated P7’s BFR should be set at 450 mL/min. a. Review of a, “Treatment Details Report,” dated 11/01/23, indicated P7’s treatment was initiated at 3:53 PM, with a BFR set at 450 mL/min. The BFR at 5:08 PM, was 250 mL/min, and from 5:36 PM, until the end of the treatment at 7:06 PM, the BFR was set at 400 mL/min. The RN verified the prescription on 11/01/23 at 7:41 PM, after the patient had left the treatment floor. There was no documented explanation as to why the physician’s prescription was not followed. b. Review of a, “Treatment Details Report,” dated 11/02/23, indicated P7’s treatment was initiated at 1:09 PM, with a BFR set at 400 mL/min and remained there until the treatment was discontinued at 2:36 PM. P7 was receiving an additional treatment to take off extra fluid. The RN verified the prescription on 11/02/23 at 1:10 PM. There was no documented explanation as to why the physician’s prescription was not followed. c. Review of a, “Treatment Details Report,” dated 11/08/23, indicated P7’s treatment was initiated at 4:06 PM, with a BFR set at 400 mL/min and it remained there until the treatment ended at 6:36 PM. The RN verified the prescription on 11/08/23 at 4:43 PM. There was no documented explanation as to why the physician’s prescription was not followed. d. Review of a, “Treatment Details Report,” dated 11/10/23, indicated P7’s treatment was initiated at 3:29 PM, with a BFR set at 400 mL/min. The BFR remained set at 400 mL/min until 5:35 PM, at which time the treatment was paused for P7 to go to the bathroom. The treatment was resumed at 6:05 PM, until termination at 6:35 PM, with a BFR set at 400 mL/min. The RN verified the prescription on 11/10/23 at 4:45 PM. There was no documented explanation as to why the physician’s prescription was not followed. During an interview on 11/16/23 at 1 PM, and again on 11/17/23 at 12:18 PM, the Manager of Clinical Services confirmed the dialysis prescription for P2, P4, and P7 had not been followed. The Manager of Clinical Services said there should have been a documented reason either on the treatment sheet or in the notes as to why the physician’s prescription was not followed. Review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated 10/23, indicated ...”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 setting are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. 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 state law ... Prescription components include but are not necessarily limited to: f. Blood flow rate ...g. Dialysate flow rate ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed.””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 17991 Based on interview and record review, the facility failed to complete an initial comprehensive care plan for one (Patient (P) 6) of one new admission records reviewed. Failure to complete an initial comprehensive care plan had the potential to delay the initial care and treatment of all new patients admitted to this facility. Findings include: Review of an, “IDT (Interdisciplinary Team) Rounding Worksheet,” indicated P6 was admitted to the facility on 09/23/23. Review of, “Draft Plan of Care” (not dated), indicated the due date of the care plan was 10/23/23 ...IDT Meeting Date, “Pending.” Completion Status MSW (Master of Social Work) Complete, RD (Registered Dietician) Complete, RN (Registered Nurse), “Not Started.” During an interview on 11/17/23 at 2:49 PM, the Facility Administrator stated the Clinical Care Coordinator was responsible for completing the care plans and had been working on the treatment floor leaving no time for other duties. The Facility Administrator stated the Clinical Care Coordinator was not available for an interview because he/she was currently out of the country due to a family emergency and was not expected to return until January 2024. Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 07/23, indicated, “2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care ...4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines ...14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.””

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 17991 Based on interview and record review, the facility failed to complete a three-month follow-up reassessment care plan for one (Patient (P) 4) of seven records reviewed. Failure to complete a three-month follow-up reassessment and care plan had the potential to delay the care and treatment of all new patients after the initial three months of treatment at this facility. Findings include: Review of an, “IDT (Interdisciplinary Team) Rounding Worksheet” (undated), indicated, P4 was admitted on 05/18/23. Review of P4’s, “Patient Plan of Care,” indicated the initial care plan was completed on 06/10/23. During an interview on 11/17/23 at 11 AM, the Manager of Clinical Services confirmed the 90-day care plan had not been initiated or completed. During an interview on 11/17/23 at 2:49 PM, the Facility Administrator said the Clinical Care Coordinator was responsible for completing the care plans but had been working on the treatment floor leaving no time for other duties. The Facility Administrator confirmed the Clinical Care Coordinator was not available for an interview. The Facility Administrator stated the Clinical Care Coordinator was currently out of the country due to a family emergency and was not expected to return until January 2024. Review of a policy, given by the facility, entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 07/23, indicated, “2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care ...4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines ...5. A follow up 90-day re-assessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care ...14. The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative, and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 17991 Based on interview and record review, the facility failed to assess and complete monthly care plans for two (Patient (P) 1, P7) of two unstable patient records reviewed. Failure to complete unstable care plans, due monthly, had the potential to delay the care and treatment of all patients receiving treatment at this facility and identified as unstable. Findings include: 1. Review of, “IDT (Interdisciplinary Team) Rounding Worksheet,” indicated, P1 was admitted to the facility on 04/15/11. a. Review of, “Patient Plan of Care,” indicated the IDT meeting date was 04/14/23. P1’s status was deemed, “Unstable.” The reason for P1 being unstable was not documented. All members of the IDT team and P1 signed acknowledgement and approval of the care plan. b. Review of the, “Current Plan of Care,” indicated the due date was 06/29/23, the IDT Meeting Date “Pending,” Completion Status MSW (Master of Social Work) Complete, RD (Registered Dietician) Complete, RN (Registered Nurse) “Not Started” ...”Stability Status: Unstable.” c. Review of, “Patient Plan of Care,” indicated the IDT meeting date was 09/28/23. The plan of care indicated P1 was stable, however the attached assessment was dated 06/07/23. All members of the IDT team signed acknowledgement and approval of the care plan. P1 did not sign the care plan and the reason was not documented. During an interview on 11/16/23 at 10 AM, the Manager of Clinical Services stated there was no clear understanding of why the unstable monthly assessments had not been completed after the unstable diagnoses on 04/14/23 and 06/29/23. The Manager of Clinical Services stated the staff responsible for coordinating care plans at that time was no longer working at the facility, and the Clinical Care Coordinator responsible for completing the nursing assessment was currently out of the country. 2. Review of, “Patient Plan of Care,” indicated the IDT meeting date was 05/17/23. P7’s status was documented as, “Unstable.” The reason P7 being unstable was not documented. Members of the team present included the MSW, RD, RN, and Physician. The plan of care was reviewed with P7. Review of, “Patient Plan of Care,” indicated the IDT meeting date was 09/28/23. The plan of care indicated P7 was, “stable.” There were no monthly assessments or plans of care between 05/17/23 through 09/28/23 (June, July, or August), to indicate when P7 was identified by the IDT team as, “stable.” All members of the IDT team signed acknowledgement and approval of the care plan. P7 did not sign the care plan, the reason was not documented. During an interview on 11/17/23 at 12:18 PM, the Manager of Clinical Services confirmed the unstable monthly assessments and plans of care had not been completed for P1 and P7. During an interview on 11/17/23 at 2:49 PM, the Facility Administrator said the Clinical Care Coordinator, who was responsible for completing the care plans, had been working on the treatment floor leaving no time for other duties. The Facility Administrator confirmed the Clinical Care Coordinator was not available for an interview because he/she was currently out of the country due to a family emergency and was not expected to return until January 2024. Review of a policy, given by the facility, entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 07/23, indicated, “2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care ...7. A comprehensive reassessment of each patient and a revision in the plan of care will be conducted: At least monthly for unstable patients ...14 The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative, and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.””