Davita Tustin Ranch Dialysis

“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: 50003 Based on interview and record review, the facility failed to ensure the dialysis prescription was followed for one of four sampled patients (Patient 1). This failure had the potential for the patient to sustain the dialysis access’ complications and blood loss. Findings: Review of facility’s P&P titled Prescription Verification and Safety Check Procedure for Conventional Dialysis Delivery System last revised March 2015 showed the trained teammates will verify the dialysis prescription and perform the safety checks prior to each treatment initiation. The staff verifies for the patient to receive the safe and effective treatment as prescribed. On 1/17/25 at 1010 hours, Patient 1’s medical record review was initiated. Patient 1 was admitted to facility on 12/28/22, with End Stage Renal Disease. Further review of Patient 1’s dialysis prescription dated 12/16/24, showed to use 15-gauge needles for cannulation of the patient’s left upper arm AVF access. Review of the Treatment Details Report dated 12/16/24, showed the following: - At 1306 hours, PCT 2 documented the treatment started without complications. Normal saline (an IV solution) prime was given. Heparin (anticoagulant medication) infusion was startet. PCT 1 cannulated Patient 1. - At 1523 hours, PCT 2 documented Patient 1’s treatment was paused. The lines were clotted. The rinse back was done. The blood lines were changed and RN 1was informed. Review of the nurses’ progress notes regarding Patient 1’s treatment dated 12/16/24, showed the RN documented Patient 1 had 16-gauge needle used for HD treatment instead of 15-gauge needle on Monday, 12/16/24. The physician was notified and verified to move forward to use 15-gauge needle for HD. On 1/17/25 at 1325 hours, an interview was conducted with PCT 1. PCT 1 stated PCT 1 had cannulated Patient 1’s left upper arm AVF access with the 16-gauge needles on the treatment date of 12/16/24. PCT 1 further stated PCT 1 should have verified the dialysis prescription order before cannulating Patient 1’s dialysis access to prevent any issues. On 1/17/25 at 1430 hours, an interview was conducted with RN 1. RN 1 confirmed Patient 1 had an order to be cannulated using 15-gauge needles, but the physician’s order was not followed on the treatment date of 12/16/24. The treatment blood lines were clotted during the last hours of treatment due to the high venous pressure, the patient’s blood was returned back completely with minimal blood loss, new blood lines were set up, and the patient was able to complete dialysis treatment. RN 1 further stated verification of the treatment orders prior to patient cannulation and initiation of dialysis treatment was important to prevent the complications related to dialysis access and risks of blood loss. On 1/17/25 at 1610 hours, a concurrent interview and review of Patient 1’s medical record was conducted with the Facility Administrator. The Facility Administrator verified the findings and stated the staff should verify the prescription orders for every patient before cannulation and treatment initiation.”

“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: 50003 Based on interview and record review, the facility failed to ensure the RN was notified of the abnormal blood pressure readings for one of four sampled patients (Patient 1) as per the facility’s P&P. This failure has the potential to place the patient at risk for delays in receiving immediate intervention and treatment necessary to ensure the patient’s safety. Findings: Review of the facility’s P&P titled Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment last revised April 2024 showed abnormal findings should be reported to the licensed nurse and documented in the patient’s medical record, including intradialytic SBP greater than 180 mmHg or less than 90 mmHg and DBP greater than or equal to 100 mmHg or less than 50 mmHg. Review of the facility’s Abnormal Findings Job Aid handout dated 4/1/24, showed a difference of 20 mmHg increase or decrease from the patient’s last intradialytic treatment BP reading is significant and should be reported to the licensed nurse. On 1/17/25, review of Patient 1’s medical record was initiated. Review of the Treatment Details Report dated 12/20/24, showed Patient 1’s dialysis treatment was started at 1313 hour and ended at 1701 hours. Further review of the Treatment Details Report showed the following: - At 1331 hours, the patient’s BP was 131/72 mmHg. - At 1402 hours, the patient’s BP was 111/72 mmHg (the patient SBP had a decrease of 20 mmHg). However, there was no documentation to show the PCT informed the RN of the decreased BP reading. Further review of treatment flowsheet showed the patient’s BP continued to trend down. - At 1532 hours, the patient’s BP was 89/58 mmHg. - At 1534 hours, the patient’s BP was 87/60 mmHg. The PCT documented the RN was notified. - At 1823 hours, the RN documented Patient 1 was evaluated, and the patient’s BP trend would be monitored. Patient 1 was not seen and assessed by the nurse for approximately two hours with concerns related to the decreased in Patient 1’s BP. On 1/17/25 at 1325, an interview was conducted with PCT 1. PCT 1 verbalized understanding of the expectation related to intradialytic BP monitoring which included notifying the nurses when the patient’s BP increased or decreased at 20 mmHg or more compared to the previous BP reading. On 1/17/25 at 1430 hours, an interview was conducted with RN 1. RN 1 was asked regarding the intradialytic BP monitoring. RN 1 stated the PCTs were expected to inform the nurses of a difference of 20 mmHg as compared to the patient’s previous BP reading to ensure the patient assessment was conducted and the appropriate interventions were immediately provided. On 1/17/25 at 1610 hours, during an interview with the Facility Administrator, the Facility Administrator was informed and verified the findings.”