Davita Jurupa Valley Dialysis

“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: 36038 Based on interview and record review, the facility failed to ensure the patient’s blood pressure (BP) goals were met and the protocol for hypertension (elevated BP) was followed for one of three sample patients (Patients A) when: 1) Patient A’s goal for systolic blood pressure (the top number and refers to the amount of pressure experienced by the arteries while the heart is beating) was not achieved, as the blood pressure consistently remained above 140; and 2) The physician was not notified when Patient A’s BP was persistently high, even after two doses of clonidine (a medication to lower BP) on June 22, 2024, during hemodialysis ( (HD-process of purifying the blood of a person whose kidneys are not working normally). These failures had the potential to result serious health complications for Patient A including stroke, falls and injuries, and hospitalization. Findings: Patient A’s record was reviewed. Patient A was admitted to the facility on February 14, 2023, with diagnoses which included ESRD (medical condition in which a person’s kidneys cease functioning on a permanent basis). Patient A’s HD prescription was three times a week, for three hours 4:30 a.m. to 7:30 a.m. Patient A’s HD treatment record dated June 22, 2024, indicated the following: a. On June 22, 2024, at 4:13 a.m. Pre-dialysis BP was 209/87. b. On June 22, 2024, at 7:18 a.m. Post -dialysis BP was 218/104. c. On June 22, 2024, at 5:33 a.m., BP was 205/100. d. On June 22, 2024, at 6:33 a.m., BP was 225/ 101. e. On June 22, 2024, at 7:09 a.m., BP was high at 229/111. A review of Patient A’s “Patient Plan of Care,” dated June 18, 2024, indicated, “...Medications...Clonidine, 0.1 Milligram Oral...Every hour as needed...” A review of Patient A’s “Treatment Details Report,” dated June 22, 2024, indicated: a. “...PRN (as needed) Medications...Ordered Dose Administered...Yes...Given...0.1 Milligram (name of RN) 06/22/2024 05:35...Response Documented...not effective...” b. “...PRN Medications...Ordered Dose Administered...Yes...Given...0.1 Milligram (name of RN) 06/22/2024 06:25...Response Documented...not effective...” Further review of Patient A’s hemodialysis treatment and “Treatment Details Report,” dated June 22, 2024, indicated there was no documentation that the physician was notified when the patient’s blood pressure was not lowered. On July 5, 2024, at 2:52 p.m., during a concurrent interview and record review of Patient A’s treatment flow sheet from June 22, 2024, with Registered Nurse (RN) 1, RN 1 stated Patient A’s BP was high throughout the treatment. RN 1 stated a potential side effect of high blood pressure is stroke (which occurs when the blood supply to part of the brain is blocked or reduced). RN 1 further stated the RN should have notified the physician after two doses of Clonidine if the BP remained high. On July 11, 2024, at 1:14 p.m. during an interview with RN 2, RN 2 stated, Patient A started with a high BP 209/87. RN 2 stated she administered Clonidine 0.1 mg by mouth at 5:35 a.m., and after an hour, Patient A’s blood pressure remained high at 225/101 prompting administration of a second dose of Clonidine 0.1 mg at 6:35 a.m. RN 2 stated the treatment ended at 7:09 a.m. with Patient A’s blood pressure at 229/111. RN 2 stated there was no documentation indicating the physician was notified. On July 18, 2024, at 2:11 p.m., during an interview with RN 2, RN 2 stated if the BP goal was not achieved, it should be communicated to the physician. RN 2 stated the goal for Patient A was for systolic BP to be less than 140 and diastolic blood pressure to be less than 90. RN 2 stated the patient’s plan of care should be revised if the goal was not met to address the need of the patient. A review of the undated facility’s Hypertension Protocol indicated, “ ...Provider Instructions: SBP > (more than) 180 AND OR DBP (diastolic blood pressure is the bottom number and refers to the amount of pressure in the arteries while the heart is resting in between heartbeats) >100, give 0.1mg PO (by mouth) x 1, if SBP still >180, and or DBP>100, may administer additional 0.1mg PO x1 within one hour, and if SBP>140 within the last hour ... If BP still remains unchanged, notify MD (physician).”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 37536 Based on observation, interview, and record review, the facility staff failed to use the suction equipment on a patient who was having seizures (sudden uncontrolled burst of electrical activity in the brain that can cause unusual movements) due to missing connection tubing for one of five sampled patients (Patient 1). In addition, the facility failed to ensure the emergency cart (crash cart) was checked on a regular basis to ensure that emergency equipments were safe, in functional working condition, and immediately available for the use. This failure had to potential to result in the patient to not receive the necessary emergency care during an emergency which could have resulted in injury or death. Findings: On June 4, 2024, a record review was conducted for Patient 1. Patient 1 was admitted to the facility on April 26, 2024, with a diagnosis of acute kidney injury (AKI - a malfunction of the kidneys). On June 4, 2024, a review of Patient 1’s document titled, “Treatment Detail Report,” dated May 27, 2024, indicated, “...Patient had seizure, treatment was ended with six minutes left on the treatment. Patient was turned to the left side, blood was returned. Activated emergency services and was sent to the hospital...” On June 4, 2024, at 10:32 a.m. an interview was conducted with Registered Nurse (RN 1). RN 1 stated there were three checklists, daily, weekly, and monthly, which the RN’s were responsible for checking the crash cart. RN 1 stated the opening RNs were responsible for conducting the daily checks, and the weekly checks were performed on Mondays. RN 1 stated, the daily checklist documented that the defibrillator (machine used to send an electrical charge to the heart), the suction machine, and the codes lock were all present and accounted for, and in working condition. RN 1 stated the suction tubing was checked during the weekly and monthly checks. RN 1 stated all emergency supplies should always be ready and available for use. RN 1 stated she was not aware of missing cart supplies prior to May 27, 2024. On June 4, 2024, at 1:49 p.m. an interview was conducted with the Facility Administrator (FA). The FA stated it was his expectation that the opening nurses (the registered nurses who start the day) be responsible for conducting the daily, weekly, and monthly crash cart logs. The FA stated the RNs should be regularly checking the crash cart logs according to the facility policy. The FA stated he was not aware of missing supplies prior to May 27, 2024. The FA stated the crash cart was last used on May 27, 2024, when a patient had a seizure. The FA stated the RNs attempted to use the suction equipment but found that a part of the tubing was missing rendering the suction equipment unusable. The FA stated the patient was turned on the side to prevent aspiration and the emergency services were called and arrived to transport the patient out from the facility. The FA stated the physician was present during the episode and supported the RN’s interventions. The FA stated if equipment was not functioning or missing from the crash cart there was a potential for a patient to not receive the necessary emergency interventions. On June 5, 2024, at 1:08 p.m. an interview was conducted with RN 3. RN 3 stated he was the opening nurse on May 27, 2024, and that he did not perform the daily or the weekly crash cart checks. RN 3 stated when he attempted to turn the suction on to have it ready for use, he noted the tubing that connects the suction from the patient to the suction cannister was missing. RN 3 stated he could not locate the missing tubing and could not use the suction machine. RN 3 stated all emergency equipment and supplies should be ready and available for use at all times. RN 3 further stated that there was a potential for a patient to aspirate (swallow fluids or solid matter into the lungs) during a seizure or during a choking episode. RN 3 stated, the suction should be available to prevent aspiration. RN 3 stated, he should have checked the cart in the morning but it was not checked until the late afternoon on May 27, 2024. On June 5, 2024, at 2:15 p.m. an interview was conducted with RN 4. RN 4 stated she could recall on May 27, 2024, when the suction on the crash cart was found to be unavailable for use. RN 4 stated the tubing that connects the suction canister to the patient could not be found. RN 4 statd the emergency equipment should be checked daily, weekly, and monthly. RN 4 stated all emergency equipment and supplies should be working and available for use. RN 4 stated she was the opening RN on April 24 and April 25, 2024, and that the daily check for the cart was not completed. RN 4 stated the daily checklists should be completed according to the facility policy. On June 4, 2024, a review of the facility documents titled, “Incenter Hemodialysis Policies Procedures Emergency Equipment Checklist (weekly crash cart checklist) for the months of April, May, and June 2024 indicated, there was no documentation the emergency equipment for the month of May 2024, was checked by the opening RN. Further review of the facility documents titled, “Daily Zoll AED and Emergency Medication Lock Logs,” from April, May, June 2024 indicated the following: - For April 2024, there was no documentation the emergency equipments were checked on April 12, 20, 24, 25, and 27, 2024. - For May 2024, there was no documentation the emergency equipments were checked on May 25, 2024. The facility policy and procedure titled, “Emergency Equipment Checks,” dated April 2024, indicated: “ ...emergency equipment, including, but not limited to, oxygen, airways, suction, automated external defibrillator (AED), and artificial resuscitator (ambu bag), and emergency drugs will be on the premises at all times ...The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional ...weekly ...suction is operational ...in the event supplies are used from the emergency cart, replacement supplies will be obtained and placed on the cart ...the FA or designee will review the contents ...monthly.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36038 Based on observation, interview, and record review, the facility failed to ensure access sites (entry/exit site of a patient to filter their blood) for one of five sampled patients (Patients A) were consistently within view by staff at all times during hemodialysis (HD- process of removing waste from the blood with the use of a machine) treatment. This failure had the potential to cause accidental needle dislodgement or a line disconnection to go undetected by staff which could lead to excessive bleeding/hemorrhage in the patients. Findings: On June 4, 2024, at 9:20 a.m., during observation of Patient A at Station 1, the access site on the right chest central venous catheter (CVC) was completely covered with the patient’s shirt. Patient A’s access site remain uncovered for a total of 45 minutes (9:20- 10:05 a.m.). On June 4, 2024, at 10: 05 a.m., the PCT was interviewed. The PCT stated, Patient A’s t-shirt covered Patient A’s access site. The PCT further stated, if the access site is not visible to staff, there is a danger of not detecting bleeding if the connection between the dialysis machine and the patient becomes undone. During an interview on June 4, 2024, at 10: 20 a.m., with the Registered Nurse (RN), the RN stated the access was covered by Patient A’s t-shirt. The RN further stated , they need to always see the access site, to detect any bleeding immediately and address it right away. During a review of facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT,” dated, April 2024, indicated, “...Nursing Assessment ...the vascular access site, blood line connections...should be visible throughout the dialysis treatment...””