Davita Bristol Dialysis

“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: 36704 Based on interview and record review, the facility failed to ensure an initial comprehensive assessment was completed within 30 calendar days beginning the first dialysis treatment for one of five sampled patients (Patient 1), creating the increased risk of inappropriate care provided to the patient. Findings: Review of the facility’s P&P titled Interdisciplinary Teams (IDT) Patient Assessment and Plan of Care dated July 2023 showed the facility’s IDT consists of, at a minimum, the patient or the patient’s personal representative, a RN, a physician or allied health professional treating for ESRD, a social worker, and a dietitian. The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient hemodialysis sessions) beginning with the first outpatient dialysis treatment. Review of Patient 1’s medical record was initiated on 8/7/24. Patient 1’s medical record showed the patient was admitted to the facility on 6/28/24. Review of Patient 1’s treatment logs for the months of July and August 2024 showed Patient 1 had received hemodialysis treatments two times per week since 6/28/24. Review of the Assessment and Plan of Care History showed the staff documented Patient 1’s initial assessment was overdue due on 7/28/24. However, Patient 1’s medical record review showed the patient’s initial comprehensive assessment was in progress mode on 8/7/24. During an interview and concurrent medical record review of Patient 1 with RN 2 on 8/7/24 at 1558 hours, RN 2 confirmed the findings. An interview conducted with the Facility Administrator on 8/7/24 at 1630 hours. The Facility Administrator was informed and verified Patient 1’s plan of care should have been completed on 7/28/24.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the Medical Director failed to ensure the staff adhered to the facility’s P&Ps for two of five sampled patients (Patients 1 and 2) in order to provide safe and effective patient care as evidenced by: 1. For Patient 2, the RN failed to ensure during the initiation of dialysis with CVC, the mask was completely covered the patient’s nose. In addition, the RN failed to change the dirty gloves and do hand hygiene during Patient 2’s CVC dressing change. 2. For Patient 1, the RN failed to notify the physician and documented on the patient’s medical record the sign/symptom of potential vascular access site infection. These failures created the risk of substandard health outcomes for the patients. Findings: 1. Review of facility’s P&P titled Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure dated October 2023 showed to place the patient in comfortable supine position, as tolerated; verify patient’s clothing is secured away from the exit site or work area; place the second moisture proof barrier under catheter limbs; instruct patient to turn head to opposite side of the CVC exit site; remove old dressing and discard; observe for signs and symptoms of infection such as redness, drainage, swelling or tenderness, if present report to physician or RN; observe the CVC site at exit site for evidence of cuff migration, cracks, leaks in the catheter limbs; verify that both arterial and venous catheter limbs are clamped; remove gloves and discard; perform hand hygiene per procedure and re-glove; holding catheter with non-dominant hand and using antiseptic technique, clean exit site with 2% chlohexidine gluconate (antiseptic) or 70% isopropyl alcohol swab for minimum of 30 seconds, apply to the CVC exit site in a back and forth pattern, using gentle friction progressing from insertion site to the periphery using both sides of the swab; clean each CVC limb or cap with a new large alcohol prep pad, starting close to the exit site and finishing with the cap; remove gloves and discard, perform hand hygiene per procedure and re-glove; and place sterile two cm by two cm gauze over the catheter exit site leaving connections accessible. On 8/7/24 at 0944 hours, an observation and concurrent interview was conducted with RN 1 for Patient 2 CVC site care and dressing change prior the initiation of the dialysis treatment. The following was identified: - RN 1 was noted to be working with Patient 2 on chair number 20 on the second shift. Patient 2 was wearing a cloth mask. The cloth mask was noted to be covering the patient’s mouth; however, the face mask was not covering the patient’s nose. Patient 2 and RN 1 were seen having conversation. RN 1 removed the gauze covering of the dialysis catheter limbs and placed a clean chuck pad and gauze underneath the dialysis catheter limbs. RN 1 removed the catheter tip cap cover one at a time and wiped both limbs in a circular motion for approximately 10 seconds, then checked each port for blood return by connecting to a 10 ml syringe. - RN 1 had removed the CVC gauze/dressing over the insertion site, used one antiseptic stick to clean around the insertion site in one quick circular motion and applied a clean 2 x 2 gauze dressing to cover the CVC insertion site. The contact swabbing time of 30 seconds and 60 seconds dry time was not noted to had been performed by RN 1. RN 1 also did not change his gloves and did not perform hand hygiene after the old dressing was removed and new pair of gloves were donned during the CVC site care. - During the process of RN 1 performing the CVC site care, Patient 2 and RN 1 were having conversation and the face mask did not cover Patient 2’s nose. When RN 1 was asked about the face mask not covering the nose and patient’s head not turned away from the site of CVC while the CVC site care was being performed, RN 1 stated the patient was wearing a nasal cannula for her oxygen use. RN 1 instructed Patient 2 to cover her nose with the facemask. The observation was verified with RN 1. RN 1 stated he did not perform hand hygiene and changed his gloves when the CVC catheter care was done. 2. Review of the facility’s P&P titled Per-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment dated April 2024 showed the following: * The nursing assessment will be performed and documented by a licensed nurse. * The Pre-Treatment Data Collection Assessment section showed any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and reported to the licensed nurse. The licensed nurse will assess the patient prior to initiation of dialysis. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. The licensed nurse will use her/his clinical judgment based on individual patient need to determine if any clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis. * The Abnormal Findings section showed a vascular access abnormal findings include swelling, pain, redness, warm to touch. Review of facility’s P&P titled Infected Permanent Vascular Access Care Policy dated October 2023 showed this is to provide guidance for the inspection, assessment, and intervention of suspected vascular access infection. Signs and symptoms of an infected vascular access may include redness/increased warmth of vascular access. When signs and symptoms of an infected vascular access are identified, notify the physician prior to use. Interventions may include blood cultures and administration of medications. The finding and interventions are documented in the patient’s electronic health record. On 8/7/24 at 1012 hours, review of Patient 1’s Treatment Details Reports was initiated. The following was identified: - The Treatment Details Report dated 7/5/24 at 0538 - 0912 hours, showed for the pre-treatment access evaluation, RN 2 documented the exit site had redness; dressing was not in place; applied triple antibiotic cream and new dressing; and would monitor. - The Treatment Details Report dated 7/8/24 at 0543 - 0857 hours, showed for the pre-treatment access evaluation, RN 2 documented the RN noted some redness around CVC site but improving; applied triple antibiotic cream; changed the CVC dressing; and would continue to monitor. On 8/7/24 at 1558 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 2. RN 2 was asked what had been done when the RN noted the redness on Patient 1’s CVC exit site. The Treatment Details Report dated 7/5 and 7/8/24, showed RN 2 documented on the nurse assessment for access CVC “Noted redness around CVC exit site, no drainage or pain noted. Applied triple ATB cream, new dressing, will monitor.” In addition, on 7/8/24, RN 2 documented “ the patient came in with restraint gloves due to pulling on CVC and CVC lines.” RN 2 stated she assessed the site, cleaned, and put triple antibiotics for the redness; no order was needed; and she put on new dressing. When asked if the physician was informed of the redness and the patient was trying to pull on the CVC and the lines. RN 2 stated no and she did not document anywhere else about the findings but the treatment sheet. RN 2 stated Patient 1 came in with a binder from the nursing home. RN 2 had written her notes on the binder for the facility to keep the dressing on and to communicate with the nursing home staff. Again, when documentation was requested, RN 2 could not provide any. RN 2 verified she should had documented on Patient 1 medical record the abnormal findings on the CVC and notified the physician. On 8/7/24 at 1630 hours, an interview was conducted with the Facility Administrator. The Facility Administrator was informed of the abnormal findings on Patient 1’s CVC exit site not being document on the patient electronic health record and the physician was not notified as per the facility’s P&P. The Facility Administrator acknowledged it should had been documented and verified the findings.”