Davita Valencia Dialysis

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure for one of four sampled employees (Registered Nurse 1 [RN 1]), RN 1 had documentation of Hepatitis B (a serious liver infection caused by the hepatitis B virus) vaccination (administration of a vaccine [contain a microorganism or virus in a weakened, live, or killed state] to help the immune system develop immunity from a disease) and/or documentation of Hepatitis B virus (HBV) titer test (measures the level of antibodies in your blood to determine if you have immunity to the HBV) upon hire on 12/7/2015. This deficient practice had the potential for RN 1 being exposed to HBV, acquiring the infection and spreading the virus to vulnerable ESRD (End Stage Renal Disease) patients. Findings: During a concurrent interview and record review on 12/5/2024 at 9:46 a.m., with Facility Administrator (FA), RN 1’s personnel files, was reviewed. The FA verified RN 1 was hired on 12/7/2015. The FA stated RN 1’s personnel file did not have documentation of RN 1’s proof of vaccination series for HBV and/or RN 1’s titers for HBV immunity. In the same interview on 12/5/2024 at 9:46 a.m., the FA stated RN 1 should have documentation of HBV screening upon hire. During a review of the facility’s policy and procedure (P&P) titled, “Infection Control for Dialysis,” dated 4/2023, the P&P indicated the facility followed the Centers for Disease Control and Prevention’s (CDC - the nation’s leading science-based, data-driven, service organization that protects the public’s health) recommendations for preventing transmission of infections among chronic hemodialysis (a treatment that filters waste, salts, and fluid from the blood when the kidneys are no longer able to do so) patients. During a review of the facility’s policy and procedure (P&P) titled, “Teammate Health Monitoring Program,” dated 4/2019, the P&P indicated the following: 1. Facility will regularly monitor staff for Hepatitis B (HBV), Hepatitis C, and tuberculosis, as indicated, based on immunity status, as required by state/local health departments. 2. New hires will be screened for HBV, Hepatitis C, and tuberculosis. 3. New hires will be offered the HBV vaccination series. During a review of a document titled, “CDC’s (Centers for Disease Control and Prevention, a service organization that protects the public’s health) Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” dated 4/2001, the CDC document indicated the following: 1. Vaccinate against HBV to prevent transmission and revaccinate when serum anti-HBs titer falls below 10 milli-International Units per milliliters (mIU/ml, units of measurement). 2. The presence of anti-HBs typically indicates immunity against HBV infections. 3. The 3-dose Hep B vaccine series produces a protective antibody response (anti-HBs greater than 10 mIU/ml) in over 90% of adults. 4. HBV is recommended for both hemodialysis patients and staff members since the vaccine became available in 1982.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure the medical records for one of five sampled patients (Patient 1), was accurate and complete. This deficient practice resulted in no documentation of Patient 1’s unwitnessed fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in the lobby, on 11/1/2024, in which Patient 1 sustained injuries, which required hospitalization. Findings: During a review of Patient 1’s history and physical (H&P - a comprehensive assessment of a patient’s health that includes a medical history, physical exam, and documentation of findings), dated 11/1/2023, the H&P indicated Patient 1 had history of end-stage-renal-disease (ESRD - the final stage of chronic kidney disease, where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood and requires ongoing treatments, including dialysis or kidney transplantation, to maintain life), on hemodialysis (a medical treatment that removes waste products and excess fluids from the person’s blood, when the kidneys are unable to do so), with previous history of a stroke (occurs when blood flow to the brain is interrupted, causing brain cells to die) and high blood pressure. During a concurrent interview and record review on 12/5/2024 at 12:40 p.m. with Registered Nurse (RN) 1, Patient 1’s Treatment Report, dated 11/1/2023, was reviewed. RN 1 stated the Treatment orders indicated the following: 1. weight 65 kilograms, 2. dialyzer (a medical device that removes waste and excess fluid from the blood when a patient’s kidneys are unable to do so) F-180, 3. dialysate (a solution that is used in dialysis to filter waste products from the blood) 2 K (potassium, a mineral for nerves to function), CA (calcium, mineral for strong bones and teeth) 2.5, Bicarb (neutralizes acids) 35, blood flow rate 300 milliliters (ml), 4. dialysate flow rate 500 ml, 5. treatment duration 3 hours. Concurrently, RN 1 stated, after reviewing the video of the lobby during the time of Patient 1’s fall on 11/1/2023, Patient 1 was taken to the lobby, via wheelchair, by Patient Care Technician (PCT) 3, who handed patient (Patient 1) over to the transport staff, and returned to the treatment area. The transport staff was waiting for Patient 1, in the lobby, to transport the patient (Patient 1) back to the skilled nursing facility (SNF - convalescent hospitals, nursing home). Afterwards, the transport staff left Patient 1, alone in the lobby without notifying the facility staff, and went to get the vehicle. When the transport staff returned to the lobby, Patient 1 was found on the floor. Concurrently, RN 1 stated she (RN 1) was the nurse on duty on 11/1/2023, for Patient 1, and did not document in Patient 1’s medical record that Patient 1 fell, in the lobby, unwitnessed and unattended. During a concurrent interview and record review on 12/5/2024 at 3:32 p.m. with the Director of Clinical Services (DCS), Patient 1’s Treatment Report, dated 11/1/2023, was reviewed. DCS stated RN 1 should have documented Patient 1’s fall on 11/1/2023, because 9-1-1 was called and Patient 1 was hospitalized with injuries. DCS also said that Patient 1 already had history of falls at home and thus admitted to a Skilled Nursing Facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services to patients). During a review of the facility’s dialysis schedule, dated 11/1/2023, the dialysis schedule indicated the following: 1. Patient 1 was scheduled for third shift, start time of 12:00 p.m., end time for 3 p.m., and for three hours of dialysis. 2. RN 1 was the in-center hemodialysis nurse. 3. Patient Care Technician (PCT) 1 and 3 were on duty Concurrently, during review of Patient 1’s initial fall risk assessment, dated 4/26/2023, DCS stated patient’s total score was 9 (critical - high risk for falls). After patient fell at home, Patient 1’s fall risk assessment, dated 9/18/2023, was higher than initial score - 16. DCS stated after Patient 1 fell at home, Patient 1 was moved to a skilled nursing facility (nursing home). During further review of Patient 1’s History and Physical (H&P), dated 11/1/2023, documented by staff from the hospital where Patient 1 was admitted after the fall on 11/1/2023, the H&P indicated the following: 1. Patient 1 was brought into the hospital by ambulance, after having an episode of falling after completion of dialysis treatment. 2. Patient 1 had a large laceration and bruise on the right eyebrow, with bleeding in the brain - right subdural hematoma (a collection of blood that forms between the brain and the dura mater [the tough outer layer of the brain]) and right subarachnoid frontal lobe hemorrhage (a type of stroke that occurs when a blood vessel in the space between the brain and its protective membranes [subarachnoid space] ruptures). 3. Patient 1 was admitted to the intensive care unit with neurosurgery consulted. 4. Medical history included blunt head trauma (serious injury that occurs when the skull is struck by an external force that doesn’t break it but still moves the brain around), inability to walk, history of falls. During a review of the facility’s policy and procedure (P&P) regarding Medical Records, dated 10/2019, the P&P indicated the following: 1. The nurse is responsible for clinical care and is responsible for the supervision and authenticity of medical records services, in consultation with facility’s health information management department. 2. The custodian of medical records verifies that the medical records are complete, documented accurately, and maintained, in accordance with accepted professional standards and practices. 3. The custodian of medical records verifies that medical records contain pertinent medical information and verifies compliance with state specific regulations regarding medical records. During a review of the facility’s Progress Note policy, dated 10/2024, the policy indicated the following: 1. Notes are documented by the physician, nurse, dietician, and social worker. 2. Documentation needs to include treatment given or planned, patient encounters and the condition of the patient. 3. Notes are used to communicate information or to expand upon information or problems noted in other parts of the medical records or obtained from other sources, including consults, treatment records, etc. 4. Notes should include complete and pertinent information about the condition of the patient and should clearly portray the patient, the care and outcomes of that care. During a review of the facility’s Risk Event Management Reporting policy, dated 10/2024, the policy indicated the following: 1. Risk event is any unexpected event that is inconsistent with the routine operation of the facility, routine provision of acute dialysis treatment or ancillary renal related services that may be a risk event. 2. If a risk event involves a patient, completion of a risk event management report, does not eliminate the duty of recording appropriate entries in the patient’s medical record. 3. Only objective information directly relevant to the care and treatment of the patient is to be included in the medical record.”

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure for four of four sampled employees (Registered Nurse [RN] 1, RN 2, Patient Care Technician [PCT] 1, and the Registered Dietician [RD]) had documentation of the facility orientation for their work responsibilities. This deficient practice had the potential for hired employees (RN 1, RN 2, PCT 1 and the RD) to not be trained in performing their work responsibilities that could affect providing safe and quality care to the patients. Findings: During a concurrent interview and record review on 12/5/2024 at 9:46 a.m. with the facility administrator (FA), four personnel files for RN 1, RN 2, PCT 1, and the RD were reviewed. The FA verified there was no documentation regarding the four identified staff’s orientation to the facility. The FA stated the following: 1. RN 1’s date of hire was 12/7/2015. There was no documentation of orientation to In-Center Hemodialysis Nurse. 2. RN 2’s date of hire was 10/31/2022. There was no documentation for orientation to Peritoneal Dialysis Nurse. 3. PCT 1’s date of hire was 6/1/2016. There was no documentation for orientation to Patient Care Technician. 4. The RD’s date of hire was 4/18/2017. There was no documentation for orientation to Registered Dietician. During an interview on 12/6/2024 at 3:00 p.m. with the Director of Clinical Services (DCS), the DCS stated the facility was unable to provide proof of facility orientation for work responsibilities or the above-mentioned personnel. The DCS stated the facility should have documentation for the four above-mentioned personnel’s orientation to ensure patients receive safe, efficient, high-quality care. In the same interview on 12/6/2024 at 3:00 p.m., the DCS stated the facility was not able to provide a policy regarding orientation and training of new employees.”