Davita Norwich Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observations, facility policy and interviews for infection control, the facility failed to ensure multiuse patient equipment was cleaned and disinfected after patient use. The findings include: Observations conducted on 10/22/24 at 11:03 identified a patient was transferred into the hemodialysis chair from his/her wheelchair with a hoyer lift (mechanical lift used to transfer patients). The staff member placed the hoyer lift back in its clean location at the front of the nursing station without the benefit of cleaning and disinfecting the device. Review of the infection control for dialysis facilities policy directed that non-disposable items are to be disinfected after each patient use, prior to removal from the treatment area.”

“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: 44675 Based on observations, facility documentation, facility policy and interviews, for Patient #19 reviewed for hand hygiene, the facility failed to ensure a patient removed gloves and was offered hand hygiene before touching a high contact area per facility policy. The findings include: Observations conducted 10/21/24 at 9:57 AM identified Patient #19 was observed with a glove on his/her left hand from holding his/her right hemodialysis access after hemodialysis treatment. The patient was observed walking throughout the treatment floor, touching the charge nurse station with his/her gloved hand. Patient #19 then proceeded to the patient scale, removed his/her glove but failed to perform hand hygiene prior to leaving the treatment floor. Review of the infection control for dialysis facilities policy directed patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area.”

“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: 47491 Based on review of clinical records, facility policy, and interview for one (1) of seven (7) patients (Patient #3) reviewed for vaccinations, the facility failed to ensure the Hepatitis B vaccination series (total of 4 doses) was administered to a susceptible patient in accordance with facility policy. The findings included: Patient #3 was admitted to the facility on 4/15/24, had diagnoses that included end stage renal disease, required hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes per treatment, using an arteriovenous fistula in the upper right arm. Review of a Hepatitis B antibody level on 4/24/24 identified that the level was 7 (anything below 10 indicates that the patient is susceptible to the Hepatitis B virus). Review of Patient #3’s Vaccination Surveillance Report identified Hepatitis Vaccination doses were administered on 6/14/24, 9/12/24, and 10/17/24 ( 2, 5 and 8 months after the antibodies were drawn). Interview with the Manager of Clinical Services on 10/23/24 at 12:46 PM identified the facility’s standard of practice was to follow the dosing recommendations of the Hepatitis B Quick Reference Guide. Review of the Hepatitis B Quick Reference Guide identified the initial full series (four (4) doses) of Hepatitis vaccinations were to be administered at 0, 1, 2, and 6 months (which would have been scheduled June 2024, July 2024, August 2024).”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, facility policy and interviews, for one (1) of two (2) patients (Patient #17), reviewed for central venous catheter care, the facility failed to ensure personal protective equipment (PPE) was donned properly during catheter care per facility policy. The findings include: 1. Patient #17 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly with a right central venous catheter (CVC), blood flow rate of 400, dialysate flow rate of 500 and 2 K 2.5 Ca dialysate. Observations conducted 10/21/24 at 10:07 AM identified Staff Person #1 was accessing Patient #17’s central venous catheter (CVC) post hemodialysis treatment. Staff Person #1 had a mask on her face, however, the mask was below her nose. Review of the central venous catheter procedure directed to put on PPE and provide a mask to the patient. The teammate and patient will wear masks covering the nose and mouth during the procedure. It identified those measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as MRSA.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of seven (7) hemodialysis patients reviewed for hemodialysis prescriptions (Patient #10), the facility failed to ensure the patient’s hemodialysis treatment was administered in accordance with the physician orders. The findings include the following: 1. Patient #10 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and fifteen (15) minutes with a right central venous catheter (CVC) and an estimated dry weight (EDW) of 79.5 kg. A review of Patient #10’s treatment flowsheets dated 6/3/24 identified Patient #10’s CVC was accessed with no concerns, however, the Blood Flow Rate (BFR) at treatment initiation at 11:59 AM was 200, at 12:21 PM was 350 and at 12:51 PM was 300 for the remainder of the treatment with no rationale as to why the prescribed BFR of 400 was not met. Review of Patient #10’s kt/v labs (adequacy of the dialysis treatment) identified on 6/3/24 Patient #10’s kt/v was 1.15 (goal indicative of adequate dialysis is 1.2). Review of the pre-intra-post treatment data collection and assessment policy directed, in part, to check that the prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow.”

“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: 44675 Based on a review of clinical records, interview, and policy review for four (4) of seven (7) hemodialysis patients reviewed for blood pressures (Patients #10, Patient #11, Patient #12 and Patient #14), the facility failed to ensure an ambulating patient had a standing blood pressure and pulse pre and post hemodialysis treatment per facility policy, and for one (1) of seven (7) hemodialysis patients reviewed for fluid balance (Patient #14), the facility failed to address the patient not meeting the prescribed target weight in the medical record. 1. a) Patient #10 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and fifteen (15) minutes with a right central venous catheter (CVC) and an estimated dry weight (EDW) of 79.5 kg. Review of Patient #10’s hemodialysis flowsheets identified on 10/2/24, 10/4/24, 10/9/24, 10/11/24, 10/14/24, 10/16/24 and 10/18/24 Patient #10 ambulated independently and did not have a pre and post treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. Review of Patient #10’s clinical record for October 2024 failed to identify why Patient #10 did not have a standing blood pressure measured pre and post treatment. b. Patient #11 was admitted to the facility with diagnoses that included end stage renal disease. Patient #11’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours with a left upper arteriovenous graft (AVG) and an estimated dry weight (EDW) of 72.5 kg. Review of Patient #11’s hemodialysis flowsheets identified on 10/2/24, 10/4/24, 10/7/24, 10/9/24, 10/11/24, 10/14/24, 10/16/24 and 10/18/24 Patient #11 ambulated independently and did not have a pre-treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. Review of Patient #11’s clinical record for October 2024 failed to identify why Patient #10 did not have a standing blood pressure measured post treatment. c. Patient #12 was admitted to the facility with diagnoses that included end stage renal disease. Patient #12’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and fifteen (15) minutes with a left upper arteriovenous fistula (AVF) and EDW of 118 kg. Review of Patient #12’s hemodialysis flowsheets identified on 10/2/24, 10/3/24, 10/7/24, 10/9/24, 10/11/24, 10/14/24, 10/16/24 and 10/18/24 Patient #12 ambulated independently and did not have a pre and post treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. Review of Patient #12’s clinical record for October 2024 failed to identify why Patient #10 did not have a standing blood pressure measured pre and post treatment. d. Patient #14 was admitted to the facility with diagnoses that included end stage renal disease. Patient #14’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and forty-five (45) minutes with a right CVC and EDW of 129.5 kg. Review of Patient #14’s hemodialysis flowsheets identified on 10/3/24, 10/5/24, 10/12/24, 10/15/24 and 10/19/24 Patient #14 ambulated independently and did not have a pre-treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. Review of Patient #14’s clinical record for October 2024 failed to identify why Patient #10 did not have a standing blood pressure measured pretreatment. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that for blood pressures post treatment, if the patient is not able to stand, to document the reason. 2. Patient #14 was admitted to the facility with diagnoses that included end stage renal disease. Patient #14’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and forty-five (45)minutes, 3 K 2.5 Ca dialysate and EDW of 129.5 kg. Review of the annual care dated 8/15/24 identified Patient #14’s current goal was to obtain a post weight in relation to ordered target weight to avoid complications related to hyper or hypo-volemic states with interventions that included to provide ongoing fluid management coaching. Review of Patient #14’s hemodialysis treatment flowsheets identified the following: a. On 10/12/24 Patient #14’s post weight was 132.5 kg (3 kg above prescribed EDW). Patient #14’s post treatment assessment identified generalized edema. Review of the nursing notes failed to identify Patient #14’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. b. On 10/15/24 Patient #14’s post weight was 133.2 kg (3.7 kg above prescribed EDW). Review of the nursing notes failed to identify Patient #14’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. c. 10/19/24 Patient #14’s post weight was 133.2 kg (3.7 kg above prescribed EDW). Review of the nursing notes failed to identify Patient #14’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed if an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician is necessary. Abnormal findings for fluid status post treatment is if a patient is above 1 kg from the target weight. .”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 47491 Based on clinical record review, facility documentation, and interview for three (3) of three (3) patients reviewed for peritoneal dialysis, (Patient #4. #5 and #6), the facility failed to ensure patients used the appropriate dialysate concentrations with each treatment. The findings included: 1. Patient #4 had diagnoses including end stage renal disease, required peritoneal dialysis treatments five times weekly for 9 hours each treatment, utilizing varied dialysate concentrations and an abdominal dialysis catheter. Review of Patient #4’s electronic treatment records dated July 1, 2024, through October 22, 2024 failed to indicate the dialysate solution concentrations used with each treatment. Review of Patient #4’s manual treatment records dated June 1, 2024 through June 19, 2024, August 17, 2024 through August 30, 2024, September 1, 2024 through September 30, 2024, and October 1, 2024 through October 14, 2024 identified the dialysate solution concentrations used with each treatment, however had several missing treatment entries when compared to the electronic treatment records and therefore could only be used to verify the solution concentrations used with those documented treatments. 2. Patient #5 had diagnoses including end stage renal disease, required daily peritoneal dialysis for 9 hours each treatment, utilizing varied dialysate concentrations and an abdominal dialysis catheter. Review of Patient #5’s electronic treatment records dated July 1, 2024, through October 22, 2024, failed to indicate the dialysate solution concentrations used with each treatment. Review of Patient #5’s manual treatment records dated June 26, 2024 through July 9, 2024, August 16, 2024 through August 31, 2024, and September 1, 2024 through September 10, 2024 identified the dialysate solution concentrations used with each treatment, however had several missing treatment entries when compared to the electronic treatment records and therefore could only be used to verify the solution concentrations used with those documented treatments. Furthermore, Patient #5 was not compliant in following the fluid use guidelines provided with treatments dated June 26, 2024 through September 10,2024 as the guidelines used were based on weights of 175.2 pounds to 210.6 pounds and the patient’s actual weight was between 164.4 pounds and 166.0 lbs. Patient #5’s fluid guidelines were updated 9/11/24 to reflect a target weight of 166.0 pounds. 3. Patient #6 had diagnoses including end stage renal disease, required peritoneal dialysis treatments four times weekly for 9 hours each treatment, utilizing varied dialysate concentrations and an abdominal dialysis catheter. Review of Patient #6’s electronic treatment records dated July 1, 2024, through October 22, 2024 failed to indicate the dialysate solution concentrations used with each treatment. Review of Patient #6’s manual treatment records dated June 1, 2024 through June 26, 2024, July 1, 2024 through July 15, 2024, August 2, 2024 through August 30, 2024, September 1, 2024 through September 18, 2024, identified the dialysate solution concentrations used with each treatment, however several entries identified solution used was not in accordance with the fluid use guidelines provided by the facility (which identified the dialysate concentration to use according to weight and/or blood pressure). Furthermore, the manual treatment records had several missing treatment entries when compared to the electronic treatment records and therefore could only be used to verify the solution concentrations used with those documented treatments. Interview with Staff Person #2 on 10/23/24 at 11:07 AM identified he/she started overseeing the peritoneal dialysis unit in July 2024 and has trained new patients to enter the dialysate concentrations used with treatments into the dialysis machine, creating an electronic treatment record, however he/she has not yet had the opportunity to reprogram all patient’s dialysis machines to require entry of the dialysate concentration(s) used with each treatment. Staff Person #2 further identified he/she has not been able to verify patients are following their treatment prescriptions related to dialysate use as patient’s that use the manual treatment log sheets (and do not enter dialysate concentration use into their dialysis machine) have not been documenting each treatment as they should be and that some patients have been non-compliant in following their prescription guidelines. Review of the Peritoneal Dialysis Home Training Agreement and Training Release directs adherence to prescribed treatments, the expectation to dialyze as prescribed by the physician, and to document all treatments accurately and completely.”

“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: 47491 Based on review of clinical records, interviews and review of facility documents for two (2) of seven (7) patients (Patient #8 and #10) reviewed for treatments, the facility failed to administer a patient’s treatment at the prescribed blood flow rate. The findings included: 1) Patient #8 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for three (3) hours and fifteen (15) minutes, at a blood flow rate (BFR) of 400, using a central venous catheter. Review of Patient #8’s treatment records identified the following: a. On 8/14/24, Patient #8’s treatment was administered at a BFR of 350 instead of the prescribed BFR of 400 for two (2) hours and thirty (30) minutes of treatment without notation of the reason for the change/adjustment. b. On 8/23/24, Patient #8’s treatment was administered at a BFR of 390 instead of the prescribed BFR of 400 for one (1) hour and thirty (30) minutes and then at a BFR of 300 for forty-nine (49) minutes of treatment without notation of the reason for the change/adjustment. c. On 10/2/24, Patient #8’s treatment was administered at a BFR of 350 instead of the prescribed BFR of 400 for two (2) hours of treatment without notation of the reason for the change/adjustment. d. On 10/7/24, Patient #8’s treatment was administered at a BFR of 350 instead of the prescribed BFR of 400 for one (1) hour and thirty (30) minutes and then at a BFR of 300 for one (1) hour of treatment without notation of the reason for the change/adjustment. e. On 10/14/24, Patient #8’s treatment was administered at a BFR of 390 instead of the prescribed BFR of 400 for the entire treatment without notation of the reason for the change/adjustment. 2. Patient #10 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and fifteen (15) minutes with a right central venous catheter (CVC) and an estimated dry weight (EDW) of 79.5 kg. A review of Patient #10’s treatment flowsheets dated 6/3/24 identified Patient #10’s CVC was accessed with no concerns, however, the Blood Flow Rate (BFR) at treatment initiation at 11:59 AM was 200, at 12:21 PM was 350 and at 12:51 PM was 300 for the remainder of the treatment with no rationale as to why the prescribed BFR of 400 was not met. Review of Patient #10’s kt/v labs (adequacy of the dialysis treatment) identified on 6/3/24 Patient #10’s kt/v was 1.15 (goal indicative of adequate dialysis is 1.2). Interview with the Clinical Coordinator on 10/22/24 at 2:03 PM identified facility practice was to document the reason for any change in the prescribed blood flow rate (BFR) in the vitals line of the electronic medical record during the patient’s treatment. Review of the Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment policy directed if the dialysis prescription was not being met (including the dialysis flow rate or change to/inability to obtain the prescribed blood flow rate) the reason would be documented.”