Davita Torrington Dialysis

“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: 47491 Based on observations, interview, and review of clinical records for two (2) of five (5) patients reviewed for hand hygiene, the facility failed to ensure a patient was offered hand hygiene prior to leaving the treatment floor. The findings included: 1. On 11/14/24 at 11:05 AM, Patient #9 was observed holding his/her hemodialysis access site with his/her gloved left hand, the patient removed the glove at 11:10 AM and did not perform hand hygiene, walked to the weigh station, pressed a button at the weight station with his/her left hand, informed the staff member of his/her weight, and then pressed the auto door opener with his/her left hand upon exiting the clinic without performing hand hygiene. 2. On 11/14/24 at 10:35 AM, Patient #10 was observed holding his/her hemodialysis access sites with his/her gloved right hand. At 10:45 AM, Staff Person #1 assisted the patient in removing his/her glove at 10:45 AM and did not offer him/her hand sanitizer. Patient #10 then walked to the weight station, pressed a button at the weigh station, then pressed the auto door opener, and exited the clinic without performing hand hygiene. Interview with the Facility Administrator on 11/14/24 at 11:33 AM identified patients who hold their site(s) following treatment should perform hand hygiene following glove removal with hand sanitizer prior to going to the scale to weigh. The Facility Administrator further identified staff should the disinfect surfaces the patient contacted if hand hygiene did not occur. Review of the Infection Control for Dialysis Facilities policy directed patients will be encouraged to perform hand hygiene after treatment, before leaving the treatment area.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47491 Based on observations, interview, and review of facility policy for one (1) of six (6) patients (Patient #11) observed after completeing hemodialysis treatment, the facility failed to ensure staff and patients wore proper protective equipment when disconnecting treatment lines from a patient’s Central Venous Catheter (CVC). The findings included: Patient #11 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and thirty (30) minutes utilizing a 1.0 potassium / 2.5 calcium bath, and a CVC. Observations conducted on 11/14/24 at 11:03 AM identified Staff Person #2 disconnecting Patient #11’s arterial blood line from his/her CVC at the end of treatment and attaching it to a line on the machine to initiate the blood return process while the patient was not wearing a mask. Interview with the Facility Administrator on 11/14/24 at 11:16 AM identified the patient should be wearing a mask throughout the CVC disconnection process. Review of the Central Venous Catheter with Clearguard Hemodialysis Antimicrobial End Caps Procedure directed the teammate and patient to wear masks covering the nose and mouth during the discontinuation of dialysis procedure.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 47491 Based on observation and review of facility policy, the facility failed to clean and disinfect the hemodialysis station after hemodialysis treatment in accordance with facility policy. The findings included: Observation conducted on 11/14/24 at 10:45 AM identified Staff Person #2, upon disinfecting Station #7 following a patient’s treatment, failed to clean the Hanson tubing on the right side of the dialysis machine, the tubing on the front of the dialysis machine and extending from the front of the dialysis machine to the wall box, and the left side of the dialysis machine that housed the blood pressure cuff container. Review of the infection control for dialysis facilities policy directed at the end of each treatment, the dialysis station will be cleaned and disinfected. It directed the wall box, drain and watery supply lines are considered part of the dialysis delivery system. It further directed to disinfect all surfaces in touch with the patient or their belongings and surfaces frequently contacted by healthcare personnel.”

“PE-LSC-SPRINKLERS CFR(s): 494.60(e)(2) (2) Notwithstanding paragraph (d)(1) of this section, dialysis facilities participating in Medicare as of October 14, 2008 that require sprinkler systems are those housed in multi-story buildings construction Types II(000), III(200), or V(000), as defined in the Life Safety Code, section 21.1.6.1, which were constructed after January 1, 2008, and those housed in high rise buildings over 75 feet in height, which were constructed after January 1, 2008. This Standard is not met as evidenced by: 32738 Based on observation during tour on 11/12/24 at 10:30 AM, while accompanied by the Bio Med Technician, the Regional Bio Med, and the facilities FA, the facility failed to maintain the automatic sprinkler as required. The findings include the following: On 11/12/24 at 10:30 AM the surveyor while accompanied by the Bio Med Technician, the Regional Bio Med, and the facilities FA, observed that sprinkler heads on the treatment floor (4) were missing the required escutcheon plate as required by NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems” i.e.: missing escutcheon plates prevent the sprinkler system to operate as designed.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of five (5) hemodialysis patients reviewed for hemodialysis prescription adherence (Patient #2), the facility failed to address an abnormal finding with the licensed nurse. The findings include the following: Patient #2 had diagnoses that included ESRD. Review of the physician’s order directed hemodialysis three times weekly for three hours and thirty minutes with a right upper Arteriovenous Fistula (AVF), 2K 2.5 Ca dialysate and an estimated dry weight (EDW) of 78.1 kg. Review of Patient #2’s annual stable care plan dated 3/19/24 identified Patient #2’s chronic bradycardia (low heart rate less than 60 beats per minute) was not addressed. Review of Patient #2’s hemodialysis treatment flowsheets identified the following: a. On 10/26/24 Patient #2’s pretreatment pulse was 47 Beats Per Minute (BPM) standing and 46 BPM sitting (normal pulse range is 60-100 BPM). Treatment was initiated by a PCT at 7:28 AM and Patient #2’s pulse was 45 BPM. The flowsheet failed to identify if the licensed nurse was notified of Patient #2’s abnormal pulse prior to treatment initiation. The nursing assessment was completed at 7:32 AM and although the nurse identified Patient #2’s heart was of regular rate and rhythm, Patient #2’s pulse was 47 BPM (abnormal rate). b. On 11/2/24 Patient #2’s pretreatment pulse was 48 beats per minute sitting and standing. Treatment was initiated by a PCT at 7:28 AM and Patient #2’s pulse was 36 BPM. The flowsheet failed to identify if the licensed nurse was notified of Patient #2’s abnormal pulse prior to treatment initiation. The nursing assessment was completed at 7:37 AM and although the nurse identified Patient #2’s heart was of regular rate and rhythm, Patient #2’s pulse was 48 BPM (abnormal rate). The post treatment nursing assessment was completed at 11:24 AM and although the nurse identified Patient #4’s heart was of regular rate and rhythm, Patient #2’s pulse was 53 BPM standing and 45 BPM sitting (abnormal rate). The nursing assessment failed to identify that Patient #2’s bradycardia was addressed prior to discharge home. c. On 11/5/24 Patient #2’s nursing assessment was completed at 7:18 AM and identified Patient #4’s pulse was 64 BPM (normal rate and rhythm). At 8:00 AM Patient #2’s pulse was 51 BPM and signed off by a PCT. The flowsheet failed to identify if the licensed nurse was notified of Patient #2’s change in pulse to an abnormal rate. The post treatment nursing assessment was completed at 11:12 AM and although the nurse identified Patient #2’s heart was of regular rate and rhythm, Patient #2’s pulse was 48 BPM sitting (abnormal rate). The nursing assessment failed to identify that Patient #2’s bradycardia was addressed prior to discharge home. Interview with the Clinical Coordinator on 11/13/24 at 2:00 PM identified Patient #2 had baseline bradycardia. She identified if a patient has an abnormal vital sign but is asymptomatic and that is the patients baseline, nursing has one hour to complete the pretreatment assessment. However, review of Patient #2’s orders and plan of care did not identify that Patient #2 had baseline bradycardia that was addressed by nephrologist. She further identified if a patient has an abnormal vital sign it needs to be reported to the nurse. Interview with the Clinical Services Director on 11/14/24 at 2:30 PM identified Patient #2 should have parameters in his/her orders to dialyze with a pulse less than 60 BPM. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “abnormal findings” section in this policy). The policy directed an abnormal heart or pulse rate pre/intra/post treatment would be less than 60 beats per minute.”

“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 one (1) of five (5) hemodialysis patients review for fluid balance, (Patient #4), the facility failed to address the patient not meeting the prescribed target weight in the medical record and for three (3) of five (5) hemodialysis patients reviewed for blood pressures (Patients #3, #5 and #6), 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. The findings include the following: 1. Patient #4 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three(3) times weekly for three (3) hours and thirty (30) minutes with a left upper arteriovenous fistula (AVF) and an Estimated Dry Weight (EDW) of 88.0 kilograms (kg). The annual stable care plan dated 7/16/24 identified Patient #4’s current fluid/blood pressure goal was to meet and maintain a post-weight in relation to the ordered target weight to avoid complications related to hyper or hypovolemic states. The interventions included to implement fluid management care activities as appropriate and provide ongoing fluid management coaching. Review of Patient #4’s hemodialysis treatment sheets identified the following: a. On 10/23/24 Patient #4’s prescribed target weight was 86.8 kg. Patient #4’s post weight was 90.1 kg (3.3 kg above prescribed EDW). Patient #4’s post treatment nursing assessment identified Patient #4 had generalized edema. Review of the flowsheet and nursing notes failed to identify Patient #4’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. b. On 10/23/24 Patient #4’s post weight was 89.9 kg (3.1 kg above prescribed EDW). Review of the flowsheet and nursing notes failed to identify Patient #4’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. c. On 10/29/24 Patient #4’s post weight was 89.8 kg (3.0 kg above prescribed EDW). Review of the flowsheet and nursing notes failed to identify Patient #4’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. d. On 11/7/24 Patient #4’s prescribed target weight was changed to 88 kg. Patient #4’s post weight was 91.6 kg (3.6 kg above prescribed EDW). Review of the flowsheet and nursing notes failed to identify Patient #4’s EDW not being achieved, interventions and education provided (if any), and if the physician was notified. Interview with the Clinical Coordinator on 11/13/24 at 2:30 PM identified she prints out a blood pressure and fluid report weekly for the physicians to review. She identified Patient #4 gets offered an ultrafiltration treatment (treatment to remove excess fluid) when he/she is over his/her target weight, however it was not documented in Patient #4’s medical record. 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. 2. a. Patient #3 had diagnoses that included end stage renal disease. Patient #3’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes, 1 K 2.5 Ca dialysate and an estimated dry weight (EDW) of 55.0 kg. Review of Patient #3’s hemodialysis flowsheets identified on 11/5/24, 11/7/24 and 11/9/24 Patient #3 ambulated independently and did not have a post treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. b. Patient #5 had diagnoses that included end stage renal disease. Patient #5’s physician orders included hemodialysis treatment three times a week for three hours, 2 K 2.5 Ca dialysate and EDW of 48.8 kg. Review of Patient #5’s hemodialysis flowsheets identified on 10/5/24, 10/15/24 and 11/11/24 Patient #5 ambulated independently and did not have a post treatment standing blood pressure and/or the reason why a standing blood pressure was not obtained documented. c. Patient #6 had diagnoses that included end stage renal disease, an order for hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes, at a blood flow rate (BFR) of 450 and dialysate flow rate (DFR) of 600 when using the arteriovenous graft in the upper left arm, and a BFR of 400 and DFR of 600 when using the central venous catheter (CVC). Review of Patient #6’s treatment flowsheets dated 10/1/24, 10/2/24, 10/7/24, and 11/8/24 identified Patient #6 was ambulatory, however failed to identify a post-treatment standing blood pressure was documented, and/or the reason the post treatment standing blood pressure was not obtained. Interview with the Clinical Coordinator on 11/14/24 at 2:16 PM identified staff was to obtain a post-treatment standing blood pressure for ambulatory patients. The Clinical Coordinator further identified if the patient refused, staff was to document the reason for refusal and update the physician regarding the refusal. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed to document the reason a post treatment blood pressure was not obtainable. 47491 Based on a review of clinical records, interview, and policy review for one (1) of two (2) hemodialysis patients (Patients #6) reviewed for blood pressures, the facility failed to ensure an ambulating patient had a post treatment standing blood pressure in accordance with facility policy. The findings included the following:”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of five (5) hemodialysis patients reviewed for anemia (Patient #4), the facility failed to address and document interventions for a decrease in hemoglobin. The findings include the following: 1. Patient #4 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a left arteriovenous fistula (AVF) and an estimated dry weight (EDW) of 88 kg. The stable care plan dated 7/16/24 identified Patient #4’s current anemia goal was to use the lowest dose of Epogen to reduce the risk of transfusions with the intervention to provide ongoing anemia coaching. A physician’s order dated 9/10/24 - 9/21/24 directed Epogen (increase red blood cell production) 5,000 units three (3) times a week. Review of Patient #4’s labs identified on 10/4/24 Patient #4’s hemoglobin was 10.1 (expected lab range 10-12). A physician’s order dated 10/7/24 - 10/24/24 directed Epogen 4,800 units three (3) times a week. Review of Patient #4’s labs identified on 10/16/24 (resulted on 10/19/24) Patient #4’s hemoglobin was 8.9 (expected lab range 10-12). Review of Patient #4’s labs identified on 10/23/24 (resulted on 10/24/24) Patient #4’s hemoglobin was 8.5. A physician’s order dated 10/24/24 - 11/8/24 directed Epogen 6,000 units three (3) times a week. Review of Patient #4’s stat labs identified on 10/30/24 Patient #4’s hemoglobin was 7.6. The anemia progress note dated 10/21/24 identified Patient 4’s hemoglobin decreased from 10.1 to 8.9 and the Epogen dose remains at 4,800 units three times a week. The note further identified she requested the clinic to assess for Patient #4’s drop in hemoglobin and to discuss with Patient #4’s provider. Review of the clinical record failed to identify the facility assessed for Patient #4’s drop in hemoglobin and if it was discussed with the provider for the Patient #4’s hemoglobin on 10/16/24 and 10/23/24. A Registered Nurse (RN) progress note dated 10/30/24 (eleven days after Patient #4’s initial decrease in hemoglobin below goal) identified Patient #4’s hemoglobin had trended down from 12 in September 2024 to 7.6 today. It further identified the physician wanted Patient #4 evaluated in the emergency department. The RN identified she called Patient #4 and Patient #4 identified they would go in the morning and the physician was aware. Interview with the Clinical Coordinator on 11/13/24 at 2:00 PM identified the facility has an off-site anemia manager who reviews the patient’s hemoglobin labs. However, she identified the anemia manager does not have access to secure messaging to directly communicate with the physicians. She identified she was not notified of Patient #4’s decrease in hemoglobin from the anemia manager on 10/21/24. She identified on 10/30/24 she communicated with the physician about Patient #4’s decrease in hemoglobin and the physician ordered Patient #4 to go to the emergency department. Interview with the FA on 11/14/24 at 2:30 PM identified the facility utilizes an off-site anemia manager to review patient anemia labs. She identified part of the anemia managers tasks is communicating with the physician in regard to abnormal labs.”

“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 one (1) patient of two (2) patients (Patient #8) reviewed for peritoneal dialysis, the facility failed to ensure dialysate concentrations were in correlation with the fluid balance charts provided to the patient. The findings included: Patient #8 had diagnoses including end stage renal disease, an order for daily peritoneal dialysis treatments, utilizing varied dialysate concentrations and an abdominal dialysis catheter. Review of Patient #8’s paper chart identified two (2) Fluid Balance Charts, one without a date and one dated 10/10/24, the patient was to use when selecting solutions for his/her dialysis treatment . The undated Fluid Balance Chart directed use of two (2) 1.5 % dialysate solutions, one (1) 7.5% extraneal solution while using the cycler and use of one (1) 2.5% dialysate solution when performing his/her day exchange when weight was between 295 and 299.2 pounds. This was the lowest weight guideline listed on The Fluid Balance Chart. Review of Patient #8’s electronic treatment records dated August 1, 2024 through October 3, 2024 identified weights ranging from 272.8 pounds to 286 pounds and use of two (2) 2.5% dialysate solutions, one (1) 7.5% extraneal solution (which under The Fluid Balance Chart was to be used for weights between 306 pounds and 314 pounds) while using the cycler and failed to identify the dialysate solution used for the patient’s day exchange. Review of Patient #8’s fluid guidelines dated 10/10/24 directed to use one (1) 4.25% dialysate solution, one (1) 2.5% dialysate solution, and one 7.25% extraneal solution while using the cycler and use of one (1) 2.5% dialysate solution when performing his/her day exchange when weight was between 288 pounds to 293 pounds. This was the highest weight guideline listed on The Fluid Balance Chart. Review of Patient #8’s electronic treatment records dated October 10, 2024 to October 31, 2024 identified weights ranging from 297 pounds to 299 pounds and use of two (2) 2.5% dialysate solutions, one (1) 7.5% extraneal solution (which under The Fluid Balance Chart was to be used for weights between 280 pounds and 287 pounds) while using the cycler and failed to identify the dialysate solution used for the patient’s day exchange. The clinical record failed to identify that there had been a discussion with the patient on the use of different solutions that did not correlate with the fluid balance charts. Interview with the Peritoneal Dialysis Nurse on 11/13/24 at 1:06 PM identified he/she should have been checking the dialysate solutions used with treatments with The Fluid Balance Chart parameters established by the physician when reviewing Patient #8’s treatments to ensure the patient was following his/her treatment guidelines. Review of the Home Training Agreement and Training Release dated 11/2/21 directed adherence to prescribed treatment is necessary to get the optimal effect of dialysis and the expectation to dialyze as prescribed by the physician.”

“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 a review of clinical records, interview, and policy review for one (1) of two (2) patients reviewed for hemodialysis prescriptions (Patient #6), the facility failed to ensure the patient’s hemodialysis treatment was completed in accordance with the physician orders. The findings included: Patient #6 was admitted to the facility with diagnoses that included end stage renal disease. Patient #6’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes, 2.0 K 2.5 Ca dialysate, an estimated dry weight (EDW) of 57.4 kg, and blood flow (BFR) of 450. Review of the treatment flowsheet dated 10/1/24 identified Patient #6 was cannulated successfully, however for ninety (90) minutes of treatment, Patient #6’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. Review of the treatment flowsheet dated 10/4/24 identified Patient #6 was cannulated successfully, however for thirty (30) minutes of treatment Patient #6’s BFR was 400 and then lowered again to 350 for fifteen (15) minutes with no rationale as to why the prescribed BFR of 450 was not met. Review of the treatment flowsheet dated 10/28/24 identified Patient #6 was cannulated successfully, however for the entirety of the treatment Patient #6’s BFR was 405 with no rationale as to why the prescribed BFR of 450 was not met. Interview with the Clinical Coordinator on 11/14/24 at 2:15 PM identified facility practice was to run a treatment at the prescribed BFR and if not attainable, to document the reason for the modification. 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.”