Davita Housatonic Dialysis

“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: 47491 Based on observations, interview and review of facility policy for one (1) of three (3) patients (Patient #9 ) reviewed for catheter care, the facility failed to ensure a patient and staff donned personal protective equipment appropriately per facility policy. The findings included: 1. Patient #9 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours utilizing a central venous catheter (CVC). Observations conducted on 1/7/25 at 1:18 PM identified Staff #1 discontinuing Patient #9’s dialysis treatment. During the disconnection process, Patient #9’s face mask was inappropriately applied, falling just below the tip of his/her nose, exposing the upper portion of the nares, and remained there during disconnection of both the arterial and venous blood lines from Patient #9’s CVC. . Interview with the Clinical Coordinator on 1/9/25 at 3:00 PM identified facility practice was for staff and patients to cover both their mouths and noses during the initiation and discontinuation processes/procedures of treatment and that the mask should cover up to the bridge of the 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 sit to nasal droplets and infectious bacteria such as MRSA.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 41746 On 01/07/25 at approx. 9:50 and during document review, the facility failed to ensure that the water purification system was being maintained as required by their policies. The finding includes: The brine solution tank was not filled to the proper level, the level was approx. 1/3 full, negating its ability to function properly.”

“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: 47491 Based on a review of clinical records, interview, and policy review for two (1) of four (4) hemodialysis patients reviewed for prescription adherence (Patient #2), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with physician orders. The findings include the following: 1. Patient #2 had diagnoses which included end stage renal disease, a physician’s order for hemodialysis treatment three (3) times weekly utilizing a central venous catheter in the right chest for three (3) hours and thirty (30) minutes, a 3.0 potassium/2.5 calcium dialysate bath, blood flow rate (BFR) of 400, and dialysate flow rate (DFR) of 800. A review of Patient #2’s treatment flowsheets identified the following: a. On 12/22/24, treatment was initiated and maintained at a blood flow rate (BFR) of 350 throughout the treatment and failed to indicate the reason for the reduced BFR. b. On 12/24/24, treatment was initiated and maintained at a blood flow rate (BFR) of 350 for thirty (30) minutes, and then increased to 370 for forty (40) minutes before being increased to the prescribed BFR of 400 for the remainder of the treatment, but without indicating the reason for the reduced BFR. c. On 12/29/24, treatment was initiated and maintained at a blood flow rate (BFR) of 350 throughout the treatment and failed to indicate the reason for the reduced BFR. Interview with the Clinical Coordinator on 12/9/25 at 2:55 PM identified changes to the blood flow rate (BFR) must be documented in the electronic medical record and if it persistently occurs, must be reported to the Medical Director for possible referral to the vascular center. Review of the Pre-Intra-Post Treatment Data Collection and Monitoring and Nursing Assessment policy directed the physicians components are confirmed by a licensed nurse within one hour of treatment initiation and include the blood flow rate. It further identified if the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.”

“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 clinical records, facility policy and interviews for one (1) of three (3) patients (Patient #3), reviewed for assessments, the facility failed to ensure an abnormal vital sign was addressed post treatment per facility policy. Patient #3 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 AVF with a 1K 2.5 CA dialysate. Review of Patient #3’s hemodialysis flowsheet dated 12/9/24 identified Patient #3’s post treatment heart rate sitting was 107 beats per minute (range 60-100 BPM) and standing was 114 BPM. The post treatment nursing assessment and nursing notes failed to identify if Patient #3’s abnormal heart rate was addressed prior to being discharged from the clinic. Interview with the Clinical Coordinator on 1/9/25 at 2:00 PM identified if a patient has an abnormal vital sign, it should be rechecked. If it remains abnormal the charge nurse is to inform the physician. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed any abnormal findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to the abnormal findings). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The abnormal findings section of the policy identified an abnormal heart rate was defined as less than 60 beats per minute or greater than 100 beats per minute.”

“PA-ASSESS LAB PROFILE CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: (3) Laboratory profile, This Standard is not met as evidenced by: 44675 Based on facility documentation, facility policy and interviews for one (1) of three (3) patients (Patient #1), reviewed for hyperkalemia, the facility failed to ensure potassium levels were drawn weekly in accordance with physician orders. The findings include: Patient #1 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 thirty (30) minutes with a right forearm arteriovenous fistula (AVF) with a 1 K (potassium) 2.5 Ca (calcium) dialysate. Patient #1’s potassium lab on 11/21/24 was 5.9 (range 3.5 - 5.5). The RN progress note dated 11/23/24 identified Patient #1’s potassium was 5.9 and the physician ordered to change the hemodialysis dialysate to 1K. The physician’s hemodialysis order dated 11/23/24 directed 1 K dialysate. The physician’s potassium lab order dated 11/23/24 directed weekly potassium labs. Patient #1’s potassium lab on 11/27/24 identified it did not result due to an outdated specimen. On 12/15/24 the potassium lab identified to redraw the lab due to it being clotted. On 12/12/24 the potassium lab was 4.9. Review of Patient #1’s hemodialysis treatment calendar identified Patient #1 had hemodialysis treatments on 11/30/24, 12/3/24, 12/5/24, 12/7/24 and 12/10/24. Interview with the Clinical Specialist on 1/9/25 at 2:00 PM identified patients who are on a 1K dialysate require weekly potassium labs. Review of the use of low potassium dialysate policy identified that patients with less than a 2 K bath will have potassium levels weekly.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47491 Based on clinical record review, interviews, and review of facility documentation for one (1) of four (4) patients (Patient #5), reviewed for vaccinations, the facility failed to properly assess a patient for tuberculosis in accordance with facility policy. The findings included: Patient #5 was admitted to the facility on 11/15/23, had diagnoses which included end stage renal disease, a physician’s order for hemodialysis treatments three (3) times weekly for three (3) hours using a central venous catheter (CVC) in the right chest. Review of Patient #5’s Vaccination and Surveillance Report identified a TB RAQ (Tuberculosis Risk Assessment) was completed on 11/15/23, an initial TST (Tuberculosis Skin Test) with administration dated of 11/15/23, however the second TST was not administered until 1/12/24 (58 days following the initial TST). Review of Patient #5’s treatment history identified he/she received dialysis treatments on 11/24/23, 11/28/23, 11/29/23, 12/1/23, 12/4/23, 12/6/23, 12/8/23, 12/11/23, 12/13/23, 12/15/23, 12/22/23, 12/24/23, 12/27/23, 1/3/24, 1/5/24, 1/8/24, and 1/10/24 Interview with the Clinical Coordinator on 1/9/25 at 2:48 PM identified two (2) Tuberculosis Skin Tests (TST) should be administered within one month of admission. Review of the facility’s Tuberculosis Infection Control Policy directed to administer the initial TST following admission and a second TST one to three weeks following admission or draw a QuantiFERON (a blood test used to identify if a person has been exposed to tuberculosis).”

“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: 44675 Based on facility documentation, facility policy and interviews for one (1) of three (3) patients (Patient #3), reviewed for treatment compliance, the facility failed to complete against medical advices (AMA) forms and notify the physician per facility policy, and failed to discard opened medications in accordance with facility policy. The findings included: 1. Patient #3 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 thirty (30) minutes with a left upper AVF with a 1K 2.5 CA dialysate. A sample review of Patient #1’s hemodialysis flowsheets identified the following: a. On 11/26/24 Patient #1 had 3 hours and 18 minutes of treatment (12 minutes short) with no documentation as to why Patient #1’s prescribed treatment time was not met. The medical record failed to identify an against medical advice (AMA) form was completed. b. On 12/13/24 Patient #1 had 2 hours and 56 minutes of treatment (34 minutes short) due to unsafe behavior during treatment and the charge nurse was notified. The medical record failed to identify an AMA form was completed and if the physician was notified. c. On 12/18/24 Patient #1 had 3 hours and 5 minutes of treatment (25 minutes short) due to unsafe behavior during treatment, an AMA was signed and the charge nurse was notified. The medical record failed to identify if the physician was notified. d. On 12/29/24 Patient #1 had 2 hour and 52 minutes of treatment (38 minutes short) per patient request. The medical record identified the MD was aware however, it failed to identify if an AMA form was completed. Review of the against medical advice policy directed that the AMA form will be used for patients who refuse to complete the prescribed treatment. It further directed the charge nurse will review and have the patient sign the AMA form. It directed if shortened/early termination of treatment time exceeds 30 minutes or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any). The AMA form will be maintained in the patients medical records. 2. Observation on 1/7/25 at 9:45 AM identified an expired vial of Tuberculin Purified Protein Derivative (Mantoux), five (5) TU/0.1 milliliter opened on 12/3/24 in the medication refrigerator. Interview with the Clinical Coordinator on 1/7/25 at 9:45 AM identified the Tuberculin Purified Protein Derivative (Mantoux) vial should have been discarded twenty-eight (28) days after opening (which should have been on 12/31/24). Review of the Medication policy directed medications containing a preservative must be discarded twenty-eight (28) days after opening or accessed.”