Davita New Port Richey Kidney Center

“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: 49691 Based on facility policy, observations and interviews the facility failed to ensure that staff adhere to hand hygiene to prevent possible cross contamination of microorganisms in one (Staff D) out of four staff members observed. Findings included: Review of facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD antimicrobial End Caps Procedure”, # 1-04-02B, revision 10/2024 ...Procedure 1. Perform Hang hygiene per procedure ...Hand Hygiene protects patient and teammates from cross contamination ...4. Remove the old dressing and discard ...remove gloves and discard. Perform Hand hygiene per procedure and re-glove ...Clean exit site ...Clean each CVC limb/ cap with alcohol prep pad ...remove gloves and discard, perform hand hygiene per procedure and re-glove ...place steril 2X2 gauze over catheter exit site ... seal edges of gauze with tape ...Apply label to the dressing indicating the date dressing change performed. Remove gloves and discard perform hand hygiene per procedure and re-glove ...remove each cap. One at a time disinfect each CVC hub with new alcohol prep pad ...attach sterile 10 ml syringes ...Perform hand hygiene per procedure ... On 04/29/2025 at 11:27 AM Staff D, Certified Clinical Hemodialysis Technician (CCHT) performed an initiation of dialysis with CVC and exit site care on a patient. Staff D, CCHT removed the old dressing from the CVC site. Staff D cleaned the site, disinfected the hubs and connected the ports to syringes. Staff D, CCHT applied a dressing on the CVC exit site, and used the bedside computer. Numerous hand hygiene opportunities missed (A total of 5 opportunities during this observation). During a discussion on 04/28/2205 at 12:10 PM with Staff B, RN, she stated that audits are done. Staff D CCHT is usually very good with hand hygiene.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 49691 Based on facility policies, observations, and interviews, the facility failed to adhere to designated clean and dirty areas in 1 of 2 supply clean areas. This could potentially spread infectious organisms from the waste to clean supplies. Findings included: Review of the facility policy and procedures titled, “Infection Control For Dialysis Facilities”, # 1-05-01, revision 04/2023 ...Clean area should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled ... On 04/29/2025 at 9:40 AM during a tour of the dialysis unit 2 used acid jugs were located on a counter next to clean supplies. During an interview on 04/29/2025 at 9:48 AM with Staff B RN she stated, “It is Dialysis 101 Clean and dirty are to be separated”. Photo evidence obtained”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 49691 Based on observations and staff interviews, the facility did not ensure the patient Dialysis treatment area was free from spread of potentially infectious waste by failing to secure open acid jugs leaving the fluid open to the elements, in 1 of 1 acid jug containers (Dialysis acid jugs contain a concentrate of acid that is used to mix with bicarbonate to create dialysate.) Findings included: On 04/28/2205 approximately 10:00 AM an Acid jug was on the bottom of station #17 dialysis machine with the lid not secured. Dialysis acid jugs contain a concentrate of acid that is used to mix with bicarbonate to create dialysate. During a discussion on 04/29/2025 at 10:00 AM with Staff A, Facility Administrator she stated, “The staff is to have the open jugs secured and we have the lids for that”. Photographic evidence obtained.”

“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: 49691 Based on facility policies, observation and interviews, the facility failed to ensure proper disinfection of dialysis stations between patients in 2 (Station 12, 19) of 4 observed. Finding included: Review of the facility policy and procedure titled, “Infection Control for Dialysis Facilities”, # 1-05-01, revision 04/2023 ...At the end of each treatment, the dialysis station will be cleaned and disinfected ...All surfaces in contact with the patient or their belongings ... On 04/28/2025 at 9:26 AM station #12 had a black blanket on the counter behind the recliner. Staff C, Patient Care Technician (PCT) cleaned the station but did not clean the counter behind the recliner and the used blanket was left there. On 04/28/2025 at 10:12 AM Station #19 had a green and white patient belonging bag on the counter behind the recliner in the dialysis station. On 04/28/2025 at 10:19 AM Staff D, Certified Clinical Hemodialysis technician (CCHT) cleaned the station but failed to clean the back counter, clamp bag on the IV pole. Staff D, CCHT did not open the recliner and clean in between the seat and arms of the chair. During an interview on 04/28/2025 at 9:36 AM with Staff C, PCT regarding the blanket she disclosed that it was left there by another patient. During a discussion on 04/28/2205 at 12:10 PM with Staff B, RN she was shown the blanket left by a patient and she stated “the counter should be disinfected” and “ Staff D, CCHT is usually very good with cleaning of the station”. Photographic evidence obtained.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 28028 Based on document review and staff interview it was determined the facility failed to document participation in a second full-scale exercise with analysis of the facility’s response for one of two exercises reviewed. Findings included: The facility’s Emergency Preparedness (EP) approved plan for 2023 was reviewed. Review of the facility testing of the EP plan revealed no evidence a second full-scale exercise with analysis of the facility’s response had been conducted. Interview with the Facility Administrator on 01/12/2024 at 1:30 PM confirmed there was no evidence of participation in a second full-scale exercise with analysis of the facility’s response.”

“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: 34768 Based on observation, interview and record review the facility failed to follow infection control protocols related to donning and doffing of gloves, hand sanitizing and use of numbing medication for 4 of 4 sampled patients. Findings included: An observation on 01/1/1024 at 11:00 a.m. of Staff A, Patient Care Technician (PCT) performing Central Venous Catheter (CVC) care for a patient at station 2. Staff A removed the old dressing from the CVC and discarded it. Staff A did not remove the soiled gloves, hand sanitize and apply clean gloves prior to cleaning the CVC exit site. An observation on 01/11/2024 at 10:55 a.m. of Staff B, PCT performing discontinuation of dialysis for a patient with a CVC at station 25. Staff B removed her gloves and moved across to the supply area for a barrier and replaced her gloves without hand sanitizing. She then moved to the center supply area and picked up the thermometer, used it and placed it on the mobile computer area. She removed and replaced gloves without hand sanitizing. An observation on 01/11/2024 at 11:20 a.m. Staff C, PCT was performing access to a Arteriovenous access at station 16. Staff C removed a can of numbing spray from the middle area of supplies. The supply was not sanitized prior to use. Gloves were applied and the spray was used on the site and the can was sat on the patient side table. Staff C failed to hand sanitize between glove changes after numbing medication use. Staff C did not consistently hand sanitize between glove changes throughout the procedure. An observation on 01/11/2024 at 11:40 a.m. Staff C, PCT was performing access to a Arteriovenous access at station 21. Staff C removed a can of numbing spray from the middle area of supplies. The supply was not sanitized prior to use. Gloves were applied and the spray was used on the site and the numbing can was sat on the patient side table. Staff C failed to hand sanitize between glove changes after numbing medication use. Staff C did not consistently hand sanitize between glove changes throughout the procedure. During an interview with Director of Nursing on 01/12/2024 at 2:00 p.m. she stated the expectation was for the staff to hand sanitize between glove changes. The staff was to use the thermometer without touching the patient. Then they were to replace the thermometer in the middle of the room / on supply cabinet after use. They were to clean the thermometer at the end of the day. The staff was to hand sanitize and change gloves after removing the CVC site dressing before cleaning the site. The staff was to never place a can of numbing spray on the patient’s table. If the numbing spray can was placed on the patient’s table, it was now contaminated and became the patient’s or needed to be thrown away. The numbing spray should be used and returned to the supply cabinet after cleaning not placed on the patient table. She stated that five staff members were monitored monthly for following infection control procedures. Review of the facility’s policy, “Infection Control for Dialysis Facilities,” revised April 2023 showed the purpose to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Hand Hygiene: 1. All teammates, Physicians and Non-physician (NPP) will perform hand hygiene b. prior to gloving and immediately after removal of gloves, d. after patient and dialysis deliver system contact, f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. PPE: 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites. A. Gloves should be changed when: i. when soiled with blood, dialysate, or other body fluids. Ii. When going from a “dirty” area to task to a “clean” area or task, iii. Hen moving from a contaminated body site to a clean body site of the same patient. Supplies: 10. Unused supplies (syringes, alcohol wipes, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used only for that patient and should be returned to a common clean area or used on other patients. 11. Measures will be taken to prevent cross contamination between patients. B. Electronic thermometers and / or blood glucose meters should not be placed on potentially contaminated equipment such as the dialysis delivery system. Disinfection: 14. Non-disposable items to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient. Review of the facility’s policy, “Central Venous Catheter Procedure”, revised October 2023 showed remove old dressing and discard. Remove gloves and discard. Perform hand hygiene per procedure and re-glove.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 34768 Based on interview and record review the facility failed to achieve and sustain the prescribed dose of dialysis to meet the prescribed Blood Flow Rate (BFR) and / or Dialysate Flow Rate (DFR) for six of eight sampled patients (Patients #2, #4, #5, #6, #9, #10) and failed to document in the medical record when unable to meet the prescribed blood flow. Findings included: Review showed Patient #2 was admitted to the facility on 06/03/2020 to receive dialysis three days a week with an Arteriovenous Graft (AVG). Review of the physician’s orders revealed a BFR of 400 milliliter(ml)/minute(min) and a DFR of 500 ml/min. On 01/05/2024 the DFR was documented as 610 ml/min for 6 of 8 and 600 ml/min for 2 of 8 assessments. On 01/01/2024 the BFR was documented as 350 ml/min for 6 of 8 assessments. On 12/27/2023 the BFR was documented as 350ml/min for 10 out of 10 assessments. On 12/27/2023 the DFR was documented as 610 ml/min for 4 of 10, 600 ml/min for 4 of 10, 590 for 1 of 10, and 620 ml/min for 1 of 10 assessments. Review showed Patient #4 was admitted to the facility on 02/19/2016 to receive dialysis three days a week with an AVG. Review of the physician’s orders revealed a BFR of 400 ml/min and a DFR of 500 ml/min. On 01/09/2024 the BFR was documented as 200 ml/min for 3 of 9 and 260 ml/min of 1 of 9 and 280 ml/min for 1 of 9 assessments. The DFR on 01/09/2024 averaged between 490 ml/min and 510 ml/min of the 9 documented assessments. On 01/02/2024 the DFR was documented 590 ml/min for 3 of 8 and 610 ml/min for 3 of 8 and 620 ml/min for 1 of 8 assessments. On 12/28/2023 the DFR was documented 600 ml/min for 2 of 9, 610 ml/min for 5 of 9, and 620 ml/min for 1 of 9 assessments. Review showed Patient #5 was admitted to the facility on 07/09/2021 to receive dialysis three days a week with an Arteriovenous Fistula (AVF). Review of the physician’s orders revealed a BFR of 450 ml/min and DFR of 500 ml/min. On 01/06/2024 the BFR was documented as 400 ml/min for 4 of 8 assessments. Review showed Patient #6 was admitted to the facility on 01/23/2020 to receive three days a week with a Central Venous Catheter (CVC). Review of the physician’s orders revealed a BFR of 450 ml/min. and DFR of 600 ml/min. On 01/06/2024 the DFR was documented as 500 ml/min for 6 out of 10, 510 ml/min for 3 out of 10, and 490 ml/min for 1 out of 10 assessments. On 01/04/2024 the DFR was documented as 500 ml/min for 7 of 8 and 510 ml/min for 1 of 8 assessments. Review showed Patient #9 was admitted on 10/07/2020 to receive three days a week with a AVF. Review if the physician’s orders revealed a BFR of 400 ml/min. and DFR of 500 ml/min. On 01/10/2024 the BFR was documented as 350 ml/min for 6 of 6 assessments. On 01/05/2024 the BFR was documented as 350 ml/min for 8 of 8 assessments. On 01/01/2024 the BFR was documented as 350 ml/min for 9 of 9 assessments. Review showed Patient #10 was admitted on 07/05/2022 to receive three days a week with a CVC. Review of the physician’s orders revealed a BFR of 450 ml/min. and DFR of 500 ml/min. On 01/02/2024 the BFR was documented as 400 ml/min for 4 of 7, 300 ml/min for 1 of 7, and 200 ml/min for 2 of 7 assessments. On 12/15/2023 the BFR was documented as 400 ml/min for 7 of 7 assessments. During an interview on 01/12/2024 at 12:25 p.m. the facility administrator and Director of Nursing stated that the staff was to follow the physician’s orders which included BFR and DFR orders. If the physician’s orders are not followed, then the nurse should be notified, and the nurse should document the change in the treatment notes. They verified the patients did not have documentation in their notes. Review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised October 2023 showed to obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Intradialytic Data Collection Assessment: b. at a minimum, obtain and document the following: iii. Blood and dialysate flows, arterial and venous pressure. 10. 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. 12. The licensed nurse notified the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 34768 Based on observations, interview and record review the facility failed to adequately assess two of two patients sampled related to performing a bruit and thrill on an Arteriovenous (AV) access prior to dialysis Findings included: Observation on 01/11/2024 at 11:20 a.m. and 11:40 a.m. Staff C, Patient Care Technician (PCT) neglected to evaluate access of an Arteriovenous access at station 16 and station 21 respectively by locating, palpating the cannulation site as well as performing the thrill and/or bruit. During an interview on 01/12/2024 at 2:00 p.m. the Director of Nursing stated that the staff was to check for thrill and bruit before accessing the arteriovenous site. Review of the facility’s policy, “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) vascular Access Care”, revised on October 2023 showed the purpose to reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize the lifetime of the access. 1 inspection of the AVF or AVG access includes the following: presence / absence of thrill and / or bruit”