Davita Lake Worth Dialysis

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 29151 Based on observation and interview, it was determined, the facility failed to ensure the sinks at the facility were designated for clean and dirty purposes. This failure is evidenced by failure to designate four sinks on the treatment floor. The findings included: Observation of care conducted on 05/06/24 starting at 10 AM revealed the treatment area has four sinks are not designated as clean (handwashing) or dirty sinks. Observation conducted on 05/06/24 at 10:13 AM revealed a Patient Care Technician disposing a saline bag inside the sink. The area contained two buckets with clean bleach solutions and clean supplies, the sink was not designated for handwashing or dirty uses. Interview with Staff A, a Patient Care Technician, conducted on 05/06/24 at 11:20 AM confirmed the sinks are not currently labeled and explained the sink areas with clean supplies, paper towels and bleach solutions are designated clean, and that the sinks were previously labeled, and the labels must have fallen off.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 22517 Based on clinical and administrative record review and staff interview, the facility failed to monitor and implement the established infection control policies. The facility failed to ensure 1 of 3 new admission sampled patients are offered the pneumonia vaccines. The Centers for Disease Control and Prevention (CDC) recommends that all dialysis patients are offered the pneumococcal vaccine and the immunization histories for these vaccines are tracked. The findings included: Review of the clinical record for Patient # 6 revealed that the patient was admitted to the facility on 03/05/24 and was prescribed to receive in-center hemodialysis three days a week. Further review of the clinical record failed to provide pertinent information regarding the patient’s history regarding and/or was offered the pneumococcal vaccines. An interview was conducted on 05/01/24 at 1:34 PM with the Facility Administrator (FA). The FA confirmed that the patient’s clinical record did not provide any information regarding the patient’s history regarding the pneumococcal vaccine or whether the patient was offered the vaccine.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 22517 Based on observation, policy review and staff interview, the facility staff failed to adhere to current aseptic techniques policies and procedures for intravenous medications, as evidenced by, the staff failure to dispose of opened multidose medication vials in a timely manner. The findings included: Review of the facility’s policy regarding Medication Policy, Policy: 5-07-01, Revision Date November 2023, documented, “Medications containing a preservative must be discarded 28 days after opening or accessed (e.g. needle punctured), unless the manufacturer specifies a different (shorter or longer) date.” An observation of the medication refrigerator in the home training room on 05/06/24 beginning at 10:20 AM revealed that there was a multi-dose vial of Tuberculin Purified Protein Derivative Mantoux Tubersol Multidose vial which documented an open date of 01/03/24, which remained in the refrigerator, 4 months after opening. An interview was conducted with the Home Training Nurse at the time of the observation. She was unaware of the length of time multi-dose vials are to remain open in the refrigerator but confirmed that the vial was opened in January.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 29151 Based on observation, policy review and interview, it was determined, the clinical staff failed to ensure catheter care was performed following aseptic technique. This failure affected 1 of 1 patient observed for catheter care at Station #17. The findings included: The facility’s policy regarding Central Venous Catheter (CVC) with Clearguard HD Antimicrobial ends caps procedure, Procedure: 1-04-02 B, last revised October 2023, documents the following steps: “Remove old dressing and discard. Remove gloves and discard. Perform hand hygiene per procedure and re-glove .... Clean each CVC limb/cap with a new Large alcohol prep pad, starting close to the exit site and finishing the cap. Using aseptic technique, remove each cap. One at a time, disconnect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood.” An observation of catheter care was conducted on 05/06/24 at approximately 10:30 AM. Staff C, a Patient Care Technician (PCT #C) donned clean gloves to disinfect the exit site, the staff cleaned each limb with an alcohol pad, starting from the bottom and moving towards the exit site. Then removed her gloves, performed hand hygiene, donned clean gloves put on clean gauze over the exit site and taped the edges. Staff C continued to remove the hubs and attached clean syringes. Staff C failed to clean the CVC limbs starting from the exit site and towards the cap and failed to scrub each CVC hub for 15 seconds prior to inserting the clean syringe. Interview with Staff C conducted on 05/08/24 at approximately 12:15 PM confirmed the details of the observation and stated she was nervous during the observation.”

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 22517 Based on observation and staff interview, the facility failed to ensure that the Acid Concentration distribution system at the valve panels (wall boxes) are appropriately labeled to clearly indicate the type of acid concentrate coming through the line. The facility has acid being distributed through the central delivery system to the valve panel/wall box. Acid solutions centrally delivered to treatment stations, outlets must be clearly labeled to identify specifically the chemical make-up of the solution being delivered. The findings included: An observation on the dialysis treatment floor on 05/06/24 beginning at approximately 10:45 AM revealed that 23 of 23 stations wall boxes were not labeled appropriately to indicate the dialysate bath being centrally transported to the box. The facility centrally delivers acid concentration of 2 K (potassium) 2.5 Ca (calcium). An interview was conducted on 05/08/25 at approximately 2:00 PM with the BioMed Technician. The surveyor informed him that the wall boxes at the dialysis stations were not labeled to identify the acid concentration being centrally piped into the station and did not clearly label the specific concentration being delivered.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 29151 Based on observation and staff interview, it was determined, the facility failed to ensure all supplies were maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by the failure of the staff to ensure supplies were not readily available for use beyond the manufacturer’s documented expiration date and failure to maintain the home program medication refrigerator. The findings included: 1) Observation of care conducted on 05/06/24 starting at 10 AM revealed the following items were located in the treatment floor, readily accessible for use despite expiration dates. 11 packets of RPC sterile recirculation connectors expired on 12/23/23. 3 Fistula needles, gauge 14, expired on 11/30/22. One bottle of Ex Sept Antimicrobial Exit site cleanser expired 04/08/24. Interview with The Registered Nurse conducted on 05/06/24 at 11:10 AM confirmed the items were expired and stored in the treatment floor. 22517 2) An observation of the refrigerator in the Home Dialysis Training Room was conducted on 05/06/24 at 10:20 AM with the Home Training Nurse, revealed that the refrigerator’s freezer contained 3 ice packs. However, the freezer door was unable to be closed. Observed on the freezer, on the side and underneath the freezer, there was noted ice build up in the refrigerator. An interview was conducted with the Home Training Nurse at the time of the observation. She stated she checks the refrigerator monthly but was uncertain about defrosting the freezer.”

“PE-ACCOMMODATE PT PRIVACY CFR(s): 494.60(c)(3) The dialysis facility must make accommodations to provide for patient privacy when patients are examined or treated and body exposure is required. This Standard is not met as evidenced by: 22517 Based on observation and staff interview, the facility failed to ensure that patients were provided privacy while receiving dialysis. This is evidenced by the entrance door to the treatment floor had a small window what allow full visualization to the occurrence on the treatment floor and patient’s can be visualized receiving dialysis treatment. The findings included: An observation on 05/06/24 at approximately 9:45 AM from the lobby of the facility’s dialysis unit revealed that the entry door to the treatment floor has a window on the door that allows viewers to visualize the treatment floor and patients actively receiving dialysis treatment. An interview and observation was conducted on 05/08/24 at 2:00 PM with the BioMed Technician who was shown the visibility of the treatment floor from the lobby through the window on the door. He confirmed he observation. and the visibility noted.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 29151 Based on record review and interview, it was determined, the facility failed to ensure the completion of the comprehensive assessment included physician’s evaluation for 2 of 7 in-center sampled patients, who had extended hospitalizations requiring the development of a comprehensive assessment to determine their stable or unstable status. The failure affected Patients #3 and #4. The findings included: 1) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #3 was admitted to the facility on 01/28/11 for dialysis treatments. The record indicates Patient #3 had an extended hospitalization, from 02/13/24 thru 03/02/24. The interdisciplinary team, registered nurse, dietician and social worker completed the unstable criteria assessment on 04/16/24. Review of the paper and electronic records dated 03/01/24 thru 05/08/24 failed to provide evidence of a physician evaluation to validate the integration of medical care and services as part of the comprehensive assessment. 2) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #4 was re-admitted to the facility on 02/12/24 for dialysis treatments. The record indicates Patient #4 had an extended hospitalization, from 03/15/24 thru 04/02/24. The interdisciplinary team, registered nurse, dietician and social worker completed the unstable criteria assessment on 04/19/24. Review of the paper and electronic records dated 04/01/24 thru 05/08/24 failed to provide evidence of a physician evaluation to validate the integration of medical care and services as part of the comprehensive assessment. Interview with the Facility Administrator conducted on 05/08/24 at 9:38 AM confirmed there are no physicians’ notes for Patients #3 and #4 to validate the physician participation in the development of the comprehensive assessment.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 29151 Based on record review and interview, it was determined, the interdisciplinary team failed to complete an interdisciplinary admission assessment within thirty days of admission. The failure affected 1 of 2 newly admitted patients (Patient #1). The findings included: Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #1 was re-admitted to the facility on 03/01/24 after an extended absence (12/27/23-02/29/24) to continue dialysis treatments. Review of the paper and electronic records dated 03/01/24 thru 05/08/24 failed to provide evidence that the facility had completed a Comprehensive Interdisciplinary Assessment (CIA) after re-admission on 03/01/24; the last CIA was dated 10/17/23. In addition the records failed to provide evidence of an active comprehensive assessment from the facility, where the patient was receiving treatments during his travel. Interview with The Facility Administrator (FA) conducted on 05/07/24 at 3:36 PM revealed Patient #1 was out of the country for an extended period of time and was made inactive. The computer system did not trigger the assessment as a new admission. The FA verified Patient #1 was absent from January thru March 2024 and an initial comprehensive assessment has not been completed and there is no evidence of an active assessment from another dialysis facility on file.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 22517 Based on clinical record review and interview, the facility failed to provide evidence that 1 of 10 sampled patients (Patient # 10) had a comprehensive assessment and plan of care completed by the entire interdisciplinary team at least annually for stable patients. The findings included: Review of the clinical record for Patient # 10 revealed that the patient had a change in modality to perform Peritoneal Dialysis at home on 03/02/21. Further review of the clinical record revealed the last comprehensive assessment and plan of care was completed on 02/15/23. There is no further indication that the comprehensive interdisciplinary assessment and plan of care was completed by all members of the interdisciplinary team. An interview was conducted with the Home Training Nurse on 05/08/24 at 1:20 PM, who stated, “when an assessment is due, it will appear in the CWOW, the facility electronic system. She then looked into the CWOW and explained, she did not know what happened.””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 22517 Based on clinical and administrative record review and staff interview, the facility failed to provide the necessary care and services to manage the patient’s volume status. The facility failed to ensure the appropriate administration of anticoagulation medication for 2 of 7 in-center sampled patients (Patient # 4 and 6) and the clinical staff failed to identify, report and address elevated blood pressures for 1 of 7 in-center sampled patients (Patient #7). The findings included: 1) Review of the facility policy regarding Anticoagulation, Policy: 1-06-02, Revision Date April 2024 documented, “It is recommended that the heparin hourly infusion be discontinued 60 minutes prior to the end of treatment for patients with arterio-venous (AV) fistulas and/or AV grafts per physician order. It is recommended that the heparin hourly infusion be continued for the entire treatment for patients with CVCs.” Review of the clinical record for Patient # 6 revealed that the patient was admitted to the facility on 03/05/24. The physician prescribed for the patient to receive in-center hemodialysis treatment for 4 hours (240 minutes) three times per week via a Central Venous Catheter (CVC). He also prescribed for the patient to receive Heparin 2000 units bolus at the initiation of treatment and an infusion of 500 units per hour for 4 hours (2000 units). Review of 13 treatment flow sheet, 04/09/24 - 05/07/24, revealed that the staff did not follow the physician order for the Heparin Infusion on 13 of 13 treatments. 05//07/24 - treatment time from 10:35 AM to 2:19 PM - 3 hrs 44 minutes; heparin infusion - 1750 05/04/24 - treatment time 10:06 AM to 2:19 PM - 4 hours and 13 minutes ; heparin infusion - 1750 05/02/24 - treatment time 10:26 AM to 2:45 PM - 4 hours and 19 minutes; heparin infusion 1750 04/30/24 - treatment time 10:45 AM to 2:48 PM - 4 hours and 3 minutes; heparin infusion 1750 04/27/24 - treatment time 10:28 AM to 2:32 PM - 4 hours and 4 minutes; heparin infusion 1750 04/25/24 - treatment time 10:22 AM to 2:25 PM - 4 hours and 3 minutes; heparin infusion 1750 04/23/24 - treatment time 10:37 AM to 2:38 PM - 4 hours and 1 minutes; heparin infusion 1750 04/20/24 - treatment time 10:37 AM to 2:39 PM - 4 hours and 2 minutes; heparin infusion 1750 04/18/24 - treatment time 10:29 AM to 2:28 PM - 3 hours and 59 minutes; heparin infusion 1750 04/16/24 - treatment time 11:00 AM to 2:41 PM - 3 hours and 41 minutes; heparin infusion 1750 04/13/24 - treatment time 10:20 AM to 2:25 PM - 4 hours and 5 minutes; heparin infusion 1750 04/11/24 - treatment time 10:41 AM to 1:31 PM - 2 hours and 50 minutes; heparin infusion 1750, shortened treatment. 04/09/24 - treatment time 10:20 AM to 1:25 PM - 3 hours and 5 minutes; heparin infusion 1750 with an hour shortened treatment, the heparin infusion should have been 1500. An interview was conducted on 05/08/24 at 1:34 PM with the Facility Administrator, who was unable to offer an explanation as to why their is a discrepancy in the heparin infusion administration but added, they are documenting what is generated by the computer. 29151 2) Clinical record review conducted on 05/09/24 revealed Patient #7 has physician’s order dated 12/26/23 for Clonidine 0.1 mg by mouth every four hours as needed for hypertension. Treatment records dated 04/01/24, 04/08/24, 04/13/24 and 04/30/24, revealed the patient’s blood pressure was elevated and there is no evidence the nurse implemented interventions to manage the blood pressure. Treatment record dated 04/01/24 documents blood pressures as 160/108, 155/114, 150/122, 152/119, 143/108, 144/109, 144/104 and 135/101. Treatment record dated 04/08/24 documents blood pressures as 155/112, 143/100, 153/113, 149/107, 150/110, 143/103, 162/96 and 170/111 upon discharge. Treatment record dated 04/13/24 documents blood pressures as 151/106, 160/117, 150/112, 197/136, 186/126, 162/112, 158/112, 153/114. Treatment record dated 04/30/24 documents blood pressures as 162/118, 171/116, 172/111, 165/111, 153/107, 156/111, 182/116 and 177/120 upon discharge. Interview with The Facility Administrator conducted on 05/08/24 at approximately 1:45 PM confirmed there is no evidence the nurse addressed the elevated blood pressures, administered the Clonidine as ordered or evidence of patient refusal. 3) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #4 has physician’s order for Heparin infusion, 400 units per hour as of 03/01/24. The treatment duration is four hours, totaling 1600 units. Treatment record dated 04/23/24 indicates Patient #4 did not receive the heparin infusion as prescribed. Treatment record dated 04/29/24 documents Patient #4 received 800 units of Heparin, the treatment duration noted 2 hours and 45 minutes. The patient should have received 900 units, according to the physician’s orders. Interview with The Facility Administrator on 09/08/24 at 9:38 AM confirmed Patient #4 should have receive the heparin infusion on 04/23/24 and the system does not break down the amount of Heparin per hour, so most likely the documented 800 units on 04/29/24 was a round up number.”

“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: 29151 Based on record review and interview, it was determined, the clinical staff failed to ensure dialysis prescriptions were followed for 4 of 10 sampled patients. The failure included deviation of the prescribed Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for Patient #3, #4 and #6 and failure to document the Dialysate solution used for Patient #9. The findings included: 1) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #3 has physicians’ orders for dialysis treatment as of 04/04/24 for Blood Flow Rate (BFR) of 350 and Dialysate Blood Flow Rate (DFR) of 500. Review of the treatment records indicate the following: Treatment record dated 04/06/24 indicates the staff did not follow the prescribed BFR. Treatment record dated 04/09/24 indicates the staff did not follow the prescribed DFR. Treatment record dated 04/16/24 indicates the staff did not follow the prescribed BFR. Treatment record dated 04/20/24 indicates the staff did not follow the prescribed BFR and DFR. Treatment record dated 04/23/24 indicates the staff did not follow the prescribed BFR. Treatment record dated 04/30/24 indicates the staff did not follow the prescribed BFR. The records provide no explanation for the deviation from the prescription. Interview with The Facility Administrator conducted on 05/07/24 at 3:40 PM verified the staff did not follow the prescription and did not document the rationale for the changes. 2) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #4 has physicians’ orders for dialysis treatment as of 04/01/24 for Blood Flow Rate (BFR) of 400 and Dialysate Blood Flow Rate (DFR) of 500. Review of the treatment records indicate the following: Treatment record dated 04/19/24 indicates the staff did not follow the prescribed DFR. Treatment record dated 05/03/24 indicates the staff did not follow the prescribed BFR. The clinical staff failed to document the reason for the deviation from the prescription. Interview with The Facility Administrator conducted on 05/08/24 at 9:38 AM verified the staff did not follow the prescription and did not document the rationale for the changes. 22517 3) Review of the clinical record for Patient #3 revealed that the patient was admitted to the facility on 03/05/24. The physician prescribed for the patient to receive in-center hemodialysis treatment for 4 hours (240 minutes) three times per week via a Central Venous Catheter (CVC). He also prescribed a Blood Flow Rate of 350 and a Dialysate Flow Rate of 500. Review of the 13 treatments from 04/09/24 to 05/07/24, the facility staff failed to follow the physician order for BFR/DFR on 3 treatments as follows: 1. 05/02/24 - the staff documented a BFR of 400 & 365 throughout the treatment. The staff did not document a reason, they were not following the physician order. 2. 04/27/24 - the staff documented a BFR of 295 throughout the treatment. The staff did not document a reason, they were not following the physician order. 3. 04/16/24 - the staff documented a BFR of 375 throughout the treatment. The staff did not document a reason, they were not following the physician order. An interview was conducted on 05/08/24 at 1:34 PM with the Facility Administrator. She confirmed that the staff did not follow the physician order on the above treatments. 4) Review of the clinical record for Patient # 9 who was admitted to the facility on 03/17/22 and the physician prescribed for the patient to perform Peritoneal dialysis at home six days a week, 5 cycles, 2000 volume using solutions of 2.5, 1.5 and a last fill of 1000 extraneal 2.5 solutions. Review of the home treatment records revealed that the patient is performing treatments 7 days a week. However the home records do not identify what solutions the patient is using during his treatments. An interview was conducted on 05/08/24 at 1:20 PM with the Home Training Nurse, who confirmed that the home records do not document what solutions the patient is using and the patient doesn’t keep another log to document what solution he is using.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 29151 Based on observation, policy review and interview, it was determined, the clinical staff failed to ensure vascular access care was provided while utilizing aseptic technique to minimize risk of infection. The findings included: Facility policy titled “AV Fistula or Graft Cannulation with NIPPRO or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose”, last revised October 2022 documents as follows: “Locate and palpate the needle cannulation sites prior to skin preparation....Do not palpate insertion site once area has been prepped.” Observation of care conducted on 05/06/23 at approximately 10:30 AM revealed Staff B, a Patient Care Technician, initiating dialysis treatment at Station #7. The staff donned clean gloves, disinfected the access site, then palpated the area and inserted the first needle. Staff B proceeded by disinfecting the second site, then again, palpated the area and inserted the second needle. Staff B failed to cleanse the access sites after palpating and prior to needle insertion. Interview with Staff B conducted on 05/08/24 at 12:10 PM confirmed the staff palpated the site and failed to disinfect it before inserting the needles.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 29151 Based on record review and interview, it was determined, the interdisciplinary team failed to complete an interdisciplinary plan of care within thirty days of admission. The failure affected 1 of 2 newly admitted patients (Patient #1). The findings included: Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #1 was re-admitted to the facility on 03/01/24 after an extended absence (12/27/23-02/29/24) to continue dialysis treatments. Review of the paper and electronic records dated 03/01/24 thru 05/08/24 failed to provide evidence that the facility had completed a Comprehensive Interdisciplinary Plan of Care after re-admission on 03/01/24; the last care plan was completed on 10/25/23. In addition the record failed to provide evidence of an active plan of care from the facility, where the patient was receiving treatments during his travel. Interview with The Facility Administrator (FA) conducted on 05/07/24 at 3:36 PM revealed Patient #1 was out of the country for an extended period of time and was made inactive. The computer system did not trigger the assessment and subsequent plan of care as a new admission. The FA verified Patient #1 was absent from January-March 2024 and the initial plan of care has not been completed, there is no evidence of an active plan of care from another dialysis facility on file.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 29151 Based on record review, policy review and interview, it was determined, the facility staff failed to ensure physician’s monthly visits were completed for 2 of 7 in-center sampled patients (Patient #3 and #4). The findings included: Facility By Laws documents “Rounding and Documentation Requirements: In-center and or nocturnal patients must be evaluated and examined by a nephrologist no less than once per month in-person in the facility while the patient is in dialysis. Ensure Patients are rounded on in compliance with Davita, ESRD Network, State and Federal requirements....Ensure that there are timed, dated and signed comprehensive notes in each his or her medical records at least 30 days that reflect monthly face to face evaluation and examination.” 1) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #3 was admitted to the facility on 01/28/11 for dialysis treatments. Review of the paper and electronic records dated 11/01/23 thru 05/08/24 failed to provide evidence of monthly physician’s visits. 2) Clinical record review conducted on 05/07/24 and 05/08/24 revealed Patient #4 was re-admitted to the facility on 02/12/24 for dialysis treatments. Review of the paper and electronic records dated 02/12/24 thru 05/08/24 failed to provide evidence of monthly physician’s visits. Interview with the Facility Administrator conducted on 05/08/24 at 9:38 AM confirmed there are no physicians’ visits for Patients #3 and #4. The physician does come into the facility, she has reached out to his office and there is no documentation available to validate the provider has completed the required visits.”

“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: 22517 Based on clinical and administrative record review and staff interview, the Medical Director failed to ensure the staff adhered to the established policy and procedure related to patient care. This is evidenced by the staff failing to implement the physician orders as prescribed and failed to update orders in the electronic system to reflect the accurate treatment orders for 2 of 3 Home Peritoneal sampled patients (Patient # 9 and # 10). The findings included: 1) Review of the clinical record for Patient # 10 revealed that the patient expressed symptoms of peritonitis to the Home Training Nurse. On 04/08/24 a specimen was sent and the physician prescribed for the patient to receive, Tazicef 1000 mg one time intraperitoneal and Vancomycin 1000 mg one time intraperitoneal. Then the physician prescribed for the patient to receive Vancomycin 1500 mg every 3 days times 6 doses. Further review of the medication administration of the prescribed doses confirmed 4 doses were administered on 04/11/24, 04/17/24, 04/23/24 and 04/26/24. However, there is no evidence that the nurse administered the doses prescribed for 04/14/24 and 04/20/24. An interview was conducted with the Home Training Nurse on 05/08/24 at 1:20 PM, who confirmed that there was no documentation for the 04/14/24 and 04/20/24 doses. She stated that those doses occurred on Sunday and Saturday and she “didn’t know how to document them?” 2) Review of the clinical record for Patient # 9 who was admitted to the facility on 03/17/22. Review of the physician orders revealed the 04/03/24 physician order prescribed for the patient to perform Peritoneal dialysis at home six days a week, 5 cycles, 2000 volume using solutions of 2.5, 1.5 and a last fill of 1000 extraneal 2.5 solutions. Review of the home treatment records revealed that the patient is performing treatments 7 days a week. Additional review of the home records revealed that there is a notation from the Home Training Nurse on 04/02/24 that the “PD orders was 6 days a week but it changed to 7 days a week per MD order.” However further review of the physician orders did not yield a physician order prescribing for the patient to perform PD treatments 7 days a week. An interview with the Home Training Nurse was conducted on 05/08/24 at 1:20 PM, who confirmed that the physician orders does not reflect the updated prescription prescribing for the patient to perform PD treatments 7 days a week. “I noted the change in my notes but I didn’t put it in the physician orders.””