Davita Complete Dialysis Care

“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: 40153 Based on observation, interviews and chart review, the facility staff failed to ensure proper hand hygiene for 1 of 1 patient observed during disconnection of a dialysis Central Venous Catheter (CVC), Patient #11. The findings included: A review of the policy titled “Central Venous Catheter with Clear guard HD Antimicrobial End Caps Procedure” revised in October 2024 showed the following: if teammate performing this procedure assisted the patient to put of their face mask, re-perform hand hygiene per procedure and put on clean gloves. In an observation conducted on 11/12/24 at 1:35 PM, Staff F, Patient Care Technician was performing a disconnection of dialysis CVC access site on Patient #11. Staff F was observed opening Patient #11’s personal bag taking out a bottle of water for Patient #11. He adjusted Patient #11’s facemask and continued to assist her to drink the bottled water. He placed the water bottle back in the personal bag and continued to disconnect the CVC access sites and touching the blood lines with the same dirty gloves. Staff F did perform hand hygiene or wear a new pair of gloves as needed. In an interview conducted on 11/14/24 at 1:00 PM with the facility’s Administrator she was told of the findings.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have the proper vaccination surveillance for Hepatitis B (Hep B) for Patients Patient #3. The findings included: A review of the facility’s policy titled Hepatitis B surveillance, vaccination, infection control measures and isolation guidance, dated 01/05/02, documented: Purpose is to prevent the spread of hepatitis B infection in the dialysis setting. All permanent patients will have Hep B serologic testing drawn immediately upon admission to the facility and results known within seven days of admission. Review results and determine status and next steps. If the antibody is less than 10 the status of the patient is susceptible. Offer vaccination series. 1. Patient #3 was admitted to the facility on 08/16/24. Record review revealed Patient #3 had a Hepab of 7 on 08/16/24 (<10 indicates non-immunity for Hep B). Further record review did not reveal Patient #3 was offered the Hep B vaccination series. An interview was conducted with the Clinical Coordinator (CC) on 11/13/24 at 12:00 PM. The CC acknowledged the above. 40153”

“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: 36734 Based on record review and interview, the facility failed to complete an initial nursing assessment before the initial first treatment for 1 of 10 sampled patients (Patient #3). The findings included: A review of the facility’s policy titled Initial Patient Nursing Assessment For New Patients, dated 01/03/07, documented: A registered nurse as required by federal regulation will perform an initial pretreatment evaluation of all patients prior to the initiation of their first treatment at the facility. Patient #3 was admitted to the facility on 08/16/24. Record review did not reveal an initial nursing assessment prior to the start of treatment on 08/16/24. An interview was conducted with the Peritoneal Dialysis Nurse (PD) on 11/13/24 at 12:00 PM. The PD nurse acknowledged the above.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) 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- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to complete an unstable care plan for 1 of 3 sampled unstable patients (Patient #9). The findings included: A review of the facility’s policy titled Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, dated 01/14/01, documented: Unstable patient’s assessment and care plan will be done monthly until patient is determined by the interdisciplinary team to be stable. Patient #9 was admitted to the facility on 07/20/21. A review of 6 months of care plans revealed a missing care plan for 10/25/24. An interview was conducted with the Clinical Coordinator (CC) on 11/14/24 at 10:00 AM. The CC acknowledged the above.”

“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: 51535 Based on interview and record review, the facility failed to follow the Dialysis treatment orders for BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate) and failed to follow dialysis dialysate order for 4 of 10 patients reviewed for dialysis (Patient #1, Patient #8, Patient #9 and Patient #10). The findings included: 1. A review of the doctor’s orders dated 11/09/24 showed the following: BFR at 400 millimeters (ml) per minute and DFR of 600 ml per minute. A review of chart revealed that Patient #1 was started on Hemodialysis on 08/20/24. A review of the last 10 treatments flow sheets showed the following: Treatment date 11/09/24 showed that Patient #1 received 350 ml for the BFR and 500 ml for the DFR. Treatment date 11/07/24 showed that Patient #1 received 350 ml BFR and 600 ml for the DFR. Treatment date 11/05/24 showed that Patient #1 received 400 ml BFR and 500 ml for the DFR. Treatment date 10/31/24 showed that Patient #1 received 350 ml BFR and 500 ml for the DFR. Treatment date 10/29/24 showed that Patient #1 received 350 ml BFR and 500 ml for the DFR. Treatment date 10/26/24 showed that Patient #1 received 350 ml BFR and 600ml for the DFR. Treatment date 10/24/24 showed that Patient #1 received 350 ml BFR and 500ml for the DFR. Treatment date 10/22/24 showed that Patient #1 received 350 ml BFR and 500 ml for the DFR. 2. Review of doctor’s orders dated 11/08/2024 showed the following: BFR at 400ml per minute and DFR at 800ml per minute. A review of chart revealed that patient #8 Treatment date 11/08/2024 showed patient #8 received 350 ml BFR and 800ml for DFR. In an interview on 11/13/2024 at 11:50 AM, the clinic manager states “ the technicians and staff members are required to follow the dialysis prescription as the physiscan ordered.” 40153 3. A record review revealed that Patient #10 was stared on in-house hemodialysis on 07/21/23. Treatment order dated 11/11/24 showed a BFR at 400 ml and DFR at 800 ml. The treatment flow sheet dated 11/11/24 revealed that Patient #10 was receiving BFR at 350 ml and not the 400ml as prescribed by the Physician. 36734 4. Patient #9 was admitted to the facility on 07/20/21. Record review revealed an order dated 09/18/24 until 11/06/24 for treatment for 3 hours and 15 minutes. The first 2 hours and 15 minutes was for dialysate 2K/2.5Ca, and the last hour was for dialysate 1K/2.5Ca. A review of Patient #9’s Treatment Details Report dated 10/25/24 until 11/06/24 did not reflect a change in the patient’s last hour of dialysate to the ordered 1K/2.5Ca. The record review did not reveal any documentation as to the reason for the deviation from the order for the above patients. An interview was conducted with the Clinical Coordinator (CC) on 11/14/24 at 12:00 PM. The CC acknowledged the above.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have monthly labs for 1 of 10 patients sampled (Patient#3). The findings included: A review of the facility’s policy titled Obtaining Patient Lab Specimens, dated 05/10/01, documented: Most lab specimens are drawn monthly or twice a month per physician’s order. Patient #3 was admitted to the facility on 08/16/24. Record review revealed Patient #3 did not have any laboratory values for the month of 09/24. An interview was conducted with the Peritoneal Dialysis Nurse (PD) on 11/13/24 at 12:00 PM. The PD Nurse acknowledged the above.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 51535 Based on interview and record review, the facility failed to conduct a plan of care (POC) that addresses patient needs and providing care at the facility. The findings included: The initial care plan dated 09/24/2024 does not have the physician and patient #1 signature. A review of chart revealed that Patient #1 was started on Hemodialysis on 08/20/24 and the plan of care (POC) initiated on 09/24/2024 does not have the physician and patient signature. FA was interviewed on 11/14/2024 at 1:15 PM, she acknowledges the plan of care was not signed and dated.”

“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: 40153 Based on record review and interviews, the facility failed to ensure that a monthly doctor’s notes were completed for 2 of 10 patients reviewed for dialysis (Patient #7 and Patient #4). The findings included: A review of the facility’s policy titled “Progress Note” dated 03/02/2017 revealed that the attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times. 1. A review of the clinical records showed that Patient #7 was receiving in center hemodialysis. A review of the physician’s monthly notes showed monthly notes were completed on 09/28/24 and on 10/3/124. Further review did not show any other progress notes were completed between 09/28/24 and April 2024. In an interview conducted on 11/13/24 at 2:00 PM, with the facility’s Administrator, she was not able to provide the missing progress monthly notes for Patient #7. 36734 2. Patient #4 was admitted to the facility on 03/20/23. Record review revealed Patient #4 was missing 4 months of physician progress notes from 03/11/24 until 08/30/24. An interview was conducted with the Clinical Coordinator (CC) on 11/13/24 at 12:00 PM. The CC acknowledged the above.”

“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: 36734 Based on record review and interview, the facility failed to retrieve and review Peritoneal Dialysis (PD) home treatment flow sheets for 1 of 3 PD patients (Patient #3). The findings included: A review of the facility’s policy Daily Overeaten Records (Flowsheet), dated 05/01/29, documented: The purpose is to provide guidance for proper documentation of home peritoneal dialysis treatments and to collect data to assist in assessing the patient’s response to peritoneal dialysis treatments. To provide definition of an acceptable daily home treatment record types and submission of these records. As clinically applicable, all treatment data outlined on the daily home treatment record must be collected. Completed daily home treatment records must be reviewed to assist in evaluating the patient’s progress and self-care decision making process. This post treatment data review will be verified by the peritoneal dialysis registered nurse documenting review in the medical record per guidance below: a. The licensed nurse will review the patient’s data via the submitted daily home treatment records b. The licensed nurse will report any abnormal findings or concerns. c. The RN will use their clinical judgment based on individual patients needs to determine if any clinical interventions or notification of physician is necessary. Patient #3 was admitted to the facility on 08/16/24 for home treatment. Record review on 11/14/24 revealed Patient #3’s home treatment records for 08/24, 09/24, and 10/24 was submitted on 11/13/24 and had not been reviewed. Further record review revealed the patient’s documentation was not properly submitted in the correct format and had variable inconclusive weights documented. An interview was conducted with the Peritoneal Dialysis Nurse (PD) on 11/14/24 at 12:00 PM. The PD nurse acknowledged the above.”

“PQ-SW-MSW;GRANDFATHER IF HIRED BEFORE 1976 CFR(s): 494.140(d) The facility must have a social worker who- (1) Holds a master’s degree in social work with a specialization in clinical practice from a school of social work accredited by the Council on Social Work Education; or (2) Has served at least 2 years as a social worker, 1 year of which was in a dialysis unit or transplantation program prior to September 1, 1976, and has established a consultative relationship with a social worker who qualifies under §494.140 (d)(1). This Standard is not met as evidenced by: 40153 Based on record review and interviews, the facility failed to ensure that the current facility Social Worker had the appropriate oversight and documentation by a Licensed Social Worker. The findings included: A review of the facility ’ s provided documents did not indicate that the current Social Worker was a Licensed Social Worker, and further review did not show recorded oversight hours by a Licensed Clinical Social Worker (LCSW). In an interview conducted on 11/14/24 at 12:10 PM with the facility ’ s Social Worker, she stated that she did not have any documentation or record keeping of any oversight hours by a LCSW. She stated she did not know she needed oversight hours from a LCSW since she was ready to take the state exam to become licensed.”