Davita Pembroke Pines Dialysis

“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: 36734 Based on observation and interview, the facility failed to have medication under the supervision of licensed personnel. The findings included: A review of the facilities policy titled medication policy dated 01/06/01 documented non refrigerated medications are to be stored in cabinets and locked at the close of each business day or if not under supervision by the licensed teammate. An observation of the facility’s treatment area was conducted on 09/16/24 at 11:00 AM. A medicine cup containing pills were observed on the chair side table of Patient #8. Further observation of the treatment area revealed there was no licensed personal in the vicinity or in view of the medication. An interview was conducted with Patient #8 on 09/16/24 at 11:05 AM. Patient #8 stated he takes his medication after his treatment was completed. An observation of Patient #8’s dialysis machine revealed the patient had 2 hours of treatment remaining. An interview was conducted with the Charge Nurse (CN) on 09/16/24 at 11:30 AM. The CN acknowledged the above.”

“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: 36734 Based on observation and interview, the facility failed to have medications labeled appropriately. The findings included: A review of the facility’s policy titled Medication Policy, dated 01/06/01, documented: All syringes prepared from single use vials ampules or multi dose vials should be prepared and administered within a four hour period. If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or it is to be administered by another teammate, the medication must be labeled with the patient’s name, name of medication, date, time prepared, dose and initials of teammate preparing the medication. An observation of the medication preparation area was conducted on 09/16/24 at 10:30 AM. Approximately 15 syringes filled with medications were observed. 1. On 09/16/24 at 10:00 AM, Staff H, a Licensed Practical Nurse, was observed grabbing a syringe filled with medication and administered the medication to Patient #13. An immediate interview was conducted with Staff H. Staff H stated she administered heparin to Patient #13. Staff H confirmed the medication was not dated and timed. 2. On 09/16/24 at 10:30 AM, the Charge Nurse (CN) was observed retrieving a syringe filed with medication from the medication preparation area. The CN was observed administering the medication to Patient #6. An immediate interview was conducted with the CN. The CN stated she administered heparin to Patient #6. The CN confirmed the medication was not dated and timed.”

“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: 40153 Based on interviews and record review, the facility failed to track immunization status and have the appropriate documentation regarding Pneumonia, Hepatitis B, and Influenza vaccines for 2 out of the 10 patients reviewed (Patients #1 and Patient #3). The findings included: A review of the facility policy titled “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” revised in March 2008 revealed the following: the patient will consent to the vaccination or will decline. The completed form will be kept in the patient ’ s health record. A review of the facility ’ s policy titled “Seasonal Influenza Management” revised in April 2018, revealed that the vaccine is needed to prevent the spread of seasonal influenzas infections in the dialysis setting. 1. A chart review revealed that Patient #1 was started on home Peritoneal Dialysis on 07/29/24. A review of the Influenzas vaccine consent form showed that Patient #1 refused the vaccine but did not have the date or the time the consent form was signed or given to Patient #1. A review of the Pneumococcal vaccine consent form showed Patient #1 refused the vaccine but did not have the date or the time that the consent form was signed or given to Patient #1. A review of the Hepatitis B vaccine ’ s consent form showed Patient #1 refused the vaccine but did not have the date or the time the consent form was signed and given to Patient #1. In an interview conducted on 09/17/24 at 12:00 PM with the facility Administrator, he acknowledged the above vaccine consent forms were missing the date and the time it was given to Patient #1. 36734 2. Patient #3 was admitted to the facility on 09/13/23. Record review did not reveal any documentation of the patient’s immunization history for receiving or declining Hepatitis B vaccination. An interview was conducted with the Facility Administrator (FA) on 09/17/24 at 1:00 PM. The FA acknowledged the above.”

“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: 40153 Based on interviews and record review, the facility failed to complete an Initial Care Plan for 1 out of 10 patients reviewed (Patient #2). The findings included: A review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised in September 2008, revealed that a Comprehensive assessment will be conducted on all new patients within 30 days or 13 dialysis sessions for hemodialysis, beginning with the first outpatient dialysis treatment. A chart review revealed that Patient #2 was admitted to the facility on 07/25/24 for in- center Hemodialysis. Further review showed that the Initial Care Plan was started on 09/12/24, about seven weeks after Patient #2 started dialysis treatment. In an interview conducted on 09/19/24 at 1:00 PM with the facility Administrator, he acknowledged that Patient #2 ’ s initial care plan was not started on time.”

“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 a monthly plan of care for 3 of 10 patients reviewed (Patient #3, #5, and #2). The findings included: A review of the facilities policy titled Interdisciplinary Team Patient Assessment and Plan of Care dated 01/14/01 documented: A comprehensive reassessment of each patient and a revision in the plan of care will be conducted at least monthly for unstable patients. 1. Patient #3 was admitted to the facility on 09/13/23. Record review revealed the patient was deemed unstable 03/15/24. Further record review revealed a missing plan of care for the months of 05/24 and 06/24. An interview was conducted with the Facility Administrator (FA) on 09/17/24 at 1:00 PM. The FA acknowledged the above. 2. Patient #5 was admitted to the facility on 08/11/20. Record review revealed the patient was deemed unstable on 03/18/24. Further record review revealed a missing plan of care for the month of 06/24. An interview was conducted with the Facility Administrator (FA) on 09/17/24 at 1:00 PM. The FA acknowledged the above. 40153 3. A chart review revealed that Patient #2 started on in- center Hemodialysis on 07/25/24. Patient #2 was in the clinic for dialysis treatments on the following days: 07/25/24, 08/13/24, 08/17/24, 08/20/24, 09/10/24, and 09/14/24. In an interview conducted on 09/17/24 at 10:35 AM with the facility Social Worker, she stated that Patient #2 has a history of missing dialysis treatments. Further chart review showed no Unstable Care Plan was started on Patient #2. In an interview conducted on 09/17/24 at 11:30 AM, with the facility ’ s Administrator he stated that Patient #2 had a common trend for missing dialysis treatments and acknowledged that an Unstable Care Plan should have started on Patient #2.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 40153 Based on interviews and record review, the facility failed to ensure Social Worker intervention in a timely manner, for 1 of 10 patients reviewed (Patient #2). The findings included: A review of the facility ’ s policy titled “Social Work Intervention and Documentation Requirements” revised in September 2008, revealed the following: “ to establish intervention and documentation parameters for social workers. The documentation should demonstrate the delivery of quality patient care. Documentation should serve as a roadmap that clearly demonstrate that thought and planning went into the care that was delivered. “ A chart review revealed that Patient #2 started on in-center Hemodialysis on 07/25/24. Further review revealed no social work interventions were provided for Patient #2 before 09/12/24. In an interview conducted on 09/17/24 at 10:35 AM with the facility Social Worker, she stated Patient #2 has a history of missing dialysis treatments and he was going through a divorce and was traveling back and forth from Miami to New York. She was not able to provide any documentation completed on Patient #2. When asked how important it is to assess patients with missing dialysis treatments and address psychosocial issues, she said,” it is very important.””

“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: 40153 Based on interviews and record review, the facility failed to ensure that the necessary signatures for acknowledging and reviewing of care plan were noted for 1 of 10 patients reviewed for Care Plans (Patient #2). The findings included: A chart review revealed Patient #2 started in-center Hemodialysis on 07/25/24. The Initial Care Plan, which started on 09/12/24, revealed the Patient and the Medical Provider did not sign the care plan. In an interview conducted on 09/17/24 at 9:45 AM, the Administrator acknowledged the Initial Care Plan was not signed by the Doctor or Patient #2. In an interview conducted on 09/17/24 at 10:25 AM, the Administrator stated that the Medical Director just signed the care plan, after surveyor intervention.”

“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: 36734 Based on record review and interview, the facility failed to have a monthly physician note for 1 of 10 Patients reviewed (Patient #3). The findings included: A review of the facility’s policy titled Progress Note Policy dated 03/02/17 documented: The attending nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a time frame that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times. Patient #3 was admitted to the facility on 09/13/23. Record review revealed the patient lacked physician progress notes for the months of 02/24 and 06/24. An interview was conducted with the Facility Administrator (FA) on 09/17/24 at 1:00 PM. The FA acknowledged the above.”