Davita Orlando Southwest 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: 50131 Based on observations and interview with staff, facility failed to ensure common medication carts were not being used to deliver medications to patients. FINDINGS: Observations of a medication pass on 02/26/24 at 11:30 a.m., noted RN-B using a common medication cart to deliver medications to individual patients while they were receiving their dialysis treatments. Continued observations noted RN-B pushing the cart from one dialysis station to another to administer prepared medications for up to 12-14 patients until all medications were administered. Interview with RN-C on 2/28/24 at 11:40 a.m. confirmed this practice as being a routine practice stating they use a common medication cart to deliver medications to the patients so they do not have to walk back and forth from the medication area.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 50131 Based on observations of facility’s medication storage and interview with staff, facility failed to provide dialysis patients with a safe treatment environment by not ensuring medication vials/bottles were dated upon initial opening for use. Findings: During an inspection of facility’s medication on 2/26/24 at 10:15 a.m., several multidose vials and PO (“per os” which is Latin for by mouth, indicating oral route administration of medication) medication bottles were observed to be open and without dates of when they were opened and without initials of who opened them. These medications included: 1- Three vials of multidose Heparin 30 ml (milliliters) vial -1:1000u concentration with a manufacture expiration date of 9/21/25. 2- Clonidine 0.1 mg (milligram) with a manufacture expiration date of 03/2026. 3- Cinacalcet 30 mg with a manufacture expiration date of 10/24. 4- Cinacalcet 60 mg with a manufacture expiration date of 08/26. 5- Calcitriol Cap 0.25 mcg (microgram) with a manufacture expiration date of 05/25. 6- Calcitriol Cap 0.5 mcg with a manufacture expiration date of 07/25. A review of facility’s policy: 1-06-01 Title: MEDICATION POLICY with a revision date of November 2023 stated: “If multidose vials are used, they must be dated upon opening and discarded within 28 days unless the manufacturer specified a different date for that medication”. Interview with RN-C on 2/28/24 at 11:15 a.m. confirmed these findings. He stated that he started putting dates on the heparin vials just this week when it was pointed out to the nurses during survey.”

“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: 13640 Based on observation, interview, record review and a review of facility documentation, the facility failed to ensure that patients received the prescribed dose of dialysis in the form of blood flow rate, correct dialysate bath and frequency of assessments to enable a timely response to blood pressure changes in four of eight sampled patients. (#3, #6, #7, #8) Findings: During observations in the facility on 2/26/23 at approximately 10:30 AM of patient #6, the dialysate bath was found to be 2 K (potassium) 2.5 Ca (calcium). A review of the medical record revealed physician orders of 1/10/24 reading: “Dialysate: 2K (potassium) and 3 Ca (calcium) . . . “ Record review indicated the treatment session had started at 10:11 AM. There were no entries in the record which gave a reason for using 2K 2.5 Ca instead of the ordered 2 K 3 Ca. During an interview with RN-A on 2/26/24 at approximately 10:45 AM, he stated he forgot to place the patient on a 2 K 3 Ca. During observations in the facility on 2/26/23 at approximately 10:35 AM of patient #7, the dialysate bath was observed to be 2 K (potassium) 2.5 Ca (calcium). Review of the medical record revealed physician orders of 2/15/24 which read: “Dialysate: 2K (potassium) 3 Ca (calcium) . . . “ Review of the record indicated the treatment session had started at 9:19 AM and there were no entries in the record which gave a reason for using 2K 2.5 Ca instead of the ordered 2 K 3 Ca. During an interview with PCT-A on 2/26/24 at approximately 10:48 AM, she stated that she “did it wrong.” During observations in the facility on 2/26/23 at approximately 10:52 AM of patient #8, the blood flow rate was observed to be running at 350 ML/Min (milliliters per minute). Review of the medical record revealed physician orders of 2/10/24 which read: “Blood Flow Rate 400 ML/Min. Review of the record indicated the treatment session had started at 6:49 AM with a Blood Flow Rate of 350 ML/Min running throughout the entire session. There were no record entries which gave a justification for running at 350 ML/Min. During an interview of PCT-B on 2/26/24 at approximately 10:58 AM, she stated the blood flow rate was lowered because of difficulty with the patient’s access. However, she confirmed she had not written a note in the medical record explaining the basis for the patient having a change in the blood flow rate and different from what was prescribed. Review of facility policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment revealed the following: The assessment includes the following components: . .. Verification of prescription including machine parameters. . . . Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. . . Prescription components include but are not limited to: . . . Blood flow rate . . . Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings.” Also: “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.” The facility was not in compliance with this policy. A review of the medical record of patient #3 revealed physician orders of 12/6/23 for a treatment time of 3 hours and 30 minutes (210 minutes). The record revealed that on 2/16/24, a hemodialysis treatment session began at 3:44 PM and ended at 6:48 PM. Aside from these two times, the record showed that the patient’s blood pressure was assessed at the following times: 5:18 PM; 5:48 PM; and 6:18 PM. The gap between 3:44 PM and 5:18 PM exceeded 30 minutes. A review of facility policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment revealed the following: “Data collection includes but is not strictly limited to: . . . Measurement of blood pressure (BP) . . . Intradialytic BP in the sitting/reclined or supine position.. . . Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes Vital signs and treatment monitoring. For non-nocturnal treatments is completed at least every thirty (30) minutes. . . . At a minimum, obtain and document the following: Blood pressure.” There were no 30 minute assessments between 3:44 PM and 5:18 PM. The facility was not in compliance with this policy. Interview with the Administrator on 2/27/24 at approximately 10:35 AM, noted he confirmed facility’s non-compliance with policies for the noted dialysis treatments.”