Davita Casselberry Dialysis

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 13640 Based on observation, interview and facility documentation, the facility failed to ensure that testing for water hardness was performed in accordance with manufacturer’s instructions. Findings: A review of manufacturer instructions for the RPC Water Hardness Test Strips revealed the following: “ (1) Dip test strip for 5 seconds into test solution; (2) Gently shake off excess liquid; (3) After 15 seconds, compare test pad color with color scale on container; (4) Comply with package insert directions.” On 7/28/25 at 1:45 PM, Patient Care Tech #1 (PCT) was observed performing a water hardness test using an RPC Water Hardness Test Strip. During the procedure, the PCT did not wait for 15 seconds until comparing the strip with the test pad color which was on the strip container. Thus, the manufacturer specified instructions were not followed. During an interview of the BioMed manager at this time he confirmed that the 15 second requirement had not been followed.”

“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 interview, record review the facility failed to ensure the provision of the care and services to manage volume status with respect to treatment duration in two of seven sampled patients, (#2, #7). Findings: 1. A review of Patient #7’s medical record revealed physician orders dated 7/12/25,that read. treatment time 2 hours and 45 minutes, (165 min). A review of the Treatment Details Report dated 7/18/25 revealed that the patient began hemodialysis treatment at 11:25 AM and it ended at 12:58 PM. This means that the patient received 93 minutes out of the ordered 165 minutes of hemodialysis treatment. A nurse’s note of 12:58 PM, the time of the termination of treatment, read: “Patient blood returned without complications; patient requested early termination due to persistent right lower leg pain; 250 normal saline rinseback.” The patient signed the “Early Termination of Treatment Against Medical Advice” form on 7/18/25, in which the patient attested to understanding the risk of terminating hemodialysis treatment prior to the prescribed time. There was nothing in the medical record which indicated that the patient was offered any additional treatment time. A review of facility policy Prescribed Treatment Time Not Met revealed the following: “Purpose: Provide requirements for teammates to follow when a patient’s treatment time is terminated early or extended. . . . Policy: . . . B. Prescribed Treatment Time Not Met. . . If the shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any).” There was no evidence in the medical record that such notification was performed. The policy continued: “If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, as appropriate: . . . Whether the patient’s nephrologist was notified. A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any). A description of all other interventions planned to address the shortened treatment, including recommendations to the patient.” There was no evidence in the medical record indicating that this was done. On 7/29/25 at 1:00 PM, the Manager of Clinical Services confirmed there was no additional documentation in the medical record regarding the early termination of hemodialysis treatment on 7/18/25. 37965 2. A review of the record for patient #2 revealed she was admitted to the dialysis center on 5/10/2023 and was receiving dialysis treatments three times a week for 3 hours per treatment. Review of the Assessment & Plan revealed “Reinforced tx (treatment) compliance. Signs off AMA frequently”. The note is electronically signed by the Physician’s Assistant on 7/14/25 at 10:32 AM. Further review of the record revealed the patient terminated her treatments early on 3 occasions between the dates of 7/7/25 and 7/25/25. She terminated early on 7/11/25, treatment was initiated at 9:40 AM and terminated at 11:59 AM. The staff noted, “pt (patient) requested to terminate early due to cramping, RN (Registered Nurse) notified. The Facility Administrator stated on 7/29/25 at approximately 2:30 PM, that he was unable to find an Early Termination of Treatment Against Medical Advice for this date. There is no documentation in the record that the patient was offered an extra treatment or provided other alternatives. On 7/16/25 patient #2’s treatment was initiated at 10:00 AM and terminated at 11:55 AM. The staff noted “Treatment terminated. Patient blood returned without complications. Pt (patient) req (requested) termination due to leg pain”. The comments section of the treatment note stated, “The patient made a repeated request to end the treatment early due to a doctor’s appoint; patient denies pain after dialysis. BP elevated. Patient asymptomatic, patient will receive her BP medications once she is back in the nursing home discharged stable per wheelchair.” A review of the Early Termination of Treatment Against Medical Advice dated 7/16/25 stated, “I (patient’s name) request to terminate my dialysis treatment prior to the prescribed time. I am fully aware that this is against the medical advice of my physician. The risk and consequences of terminating my treatment early have been previously explained to me by my physician. I understand that if, before my next treatment, I have any unusual symptoms such as shortness of breath or chest pain I should immediately contact my physician. I hereby willfully assume the risk of my early termination of dialysis treatment and agree not to hold my physician, the dialysis facility, its employees or agents responsible for any harm or injury which may result from my action.” The form stated the Prescribed treatment time was 180 minutes and that it has been shortened by 63 minutes. Reason is noted as “Patient request due to chronic bilateral lower leg pain.” There is no documentation in the record that the patient was offered an extra treatment or provided other alternatives. On 7/25/25 patient #2’s treatment was initiated at 10:06 AM and terminated at 12:27 PM Review of the treatment record for the date of 7/25/25 revealed the patient has ended her treatment after 2 hours and 21 minutes. The comments section of the treatment note stated, “The patient made a repeated request to end the treatment early due to a doctor’s appoint; patient denies pain after dialysis. BP elevated. Patient asymptomatic, patient will receive her BP medications once she is back in the nursing home discharged stable per wheelchair.” A review of the Early Termination of Treatment Against Medical Advice dated 7/25/25 stated, “I (patient’s name) request to terminate my dialysis treatment prior to the prescribed time. I am fully aware that this is against the medical advice of my physician. The risk and consequences of terminating my treatment early have been previously explained to me by my physician. I understand that if, before my next treatment, I have any unusual symptoms such as shortness of breath or chest pain I should immediately contact my physician. I hereby willfully assume the risk of my early termination of dialysis treatment and agree not to hold my physician, the dialysis facility, its employees or agents responsible for any harm or injury which may result from my action.” The forms stated the Prescribed treatment time was 180 minutes and that it has been shortened by 41 minutes. Reason is noted as “the patient made a repeated request to end the treatment due to a doctor’s appointment per patient’s verbalization.” There is no documentation in the record that the patient was offered an extra treatment or provided other alternatives.”