Davita Buena Ventura Lakes Dialysis

“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: 39943 Based on interview and record review the facility failed to follow orders for maintaining blood pressure during dialysis for 3 of 7 patients reviewed, (#1,#2, #5). Findings: 1. Patient #2 was admitted to the facility for dialysis on 8/12/24. The initial diagnosis for dialysis was hypertension. Physician order dated 8/13/25, read, clonidine HCI 0.1milligram-administer if systolic is greater than 190 or diastolic is greater than 110, may repeat x 4 if still hypertensive after 30-45 minutes. Review of the record revealed on 9/17/25 at 9:09 AM, revealed patient #2’s blood pressure was 152/133. No documentation that the doctor was notified or medication given/refused. On 9/19/25 at 6:51 AM patient #2’s blood pressure was documented to be 174/124 with a notation that blood pressure was taken manually due to machine false reading. There was no documentation that clonidine was given as ordered nor that the doctor was notified. Documentation revealed the blood pressure was taken manually throughout the rest of the dialysis treatment that day with the following readings: 7:24 AM- 154/116 7:54 AM- 152/111 9:02 AM- 151/116 9:47 AM- 150/113 10:05 AM -156/114 There was no documentation found to indicate that the physician was notified or that the clonidine was given or refused. 2. Patient #5 was admitted to the facility on 1/06/25. The initial diagnosis for dialysis was Type 2 diabetes. Review of the medical record Treatment Details Report revealed the following blood pressures for dates indicated. On 9/03/25 at 11:05 AM 116/37- Registered Nurse (RN) notified, no other intervention documented, 1:01 PM -140/41 2:05 PM -108/48. 9/08/25 at 12:02 PM -113/48 12:46 PM -105/49 12:59 PM -115/45 1:04 PM 95/21 1:08 PM -109/49 2:06 PM -116/37 2:17 PM -114/49. No documentation found to indicate the RN or physician were notified. 9/15/25 11:02 AM -112/46 1:02 PM -93/17 1:08 PM -72/28 1:17 PM -99/43 No documentation of notification to the RN or physician. No acknowledgement of low blood pressure. 9/17/25 at 10:25 AM -106.46 10:31 AM-97/44 11:02 AM-58/19 11:10 AM- 99/26 1:24 PM- 92/36. No documentation of notification to the RN or physician. No acknowledgement of low blood pressure. Review of the record revealed no documentation regarding the low blood pressures and no indication that the physician was ever notified. Patient Care Technician did not document acknowledgement of the low blood pressure. 52666 3. Patient #1 was admitted to the facility on 4/06/24, with a medical history of End Stage Renal Disease (ESRD) and Diabetes Mellitus Type 2. Treatment orders revealed orders for dialysis 3 days per week, 4-hour each session. Review of treatment records dated 9/02/25 through 9/23/25, revealed 4 of 9 treatments had documented elevated blood pressures, systolic blood pressure (SBP) greater than 179 or diastolic blood pressure (DBP) greater than 90 during treatments. On 9/5/25 at 8:56 AM, patient #1 arrived at the facility for his dialysis treatment. Patient #1’s blood pressure (BP) at that time was 205/108. Patient Care Technician (PCT) C notified Registered Nurse (RN) A of the elevated BP, and the dialysis treatment was initiated. At 10:16 AM, patient #1’s BP was 209/111 and RN-A administered Clonidine 0.1mg. At 11:02 AM, RN-B rechecked the BP and readjusted the cuff. Patient #1’s BP at 11:03 AM, was 202/114. The treatment was terminated at 12:50 PM by RN-B No documentation was found that indicated the physician was notified of the elevated BPs during entire treatment. On 9/6/25, patient #1’s BP ranged from 190/95 to 219/118. There was no documentation acknowledging the elevated blood pressure, or whether any medication was given or the physician notified. On 9/9/25 at 8:50 AM, the BP was 185/103. PCT D did not notify the nurse. No documentation found that BP medication was administered, or the physician notified. On 9/16/25, during the last hour and a half of the treatment. PTC C did not notify the nurse of the elevated BP ranging from 179/101 to 193/106. No documentation found that BP medication was administered, or the physician notified. On 9/25/25 at 4:00 PM, the Facility Administrator (FA) and Group-FA were interviewed regarding the policy/procedure for monitoring of vital signs, nursing assessments of patients and when to notify physicians. The FA and Group-FA both confirmed after reviewing the treatment records that the patients did not receive their medications as ordered and the physician should have been notified of the abnormal blood pressures. Review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” dated September 2007, and revised April 2024, read: Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Blood Pressure Pre Dialysis-Intradialytic-Post dialysis: Systolic greater than 180 mm/Hg pr less than 90 mm/Hg Diastolic greater than pr equal to 100 mm/Hg or less than 50 mm/Hg.”