Davita West Boynton Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 51535 Based on observation, administrative record review, and interview, the facility failed to have a readily functional emergency suction equipment available, failed to identify, and remove expired items in the emergency cart located in the peritoneal dialysis (PD) training area. The findings included: An observation of the emergency cart was conducted on 12/09/24 at 1:45 PM with the PD Registered Nurse (RN). The RN was instructed to demonstrate that the emergency suction equipment was operational. The RN could not get the emergency equipment to operate. The RN stated that the emergency suction equipment was missing “a piece”. An observation of the emergency evacuation cart was conducted with the PD nurse on 12/09/24 at 2:00 PM. The observation revealed three boxes of disposable gloves sizes (small, medium, and large) with an expiration date of 07/03/2024. An observation on 12/09/24 at 2:10 PM of the emergency evacuation kit checklist revealed that the checklist was not completed for the month of November 2024 and December 2024. The checklist was last completed for the month of October 2024. Facility policy titled “Emergency Equipment Checks” dated 01/02/08, documents “The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional. The Emergency Equipment Checklist may be used for documentation of emergency checks ... A list of all dated supplies will be posted with the expiration dates, on the cart and is to be checked weekly.” An interview conducted with PD nurse at the time of observation, she confirmed the above information.”

“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: 36734 Based on observation, policy review and interview, the facility failed to perform adequate hand hygiene for 1 of 6 patient’s observed (Patient #8). The findings included: A review of the facility’s policy titled Central Venous Catheter (CVC) procedure dated 01/04/02 documented: Hand hygiene protects patient and teammate from cross contamination. Perform hand hygiene per procedure. Put on PPE (personal protective equipment) and provide a masks to the patient. Remove old dressing and discard. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Cleanse site and CVC limbs/caps. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Apply antibiotic ointment to exit site (if prescribed). Place sterile 2x2 gauze over the catheter exit site and label the dressing with date and initials. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. An observation of Central Venous Catheter (CVC) care was conducted on 12/09/24 at 11:00 AM by Staff C, a Patient Care Technician, on Patient #8. Staff C washed her hands and donned gloves. Staff C removed the old dressing from Patient #8’s CVC. Staff C continued with CVC care utilizing the same pair of gloves throughout the entire procedure. An interview was conducted with the Facility Administrator (FA) on 12/11/24 at 12:00 PM. The FA was informed of the above.”

“BICARB CONC DISTRIB-WKLY DISINFECT/DWELL/CONC CFR(s): 494.40(a) 5.5.4 Bicarbonate concentrate distribution systems: weekly disinfection/dwell times/conc Bicarbonate concentrate delivery systems should be disinfected on a regular basis to ensure that the dialysate routinely achieves the level of bacteriological purity [required by these regulations]. For piped distribution systems, the entire system, including patient station ports, should be purged of bicarbonate concentrate before disinfection. Each patient station port should be opened and flushed with disinfectant and then rinsed; otherwise, it would be a “dead leg” in the system. Appropriate dwell times and concentrations should be used as recommended by the manufacturer of the concentrate system. If this information is not available, bleach may be used at a dilution of 1:100 and proprietary disinfectants at the concentration recommended by the manufacturer for disinfecting piping systems. 6.5 Concentrate distribution: The interval between disinfection should not exceed 1 week. If the manufacturer does not supply disinfection procedures, the user must develop and validate a disinfection protocol. This Standard is not met as evidenced by: 22517 Based on administrative record review and staff interview, the facility failed to provide evidence of disinfecting the Bicarbonate mixing system on a regular basis which did not exceed 1 week (7 days). Bicarbonate concentrates provide an excellent media for bacterial proliferation. The interval between disinfection on the Concentration distribution system should not exceed 1 week. The finding include: Review of the facility’s Bicarb System Bleach Disinfection Log revealed that the facility staff failed to provide evidence that the bicarbonate mixer was disinfected weekly (every 7 days) as follows: In September, the facility staff documented that they disinfected the Bicarb system on 9/17 however there is no documentation of the system being disinfected again until 10/01/24 (14 days later). There is no documentation that the staff disinfected the system on 09/24/24. In October, the facility staff documented they disinfected the bicarbonate system on 10/15/24 but did not document the system until 10/23/24 (8 days later). An interview was conducted on 12/10/24 at approximately 1:00 PM with the BioMed technician, who reported that the staff are responsible for completing the weekly disinfection of the Bicarbonate Mixer. An interview was conducted on 12/11/24 at approximately 12:15 PM with the Patient Care Technician, Staff A, who confirmed she is the staff responsible for performing the weekly disinfection, which is done every Tuesday. She stated she must have missed writing down one and/or she must have written the wrong date down. Review of the facility policy regarding Bicarbonate Concentrate System Disinfection, Policy:1-20-03, last revision, October 2023 do “Central bicarbonate systems should be rinsed and disinfected according to the manufacturer’s recommendations. At a minimum, the bicarbonate system (s) should be rinsed free of bicarbonate daily, at the end of the treatment day and disinfected at least weekly.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to conduct an independent pH test prior to the initiation of treatment for 1 of 6 patients observed (Patient #8). The findings included: A review of the facility’s policy titled Testing pH and Conductivity of Proportioned Dialysate and Verification of Temperature of Proportioned Dialysate, dated 01/03/02, documented: Independent pH is required to be performed prior to each treatment. An observation of discontinuation of treatment on Patient #1 by Staff C, a Patient Care Technician, was conducted on 12/09/24 at 10:30 AM. Staff C was observed disinfecting the station post treatment and setting up the machine for the next patient. An observation of initiation of treatment care was conducted on 12/09/24 at 11:00 AM by Staff C on Patient #8. Staff C was observed connecting the patient to the dialysis machine. Staff C did not conduct a pH test prior to the start of treatment. An interview was conducted with Staff C on 12/09/24 at 11:30 AM. Staff C confirmed the above.”

“PA-ASSESS LAB PROFILE CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: (3) Laboratory profile, This Standard is not met as evidenced by: 51535 Based on record review and interview, the facility failed to have addressed an elevated potassium (K+) level for 1 of 9 patients reviewed. The findings included: A review of the Patient #1 medical record revealed a Potassium level of 6 on 11/25/24, 5.4 on 10/07/24, and 5.3 on 09/09/24 (above 5.5 indicates hyperkalemia). Further review of Patient #1 record did not reveal any documentation of potassium level redrawn or addressed. An interview was conducted with the Registered Dietitian (RD) on 12/10/24 at approximately 12:15 PM. She stated that she will monitor Patient #1 potassium level at next lab draw on 12/23/24. She also mentioned per Dietitian Documentation Guidance (dated 10/08/2024) a potassium level is defined as a critical lab at 6.7 or higher. She acknowledged the potassium lab result of 6.0 dated 11/25/24. An interview was conducted with Registered Nurse (D) on 12/11/24 at 2:35 PM. She states that for a potassium level greater than 5.5, she will report it and call the medical doctor. However, she was not aware of Patient #1 elevated potassium level. An interview was conducted with Registered Nurse (E) on 12/11/24 at 2:40 PM. She states that a potassium level greater than 5, she will repeat it weekly and will not wait another month. She admits that she did not document regarding the potassium result of 6 and she did not recheck the potassium level per professional standards. Registered Nurse (E) acknowledged Patient #1 potassium level of 6 and the potassium level should have been rechecked prior to the next lab date of 12/23/24.”

“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: 22517 Based on observations, clinical and administrative record review and staff interview, the facility failed to ensure the appropriate time monitoring and administration of anticoagulation medication for a random observation for Patient # 9. The findings included: 1) Review of the facility’s policy regarding Anticoagulation, Policy: 1-06-02, last revision date September 2024,documented, “To anticoagulate the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least three (3) to five (5) minutes prior to the initiation of the hemodialysis treatment.” An observation of the patient at Station # 13, Patient # 9, whose dialysis treatment was being initiated. The Registered Nurse, Staff D, administered the patient’s bolus dose of Heparin on 12/09/24 at 11:10 AM. The Patient Care Technician, Staff B, initiated the patient’s treatment at 11:12 AM, approximately 2 minutes later (noted blood flowing through the blood lines). An interview was conducted on 12/09/24 at 2:30 PM with Staff B regarding initiating the treatment after the administration of the heparin. He stated you are supposed to wait 5 minutes but he confirmed he did not wait the required amount of time before initiating the treatment, I waited about a minute!”.”

“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: 22517 Based on clinical and administrative record review and interview, the facility failed to ensure that all members of the interdisciplinary team, including the patient have completed and signed the plan of care within the designated time for 1 of 7 sampled patients (Patient # 5). The interdisciplinary team consists of, at a minimum, the patient/designee, a registered nurse, the qualified social worker, the qualified dietitian, and the patient’s physician and each team member is expected to sign the plan of care. The findings included: Review of the clinical record for Patient # 5 revealed that the patient was admitted to the facility on 11/06/24 and was prescribed to receive Peritoneal Dialysis. The patient currently remains in training. Further review of the clinical record revealed an initial 30 day assessment and plan of care had been initiated for the patient. However, further review of the clinical record for Patient # 5 on 12/11/24, revealed that the patient’s plan of care had signatures by the patient, Registered Nurse, Dietitian and Social Worker. However, it was not dated. Additionally, there was no evidence that the physician had provided input on the plan of care and had not been signed by the physician. Review of the facility’s policy regarding Interdisciplinary Team Patient Assessment and Plan of care, Policy: 5-15-02, last revision October 2024, documented, “An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days ( or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment. An interview was conducted on 12/11/24 at approximately 2:30 PM, with the Dietitian and the Administrator, who confirmed that the physician had not signed the Initial Plan of Care and would not sign it until next week.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have annual peritoneal dialysis (PD) orders for 1 of 7 sampled patients (Patient #6), and failed to have PD orders signed by a physician for 1 of 7 sampled patients (Patients #.4). The findings included: A review of the facility’s policy titled Physician Orders for Patient Care, dated 03/02/03 documented: Standing orders are to be renewed and signed annually after initial signature or more frequently in the case of home hemodialysis orders in excess of three times per week more frequent dialysis. All orders entered into the electronic health record must be signed and dated by the ordering physician within 30 days. 1. Patient #6 was admitted to the facility for treatment on 01/23/23. Record review revealed a Peritoneal Dialysis Standing order for 01/20/23. Further record review did not reveal a renewed Peritoneal Dialysis Standing order for 2024. 22517 2) Review of the clinical record for Patient # 4 revealed that the patient was admitted to the facility on 02/23/24 and was prescribed to receive home peritoneal dialysis. Further review of the clinical record revealed Peritoneal Dialysis Standing Orders signed by the Peritoneal Dialysis Nurse, indicating that the orders were verbal orders signed 03/28/24. However, as of 12/11/24, the orders had not been signed by the physician over 8 months later. An interview was conducted on 12/11/24 at approximately 10:30 AM with the PD Nurse, who confirmed the orders had not been signed by the physician. The nurse was also asked about obtaining annual orders for the patients. She stated that they did not obtain annual physician standing orders.”