Davita Orlando Airport 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: 39943 Based on observation, interview, and record review the dialysis center failed to timely implement emergency equipment check procedures for their emergency crash cart for 1 of 1 crash cart. Findings: On 5/08/24 at 2:10 PM, observation revealed one emergency [crash] cart on the dialysis treatment floor. The crash cart contained emergency mediations for allergic reactions, and other emergencies. The crash cart had emergency equipment on top of it. There was a suction machine, an automated external defibrillator (AED), airways, and an artificial resuscitator (ambu bag). Emergency oxygen tanks were noted to the right side of the crash cart. On 5/08/24 at 3:00 PM, a review of the Emergency Crash Cart check list with the Facility Administrator (FA) confirmed the crash cart did not have a par list of medications and equipment check list and the FA could not state when the emergency cart contents were last checked. The FA stated the Manager of Clinical Services (MCS) completed a facility wide safety check and the emergency cart was among the concerns found during the safety check. She stated the facility had a QAPI in place and stated the facility had 30 days to bring the emergency cart into compliance. The facility’s ‘Emergency Equipment Checklist’ was then reviewed with the FA. It revealed that the emergency equipment which included the AED was last checked on 4/29/24, 9 days earlier. The FA acknowledged that the emergency equipment was supposed to be checked on a weekly basis. She said that the AED should be checked every day for a green light and check mark and that the Emergency Medication Breakaway Lock was intact. The “Daily Zoll AED and Emergency Medication Lock Log,” revealed the log only had documentation of being checked five days out of eight. The FA acknowledged the items were not checked daily. She stated it was the nurse’s responsibility to check the emergency cart. On 5/08/24 at 5:40 PM the FA stated the facility had a QAPI for the Emergency Crash Cart and they have been doing audits on the concerns found during the safety check. She stated the facility had thirty days to fix all the concerns. Review of the list of audits being completed included, daily AED checked, daily water log complete, glucometer log complete, and Patient head and access uncovered. She acknowledged that the Emergency Cart should not take thirty days and should have been addressed sooner. On 5/09/24 at 9:45 AM, the MCS stated the facility is not required by policy to have a list of what is in the crash cart. She did acknowledge that the facility takes the Emergency Crash Cart with them if and when they had to evacuate and she agreed there should be a list of contents for the cart. On 5/09/24 at 10:15 AM, the MCS checked the Emergency Cart and found expired supplies to include six-1 liter bags of Normal Saline. The MCS stated she expected the cart to be checked as required and should have no expired supplies. Review of the dialysis center’s policy and procedure, ‘Emergency Equipment Checks”, Origination date September 2007 and last revised, April 2024, included the following: “Purpose: To verify that emergency equipment is maintained in a ready-to-use condition. ... The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional. Daily: Check Status Indicator lights for [AED] ... Check break away lock is intact. ... Weekly: [Check] Oxygen supply is adequate ... Airways are available ...Suction is operational ... AED is operation and pads are compatible with AED device ... Ambu bag is operational ... Emergency cart (crash cart is clean, operation and supplies/medications have not expired ... . A list of all dated supplies will be posted with the expiration dates, on the cart and is to be checked weekly by licensed nurse teammate assigned to check the emergency cart.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 13640 Based on observation, interview and a review of facility documentation, the facility failed to ensure the maintenance of a sanitary environment concerning residue on or beneath PVC pipe elbows through which water drains out from the hemodialysis machines, water drips from a pipe elbow, as well as stained surfaces on water boxes and hemodialysis machines in 12 of 24 hemodialysis stations (2, 3, 6, 9, 12, 13, 15, 16, 17, 20, 22 and 23) and 1 of 26 hemodialysis machines . ( #14) Findings: During an observation of the treatment floor from approximately 9:30 AM to 9/55 AM the following was found. White colored residue was observed on the floor beneath the cabinets that housed water distribution and drainage piping. They were isolated to areas directly beneath respective PVC pipe elbows through which drainage water from the hemodialysis machines was directed for disposal. These elbows protruded from the bottom of the cabinet structures. This involved the following stations: 2, 6, 12, 15, 16, 17, 20, 22 and 23. A white, caked residue was observed on the PVC pipe elbows through which drainage water from the hemodialysis machines was directed for disposal. This involved station #2. Brown / black staining was observed on the PVC pipe elbows through which drainage water from the hemodialysis machines was directed for disposal. This involved the following stations: 3 and 9. Brown staining was observed on the lower, horizontal aspect of the framing of the water box at station 6. It was through this part of the frame that a vertical PVC pipe was positioned for the drainage water from the hemodialysis machines and was directed to a PVC pipe elbow for disposal.. Brown staining was observed on the horizontal platform on the front side of the hemodialysis machine, near floor level, on machine #14. This platform is commonly used to house jugs. A slow water drip was observed from PVC pipe elbows through which drainage water from the hemodialysis machines was directed for disposal, for station #13. A review of facility policy Infection Control for Dialysis Facilities revealed the following: “The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. . . . Teammates will monitor and address wall box residue / build up and patency issues.” During an interview of the Biomedical Manager on 5/9/24 at approximately 10:20 AM, he stated that the staining was residue. He confirmed that the affected areas as described above had not been cleaned appropriately. During an interview of the Administrator on 5/9/23 at approximately 12:02 PM, she confirmed the preceding.”

“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 a review of facility documentation, the facility failed to ensure that staff was competent in the process of testing total hardness of water. Findings: During an observation of testing for water hardness on 5/8/24 at approximately 11:10 AM by PCT- A, she was observed to read the strip for comparison to a color scale immediately upon removing the strip from the water sample. A review of the instructions for use of the testing 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. Since the strip was evelauated immediately, the manufacturer’s instructions had not been followed. During an interview of PCT-A at the above stated time, she confirmed that she should have waited 15 seconds to compare the test pad color.”

“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: 39943 Based on observation and interview the facility failed to ensure that equipment in the form of Vacutainer blood collection tubes were maintained with respect to expiration dates to provide a safe treatment environment. Findings: During an observation of the lab area of the facility on 5/8/24 at approximately 2:45 PM the following blood collection tubes were found to be expired: 4 containers of 100 purple top tubes expired 12/31/23 3 containers containing 100 purple top tubes and 1 container with 99 tubes expired 1/31/24 1 container containing 100 purple top tubes expired 3/31/24 3 marble top tubes expired 3/2024 3 gray top tubes expired 3/2024 8 Microorganism Collection and Transport collection kits expired 0 n 9/13/24 and 4 expired on 12/07/23 2 blue top saline collection tubes expired on 1/24. On 5/08/24 at 2:56 PM the Facility Administrator (FA) stated the facility does not have an inventory tech. She stated that whoever receives the delivery will look at the current supply and remove anything that is expired. The FA reviewed the expired tubes found and acknowledged the expiration dates.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 39943 Based on observation and interview, the dialysis center failed to display the complaint contact information of the State Agency and for patient access and use. Findings: On 5/08/24 at 9:15 AM, observation of the dialysis center’s front lobby area revealed the mailing address and telephone complaint hotline number to the State Agency was not posted. At 2:30 PM, observation of the patient treatment and care areas revealed the State Agency complaint contact information was also not posted in those areas. On 5/08/24 at 9:30 AM, the Administrative Assistant (AA) said she could not locate the State Agency poster and was not sure why it was not in the lobby. On 5/08/24 at 11:30 AM the Facility Administrator (FA) looked in the lobby for the State Agency poster and acknowledged the State Agency Poster was not in the lobby. She stated the facility just decorated the lobby and it must have been removed and not replaced.”

“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 record review and interview the facility failed to ensure patients had reached their target weight/estimated dry weight (EDW) during treatment and failed to implement a corrective action plan when the EDW was not achieved for 2 of 7 sampled patients (#1 and #7). Findings: On 5/09/24 while completing a review of patient #1’s medical record, it was noted that the physician prescribed EDW was 94.5 kilogram (kg). The patient was prescribed three treatments a week and the prescribed treatment time was three hours and thirty minutes. The staff failed to identify that patient #1 had not achieved the prescribed EDW on seven of nine treatments and failed to give a reason why the EDW was not attained. Patient #1 did not reach their EDW goal on the following dates: 4/19/24- post wt. 95.0 kg., 4/24/24-post wt. 95.2 kg., 4/26/24-post wt. 95.0 kg., 4/29/24- post wt. 95.2 kg., 5/02/23- post wt. 95.5 kg., 5/06/24-99.5 kg., and 5/08/24- post wt. 95.0 kg.. On 5/09/24, while completing a review of patient #7’s medical record, it was noted that the physician prescribed EDW was 74 kg.. The patient was prescribed three treatments a week and the prescribed treatment time was three hours and forty five minutes. Review of the treatment flow sheets from 4/18/24 to 5/07/24 revealed that patient #7 did not achieve the prescribed EDW on five of nine treatments. Pt. #7 did not achieve the prescribed EDW goal on the following dates: 4/18/24-post wt. 74.6 kg.,4/27/24-post wt. 74.8 kg., 4/30/24-post wt 74.7 kg., 5/04/24-post wt. 74.7 kg., 5/07 24-post wt. 75.3 kg.. Further record review for patients #1 and #7 revealed that there was no evidence, after each treatment, that staff identified the patients had not achieved their respective EDWs nor had they implemented a plan such as scheduling an extra treatment, increased treatment time or ensuring that the dialysis machines’ settings and ultrafiltration rates were correct, to ensure that the prescribed EDW was attained. There was no evidence on the treatment flow sheets that staff had offered an extra treatment so patients #1 and #7 could achieve the doctor prescribed dry weight. On 5/09/24 at 5:10 PM, the Facility Administrator (FA) stated that staff should have addressed the fact that the EDW was not achieved. The FA was unable to explain why #1 and #7 did not have more fluid removed during the dialysis treatment. On 5/10/24 at 6:00 PM the Manager of Clinical Services and the Facility Administrator stated that the IDT (Interdisciplinary Team) met weekly and reviewed and discussed patient charts. One of the areas reviewed is fluid and blood pressure management. Both the FA and MCS acknowledged that #1 and #7 had not been discussed in the IDT meetings regarding not meeting their EDW.”