Davita Brookside Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 40153 Based on clinical record review, staff interview, and the facility’s policy, the facility failed to ensure that Emergency Preparedness training was completed and acknowledged for 1 of 5 patients reviewed. (Patient #3). The findings included: A review of the facility’s education titled Emergency Take-Off,” dated 2018, showed the following: “once you have successfully completed the disconnect training with your Patient Care Technician (PCT), review this card frequently.” A review of the chart revealed that Patient #3 started on in-center hemodialysis on 03/10/2025. A review of the Patient education sign-in-in-sheet showed that Patient #3 was educated on Emergency Take-Off Procedures and Evacuation Plan. The form had Patient #3’s signature but did not have the date or the name of the PCT who provided the education. In an interview conducted on 5/28/25 at 2:20 PM, the Administrator acknowledged that the education form was missing the PCT name, who provided the education, and the date that the training was completed.”

“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: 40153 Based on observations, interviews, and record review, the facility failed to practice proper hand hygiene during dialysis treatments for 2 of 11 sampled patients (Patient #7 and Patient #8). The findings included: A review of the facility policy titled “Infection Control for Dialysis Facilities” dated 01/05/2001 documents the following: Hand hygiene prior to gloving and immediately after removal of gloves, and before touching clean areas such as supplies, cart, chairside, and keyboard/mouse. 1. Patient #7 was admitted on 12/26/2020 for in-center hemodialysis. On 05/28/25, an observation was conducted, during which Staff A, a Registered Nurse, was preparing to administer Heparin medication to Patient #7. She did not wash her hands and placed one glove. With her other, non-gloved hand, she grabbed a face shield and placed it on her face. She then put the other glove on her bare hand, grabbed the Heparin syringe from the medication area, and walked over to Patient #7. Staff A proceeded to administer the Heparin medication to Patient #7. 2. Patient #8 was admitted to the facility on 09/03/2021, for in-center hemodialysis. On 5/28/25 at 9:50 AM, an observation was conducted, during which Patient #8 was preparing to be disconnected from an (Arteriovenous) AV fistula access site at station 14, machine #12. Staff F, Patient Care Technician, washed her hands and placed only one glove on while holding the other glove. With her other, non-gloved hands, she pulled clean supplies from a drawer and placed them on a clean surface. She then put on her other glove before proceeding to disconnect the access site without washing her hands first. In an interview conducted on 05/29/25 at 12:00 PM with the facility ’ s Administrator, she was made aware of the findings, and she acknowledged that the staff were not following proper hand hygiene.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 40153 Based on observation, interview, and record review, the facility failed to provide the correct/appropriate dialysis prescription for Dialysate Flow Rate (DFR) and Blood Flow Rate (BFR) for 4 of 5 record review sampled residents (Patient #1, Patient #2, Patient #3 and Patient #5). The findings included: A review of the facility ’ s policy titled “Pre-Intra-Post Treatment Data Collection, monitoring, and Nursing Assessment” dated 1/03/2008 documents the following: Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment except for blood flow rate, which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate 1. A chart review revealed Patient #1 started in-center hemodialysis on 09/06/2024. A dialysis prescription dated April 30, 2025, documents a BFR order of 400 milliliters (ml) per minute. A review of the Treatment Detail Report dated May 23, 2025, revealed that Patient #1 was provided with 300 ml and 350 ml BFR during his dialysis treatment rather than the prescribed 400 ml. A review of the Treatment Detail Report dated May 14, 2025, revealed that Patient #1 was provided with 350 ml BFR during his dialysis treatment rather than the prescribed 400 ml. The treatment records do not provide an explanation for the deviation from the dialysis prescription 2. A chart review revealed that Patient #3 was admitted to the facility for in-house Hemodialysis on March 10, 2025. A dialysis prescription dated May 2, 2025, showed a BFR order for 325mg. A review of the Treatment Detail Report dated May 26, 2025, revealed that Patient #3 was provided with 400 ml BFR during his dialysis treatment rather than the prescribed 350 ml. The treatment records do not provide an explanation for the deviation from the dialysis prescription 3. A chart review revealed Patient #5 was admitted to the facility for in-house Hemodialysis on 04/28/2025. A dialysis prescription dated 05/19/2025 showed a DFR order for 600 ml. A review of the Treatment Detail Report dated 05/26/2025 revealed Patient #5 was provided with 500 ml DFR and not the prescribed 600 ml as per order. The treatment records do not provide an explanation for the deviation from the dialysis prescription In an interview conducted on 05/29/25 at 12:00 PM with the facility ’ s Administrator (FA), she was made aware of the findings, and she acknowledged that the staff were not following the orders for DFR and BFR. 51535 4. A clinical record review conducted on 05/28/25 at 4:00 PM, revealed Patient #2 has physician orders for dialysis treatment for Blood Flow Rate (BFR) of 400 ml/min (milliliter/minute). Clinical treatment record dated 05/16/25 indicates the patient did not receive the prescribed BFR 400 for 2 hours 58 minutes of 3 hours 30 minutes of treatment. 05:06 AM treatment started at BFR 300 which continued throughout the treatment until 08:02 AM. 08:24 AM an updated data entry by Staff member (E) increased BFR 400. 08:36 AM treatment terminated. An Interview with Charge Nurse (A) conducted on 05/28/24 at 4:45 PM, she acknowledged the BFR at 300 was not the prescribed rate. She also acknowledged Staff E increased BFR to 400 at 08:24 AM. The treatment records do not provide an explanation for the deviation from the dialysis prescription.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 40153 Based on observation and interview, the facility failed to obtain an immunization history regarding Hepatitis B vaccines for 1 of the five patients reviewed (Patient #1). The findings included: A review of the facility ’ s policy titled, “Hepatitis B Surveillance Vaccination, Infection Control Measures and Isolation Guidelines” dated 01/05/2002 documents the following: An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in the Patient Registration Packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient ’ s health record. A chart review revealed Patient #1 was admitted to the facility on 09/06/2024. A Hepatitis B consent form showed that Patient #1 refused the Hepatitis B vaccine. Further review revealed that the consent form lacked the date and Patient #1 ’ s signature. In an interview conducted on 05/29/25 at 12:00 PM with the facility’s Administrator she acknowledged that the consent form was missing Patient #1’s signature and date that the form was given.”

“PA-ASSESS RENAL BONE DISEASE CFR(s): 494.80(a)(5) The patient’s comprehensive assessment must include, but is not limited to, the following: (5) Evaluation of factors associated with renal bone disease. This Standard is not met as evidenced by: 40153 Based on observations, interviews, and record review, the facility failed to evaluate the Parathyroid Hormone (PTH) lab value and failed to follow protocol for 1 of 5 sampled record review patients (Patient #1). The findings included: A review of the facility ’ s protocol for dosing of PTH dated June 2022 showed the following: For intact PTH between 0-300 mcg (micrograms), there is no initiation of Calcitriol (active form of Vitamin D) dose. For intact PTH between 301-600 mcg 0.25 Calcitriol 0.25 3 times per week. For intact PTH between 601-799 mcg, 0.75 Calcitriol 3 times per week. For intact PTH between 800-999 mcg 1.0 mcg 3 times per week. A chart review revealed Patient #1 was admitted to in-house Hemodialysis on 09/06/2024. A PTH lab dated 5/12/25 showed a lab of 921 (high). Further review of the physician ’ s orders showed an order for Calcitriol 0.5 mcg, which was dated 05/14/25. An interview with the facility ’ s Registered Dietitian (RD) on 2/28/25 at 4:15 PM stated that, since the other labs for Phosphorus and Calcium were high for Patient #1, they did not increase the medication Calcitriol as per protocol. In an interview conducted on 5/28/25 at 4:25 PM with Staff A, Registered Nurse (RN), she stated that the RD is responsible for calling the Provider regarding the high PTH level. When asked why the Calcitriol was not increased as per protocol to 0.75 for Patient #1, she stated that it should have been increased. Staff A stated that a call should have been placed to the Provider, who can make the decision to increase the dosage of Calcitriol or not. In this interview, Staff A reached out to the Provider, who gave the order to increase the Calcitriol dosage to 0.75.”

“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: 40153 Based on record review and interview, the facility failed to have a comprehensive assessment/care plan signed by all Interdisciplinary Team (IDT) members and the patients for 3 of 5 record review patients (Patient #1, Patient #3, and Patient #4). The findings included: The facility’s policy titled Interdisciplinary Team (IDT) Patient Assessment And Plan of Care,” dated 01/14/2001, showed the following: The patient’s plan of care will be completed by the facility’s interdisciplinary team, including the patient or personal representative, and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this decision will be documented on the plan of care, along with the reason for not providing the signature. 1. A chart review revealed Patient #1 was admitted for in-center hemodialysis on 09/06/24. The 90-day Plan of Care was missing the signatures of both Patient #1 and the Provider. 2. A chart review revealed Patient #3 was admitted for in-center hemodialysis on 03/10/2025. The Initial Care Plan dated 4/11/2025 was missing the Provider’s signature. 51535 3. A clinical records review on 05/29/25 at 09:00 AM of patient #4, revealed an incomplete Plan of Care dated 04/07/25, the Plan of care lacked the physician signature. An interview conducted with the Facility Administrator (FA) 05/29/25 at 10:30 AM, who confirmed the hard copy labeled Plan of Care, does not have a Physician signature.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 40153 Based on observation, interview, and record review, the facility failed to have a monthly physician progress note for 1 of 5 record review sampled patients (Patient #3). The findings included: A review of the facility policy titled “Progress Note Policy” dated 03/02/2017 documents the following: “The attending Nephrologist is required to record progress notes at least monthly an for any clinical event, which must be recorded in a timeframe that always provides other interdisciplinary team members with an up-to-date picture of the status of the patient.” A chart review revealed that Patient #3 was admitted for in-center hemodialysis on 03/10/2025. Further reviews showed that a monthly physician progress note was only written on 05/16/2025. No other monthly notes were noted for the months of March 2025 and April 2025. In an interview conducted on 05/29/25 at 12:00 PM with the facility’s Administrator she was made aware of the findings.”