Caring Heart Metro West Dialysis LLC

“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: 13640 Based on observation, interview and a review of facility documentation, the facility failed to ensure the implementation of a process to confirm that emergency drugs in the form of Epipens were on the premises at all times and immediately available. Findings: During a review of the Emergency Crash Cart Checklist on 8/19/20 at approximately 9:56 PM, it was noted that one of the required items included two each of “Epipen 0.1 MG.” Inspection of the contents of the Emergency Crash Cart revealed that instead of two Epipens, there were two vials of “Epinephrine Injection 1 MG / ML. A review of facility policy Emergency Crash Cart Checks revealed the following: “Using the Emergency Crash Cart Checklist two RN’s will: Verify presence of all items by checking them off on the Emergency Crash Cart Checklist.” Therefore, nurse’s would need to check for the presence of two Epipens. During an interview of the Administrator on 8/20/24 she stated that she could not produce any internal documentation which authorized a divergence from what was stated to be a requirement on the Emergency Crash Cart Checklist. Thus, the facility was not in compliance with its policy.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 13640 Based on observation and interview, the facility failed to ensure that the facility was equipped to provide a safe treatment environment with non-expired medications. Findings: During an observation of the medication storage area (in a drawer) on 8/19/24 at 9:46 AM, a 250 ML bag of “0.9% Sodium Chloride Injection USP” was observed. The label had an expiration date which read “FEB 24 EXP.” Director of Nursing confirmed at this time, the expiration date expired in February 2024. A review of facility policy Infection Control Practices and Procedures for Dialysis Facilities and Treatments Performed in the Home revealed the following: “All medications are checked for expiration before each use. Dispose of expired medications immediately.” The facility was not in compliance with their own policy.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 39943 Based on observation and interview, the facility failed to ensure that a patient’s vascular access site was in full view of staff during hemodialysis treatment for 1of 10 sampled patients (#6). Findings: On 8/19/24, patient #6 was observed from 9:35 AM-10:05 AM lying in a treatment recliner sleeping. She was covered with a blanket from her neck to her feet. Her access site was not visible at any time during the observation. Patient Care Technician (PCT) A, PCT B and the Director of Nursing (DON) walked past the patient several times during the observation but did not stop to have patient #6 uncover the access site. On 8/19/24 at 10:05 AM, PCT A acknowledged the dialysis access site was not able to be observed due to the covers. He woke up patient #6 and instructed her to keep her left arm on top of her blanket so he could observe the site. PCT A stated the access site should always remain in site because if it is covered over, the needle could become dislodged, and the patient could bleed out very quickly. On 8/19/24 approximately 1:30 PM the Administrator stated that patients are educated to keep their access site uncovered. She stated that some of the patients were told and ten minutes later they have the site covered again. She was frustrated by the fact that the patients did not listen and was not sure what to do to ensure their access site remained uncovered. Review of the “Checking Vital signs during the Hemodialysis Treatment” effective 1/02/17 and revised 1/11/19 read: Every 30 minutes, or every 15 minutes if the patient is unstable, obtain a blood pressure and pulse reading and record the findings in the electronic medical record. Perform safety checks at each blood pressure interval: Visualize the patient access lines and face at all times to ensure that they are connected and visible (do not cover under a blanket).”

“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 observations, interview and record review, facility failed to follow hemodialysis orders and to provide documented reasons for not following the prescribed blood flow rate and dialysis flow rate in response to estimated dry weights for 4 of 5 patients reviewed for dialysis prescription, (#1, #2, #3, #4). Findings: 1. A review of physician orders for patient #1 of 7/30/24 revealed the following: “Dialysate flow rate: 800.” A review of the hemodialysis treatment flowsheet of 8/12/24 for patient #1 revealed that treatment started at 6:24 AM and ended at 9:58 AM. During the treatment, the dialysate flow rate was maintained at 500 milliliters per minute. There were no entries in the medical record which explained this variance from what had been ordered or otherwise authorized it. During an interview of the Director of Nursing on 8/20/24 at 12:30 PM, she confirmed the variance between what had been ordered and what had been performed for patient #1. She stated that she could not find any documentation which addressed the variance. 39943 2. Patient #2 was admitted to the dialysis center on 3/27/24 and required dialysis due to hypertension. Patient’s treatment orders dated 8/13/24, included an order for an estimated dry weight (EDW) of 57.0 kilograms(kg.), treatment 3 times per week and each treatment to run over 3 hours and 30 minutes. 9 treatment sheets were reviewed from 4/29/24-8/16/24. The resident had multiple hospitalizations which caused her to not be in the treatment center 3 times per week. The treatment sheets indicated the patient exceeded her EDW for 5 of 9 treatments. Treatment sheet dated 4/29/24 indicated the patient’s post dialysis weight(wt.) to be 58.0 kg. No documentation was found to include a discussion with the patient regarding the elevated wt. or offering of an extended treatment time or an extra treatment. Treatment sheet dated 5/20/24 indicated the patient’s post dialysis wt. to be 60.0 kg. No documentation was found to include a discussion with the patient regarding the elevated wt. or offering of an extended treatment time or an extra treatment. Treatment sheet dated 6/21/24 indicated the patient’s post dialysis wt. to be 60.8 kg. A note indicated the resident had an elevated blood pressure and refused medication. She requested to have her treatment stopped after 2 hours and 30 minutes. There was no note indicating an extended treatment, or an extra treatment was offered. Treatment sheet dated 6/26/24 indicated the patient’s post dialysis wt. to be 59.1 kg. A note indicated the patient leaving over the dry wt. Patient was reminded of the importance of dietary and fluid restriction, however, there was no note to indicate an extended treatment or an extra treatment was offered. 3. Patient #3 was admitted to the dialysis center on 9/29/21 and required dialysis due to diabetes. His treatment orders dated 7/30/24, included an order for an EDW of 99.0 kg., treatment 3 times per week, and each treatment to run over 4 hours and 30 minutes, blood flow rate (BFR) 400, Dialysate flow rate (DFR) 600. Review of patient #3’s treatment records from 7/29/24-8/14/24 indicated the patient’s post dialysis wt. exceeded his EDW 5 out of of 9 treatments, and the DFR was at the incorrect rate for 2 of 9 treatments. Review of the treatment record dated 8/09/24 and 8/12/24 indicated the DFR was set at 500 milliliters/minute (ml/min) for the duration of the treatment. On 8/12/24, the treatment record had a note explaining the BFR was reduced to 350 because the access infiltrated. There was no documentation to explain why the prescribed parameters for the DFR were not followed on either treatment record. Treatment records indicated the resident ‘s post dialysis wt. exceeded his EDW on the following dates: 7/29/24 - 100.8 kg., 8/05/24 - 100.8 kg., 8/07/24 - 101.3 kg, 8/09/24 - 100.5 kg., 8/12/24 - 100.6 kg. There was no documentation noted to indicate an extended treatment, or that an extra treatment was offered. 4. Resident #4 was admitted to the facility on 4/05/24 and required dialysis due to diabetes. His treatment orders dated 7/24/24, included an order for an EDW of 83.0 kg., treatment 3 times per week and each treatment to run over 3 hours and 30 minutes, blood flow rate (BFR) 400, Dialysate flow rate (DFR) 800. Treatment records reviewed for 7/29/24-8/14/24 indicated patient #4’s BFR was set at 350 ml/min on 7/29/24 and 8/05/24 without orders or documentation to explain why the prescribed parameters for BFR were not followed on either treatment record. On 8/20/24 at approximately 2:30 PM the Director of Nursing stated the previous order for the BFR was 350 and that could have been why the error occurred. She could not explain why the DFR was at the incorrect rate for patient #3 nor why the post dialysis weights were not addressed for patients #2 and #3. The policy for “Physician Standing Orders” effective 1/01/17 read: Standing orders/non-routine orders are provided for facility personnel to provide patient care and to ensure that certain orders are met on a routine basis for all patients. Any additional order written by a Nephrologist or given orally may supersede the standing order. It is the responsibility of the Nurse/Director of Nursing to ensure that treatments are: Performed as prescribed.”