Davita Tifton Dialysis

“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: 03383 Based on observation, a review of facility Policy and Procedure and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that three of four patients (P#12, P#13, P#14) observed who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal and prior to leaving the facility. Failure to perform infection control techniques such as hand hygiene, increased the risk for cross contamination with the potential to expose 86 in-center hemodialysis patients who were dialyzing at this facility. Findings were: During observation in the Patient Treatment Room on 2/21/24 between 9:00 a.m. and 10:15 a.m., the following was observed: - P #12, P#13, and P#13 who were seated at Stations (S) 14, S17 and S18 respectively, held pressure to their dialysis access sites and left the facility without performing hand hygiene. - P#12, P#13, and P#13 were not reminded by the staff to wash their hands nor were offered to use hand sanitizer after glove removal. A review of Policy: 1-05-01 titled, “Infection Control For Dialysis Facilities” last revised in April 2023 stated: Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene: b. Prior to gloving and immediately after removal of gloves, c. After contamination with blood or other infectious material, d. After patient and dialysis delivery system contact... g. Before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to: a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area... 2. Patients and caregivers will be encouraged to: a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area... According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.”

“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: 03383 Based on observation and staff interview, it was determined that the facility failed to ensure that two of two patients (P#15 and P#16) observed who were asleep, had their vascular access sites uncovered/visible to the staff throughout dialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exsanguination (severe loss of blood). The in-center hemodialysis census was 86. Findings were: During observation in the Patient Treatment Room on 2/21/24 between 9:00 a.m. and 10:15 a.m., the following was revealed: - P#15 and P#16 who were seated at Stations 15 and 14 respectively, had their dialysis access sites completely covered with a blanket. This surveyor informed PCT QQ about the covered access sites on 2/21/24 at 9:43 a.m. PCT QQ uncovered P#16’s access site, but did not uncover P#15’s access site citing behavioral issues with patient.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 03383 Based on a review of medical records, staff interviews, and a review of facility policy, it was determined that the interdisciplinary team (IDT) failed to implement the patients’ plan of care to effectively manage patient outcomes for adequacy of dialysis [effectiveness of dialysis prescriptions to avoid symptoms of uremia (build up of toxins in the blood) - measured by Kt/V], for seven of 11 sampled patients (P#1, P#2, P#3, P#6, P#8, P#9, and P#11). The facility in-center hemodialysis census was 86. Findings were: A review of treatment flowsheets dated 2/3/24 - 2/20/24 showed the following: P#1: P#1’s dialysis prescription: Treatment time: 240 minutes (4 hours), EDW (Estimated Dry Weight): 96 kg (kilogram), BFR: 400 mL/min (milliliter per minute), DFR: 600 mL/min. On 2/8/24: - P#1’s BFR was set at 350 mL/min for the entire treatment (8:32 a.m. to 10:25 a.m). - Treatment record did not show the reason for the decreased BFR. - At 6:36 a.m., RN FF verified that P#1’s prescription matched what was being delivered during the dialysis treatment when it did not match. - At 11:29 a.m., RN GG re-verified that P#1’s prescription matched what was being delivered during the dialysis treatment when it did not. On 2/10/24: - P#1 dialyzed with a BFR of 350 mL/min from 6:32 a.m. to 7:02 a.m. and was decreased to 300 mL/min until the end of treatment at 9:48 a.m. P#2: P#2’s dialysis prescriptions: Treatment time: 195 minutes (3 hours and 15 minutes), EDW: 48 kg, BFR: 400 mL/min, DFR: 700 mL/min. On 2/5/24: - P#2 dialyzed with a DFR of 600 mL/min during the entire treatment from 10:05 a.m. to 1:12 p.m. - Treatment record did not show why P#2 dialyzed with a DFR of 600 mL/min instead of 700 mL/min as ordered. - At 1:46 p.m., RN JJ verified that the patient’s prescription matched what was being delivered during the dialysis treatment when it did not match. On 2/9/24: - P#2 dialyzed with a BFR of 350 mL/min from 10:31 a.m. to 11:01 a.m., and was decreased to 300 - 320 mL/min until the end of treatment at 1:01 p.m. - Treatment record did not show why P#2 dialyzed with a BFR of less than 400 mL/min for the entire treatment. - At 12:22 p.m., RN GG verified that the patient’s prescription matched what was being delivered during the dialysis treatment when it did not match. P#3: P#3’s dialysis prescriptions: Treatment time: 210 minutes (3 hours and 30 minutes), EDW: 65.5 kg, BFR: 350 mL/min, DFR: 600 mL/min. On 2/17/24: - P#3 dialyzed with a BFR of 300 mL/min from 7:30 a.m. to 7:43 a.m., then was decreased to 270 mL/min until the end of treatment at 9:15 a.m. - Treatment record did not show why P#3 was not dialyzed with a BFR of 350 mL/min as ordered. P#6: P#6’s dialysis prescriptions: Treatment time: 195 minutes (3 hours and 15 minutes), EDW: 74.5 kg, BFR: 400 mL/min, DFR: 600 mL/min. On 2/5/24: - P#6’s treatment started at 9:21 a.m. and was discontinued at 12:35 p.m. - Treatment record showed that the BFR was at 400 mL/min at the initiation of dialysis at 9:21 a.m. until 10:02 a.m. The BFR was decreased to 0 mL/min at 10:02 a.m. and was increased to 305 mL/min at 10:32 a.m. until the end of treatment at 12:35 p.m. - There was a lack of documented reason for not setting the BFR to 400 mL/min as ordered. - At 11:41 a.m., RN II verified that patient’s prescription matched what was being delivered during dialysis treatment when it did not match. On 2/16/24: - P#6’s treatment started at 9:03 a.m. and was discontinued at 12:20 p.m. - Treatment record showed that the BFR was 350 mL/min at the initiation of dialysis at 9:21 a.m. and remained at 350 mL/min for the entire treatment that terminated at 12:20 p.m. - There was a lack of documented reason for not setting the BFR to 400 mL/min as ordered. - At 9:05 a.m., RN FF verified that patient’s prescription matched what was being delivered during dialysis treatment when it did not match. P#8: P#8’s dialysis prescriptions: Treatment time: 195 minutes (3 hours and 15 minutes), EDW: 78 kg (kilogram), BFR: 450 mL/min, DFR: 600 mL/min. On 2/9/24: - P#8’s treatment started at 1:15 p.m. and was discontinued at 4:19 p.m. (184 minutes) - Treatment record showed that the BFR was at 350 mL/min at the initiation of dialysis at 1:15 p.m. and remained at 350 mL/min for the entire treatment that terminated at 4:15 p.m. - There was a lack of documented reason for not dialyzing P#8 at the prescribed BFR of 450 mL/min for the entire treatment. P#11: P#9’s dialysis prescriptions: Treatment time: 210 minutes (3 hours and 30 minutes), EDW: 83.5 kg (kilogram), BFR: 500 mL/min, DFR: 600 mL/min. On 2/7/24: - P#11’s treatment started at 11:26 a.m. and was discontinued at 2:07 p.m. (161 minutes) - Treatment record showed that the BFR was decreased from 500 mL/min at 12:32 p.m. to 400 mL/min and remained at this rate until treatment terminated at 2:07 p.m. - There was a lack of documented reason for not dialyzing P#11 at prescribed BFR of 500 mL/min for the entire treatment. On 2/13/24: - P#11’s treatment started at 10:52 a.m. and was discontinued at 12:55 p.m. (123 minutes) - Treatment record showed that the BFR was at 400 mL/min for the entire treatment. - At 1:20 p.m., RN GG verified that the patient’s prescription matched what was being delivered during dialysis treatment when it did not match. This was documented after the treatment was completed. - There was a lack of documented reason for not dialyzing P#11 at the prescribed BFR of 500 mL/min. On 2/15/24: - P#11’s treatment started at 10:43 a.m. and was discontinued at 1:20 p.m. (157 minutes) - Treatment record showed that the BFR was at 400 mL/min for the entire treatment. - At 11:11 am., RN FF verified that the patient’s prescription matched what was being delivered during dialysis treatment when it did not match. - There was a lack of documented reason for not dialyzing P#11 at the prescribed BFR of 500 mL/min. The Facility Administrator (FA) and Group Facility Administrator (GFA) were notified and confirmed the above findings on 2/22/24 at 4:00 p.m. A review of Policy: 1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised October 2023 stated: Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of 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... Prescription components include but are not necessarily limited to: Blood flow rate [BFR] and dialysate flow rate [DFR] ...”

“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: 03383 Based on a review of medical records and facility policy and staff interviews, it was determined that the medical director failed to ensure that all Direct Patient Care Staff adhered to facility policy and standing orders pertaining to hypertension [elevated blood pressure (BP)] to ensure that four of four sampled patients (P#2, P#6, P#8, and P#11) who had elevated BP readings, received medical care/interventions appropriate to the patient’s dialysis needs. This failure could negatively affect the health and safety of P#2, P#6, P#8, and P#11 and the other 82 in-center hemodialysis patients who were dialyzing at this facility. Findings were: - A review of undated Medical Director’s Orders showed the following: Order A: If sBP (systolic BP - top number) > 170 or dBP (diastolic BP - bottom number) > 100 and asymptomatic will: 1) Repeat blood pressure (preferably at different site) 2) Treat with Clonidine 0.1 mg or nifedipine 60 mg x 1 dose 3) Repeat BP in 15 minutes; if still high 4) Notify MD (physician) if sBP >180 x 2 Order: B: If sBP > 170 or dBP > 100 and symptomatic (such as slurred speech, drooping, vision changes, headache, weakness in arms / legs) 1) Call MD A review of P#2, P#6, P#8, and P#11’s treatment flowsheets dated 2/3/24 - 2/20/24 showed the following: P#2: On 2/07/24: - P#2’s BP was 201/110 mm/Hg during the initiation of dialysis treatment at 9:42 a.m. - At 10:02 a.m., P#2’s BP increased to 206/111 mm/Hg. - At 10:16 a.m., P#2’s BP was 186/104 mm/Hg. - At 10:32 a.m., P#2’s BP was 188/109 mm/Hg. - At 11:02 a.m., P#2’s BP was 188/104 mm/Hg. - At 11:32 a.m., P#2’s BP was 184/104 mm/Hg. There was a lack of documented evidence that RN II performed interventions per Medical Director’s Order to administer medication and recheck BP within 15 minutes and notify MD of sBP > 180 x 2. P#6: On 2/05/24: - P#6’s BP was 181/101 mm/Hg during the initiation of dialysis treatment at 9:30 a.m. - At 10:00 a.m., P#6’s BP increased to 184/110 mm/Hg. - At 10:16 a.m., P#6’s BP was 181/98 mm/Hg. There was a lack of documented evidence that RN KK followed Medical Director’s Order to administer medication, recheck BP within 15 minutes and notify MD of sBP > 180 x 2. P#8: On 2/09/24: - P#8’s BP was 197/122 mm/Hg during the initiation of dialysis treatment at 10:49 a.m. - At 11:01 a.m., P#8’s BP was 175/108 mm/Hg. - At 11:31 a.m., P#8’s BP was 172/102 mm/Hg. There was a lack of documented evidence that PCT OO notified the licensed nurse about the patient’s high BP readings. On 2/16/24: - P#8’s BP was 206/121 mm/Hg during the initiation of dialysis treatment at 10:46 a.m. - At 11:01 a.m., P#8’s BP was 177/111 mm/Hg. - At 12:00 p.m., P#8’s BP went up to 182/102 mm/Hg. There was a lack of documented evidence that PCT OO notified the licensed nurse about the patient’s high BP readings. P#11: On 2/09/24: - P#11’s BP was 199/85 mm/Hg during the initiation of dialysis treatment at 11:37 a.m. - At 12:02 p.m., P#11’s BP was 186/86 mm/Hg. - At 12:32 p.m., P#11’s BP was 187/80 mm/Hg. - At 1:02 p.m., P#11’s BP was 199/99 mm/Hg. - At 2:02 p.m., P#11’s BP was 194/97 mm/Hg. - At 12:02 p.m., P#11’s BP was 213/90 mm/Hg. There was a lack of documented evidence that PCT OO notified the licensed nurse about the patient’s persistently high BP readings. There was a lack of documented evidence that the standing order for hypertension was followed. On 2/13/24: - P#11’s BP was 210/110 mm/Hg during the initiation of dialysis treatment at 10:53 a.m. - At 11:36 a.m., P#11’s BP was 183/90 mm/Hg. - At 12:02 p.m., P#11’s BP was 174/80 mm/Hg. - At 12:32 p.m., P#11’s BP was 199/95 mm/Hg. - At 12:54 p.m., P#11’s BP was 174/80 mm/Hg. There was a lack of documented evidence that PCT LL notified the licensed nurse about the patient’s high BP readings. There was a lack of documented evidence that the standing order for hypertension was followed. On 2/15/24: - P#11’s BP was 200/87 mm/Hg during the initiation of dialysis treatment at 10:46 a.m. - At 11:01 a.m., P#11’s BP was 202/108 mm/Hg. RN FF documented “BP high; monitor to see if it will reduce.” No recheck of BP was done until the following routine check of vital signs. There was a lack of documented evidence that the standing order was followed. - At 11:31 a.m., P#11’s BP was 190/88 mm/Hg. - At 12:01 p.m., P#11’s BP was 190/85 mm/Hg. - At 12:31 p.m., P#11’s BP was 211/111 mm/Hg; Notes showed “Patient monitored, eyes closed; patient resting”. An updated entry by PCT OO at 1:36 p.m. stated, “monitoring BP”. There was a lack of documentation that showed a licensed nurse was notified. - At 1:01 p.m., P#11’s BP was 201/99 mm/Hg. - At 1:12 p.m., P#11’s BP was 211/109 mm/Hg. - At 1:17 p.m., P#11’s BP was 194/75 mm/Hg. - There was a lack of documented evidence that PCT OO notified the licensed nurse about the patient’s extremely high BP readings. On 2/20/24: - P#11’s BP was 211/94 mm/Hg during the initiation of dialysis treatment at 10:32 a.m. - At 11:02 a.m., P#11’s BP was 175/81 mm/Hg. RN FF documented “BP high; monitor to see if it will reduce.” No recheck of BP was done until the next scheduled routine BP check. - At 11:31 a.m., P#11’s BP was 190/88 mm/Hg. - At 11:32 a.m., P#11’s BP was 190/85 mm/Hg. - At 12:01 p.m., P#11’s BP was 197/79 mm/Hg. - At 12:32 p.m., P#11’s BP was 191/84 mm/Hg. - At 1:02 p.m., P#11’s BP was 214/93 mm/Hg. - At 1:17 p.m., P#11’s BP was 220/110 mm/Hg. There was a lack of documented evidence that RN HH followed the standing orders for hypertension. A review of Policy: 1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised October 2023, stated: Abnormal Findings: Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: Systolic greater than 180 mm Hg or less than 90 mm/Hg Diastolic greater than or equal to 100 mm/Hg Blood pressure - Intradialytic: Difference of 20 mm/Hg increase or decrease from the patient’s last treatment BP reading... Blood Pressure Post Treatment: If the patient can stand: o Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg o Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg If the patient is not able to stand, document reason and sitting BP: Sitting BP for patient’s that cannot stand: o Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg o Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg 7. Document event, orders, treatment and patient response in the patient’s electronic health record. The Facility Administrator (FA) and Group Facility Administrator (GFA) were notified and confirmed the above findings on 2/22/24 between 3:15 p.m. and 4:00 p.m. The FA and GFA confirmed treatment records lacked evidence that showed standing orders related to high BP were followed by staff.”