Walton Dialysis Center

“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: 03383 Based on observation and staff interview, it was determined that the facility failed to ensure that there was a safe environment for all patients as evidenced by torn leather upholstery on five of 10 patient treatment chairs that could hinder effective cleaning/disinfection. The facility census was nine. Findings were: During a tour of the facility with the Facility Administrator (FA) on 7/10/24 at 9:30 a.m., the following was observed: - The leather upholstery on the patient treatment chairs in Stations 2, 3, 4, 6, and 18 had ¼ inch to 1 inch cracks and tears in the arms of each chair. The FA was present during the tour and confirmed the above findings on 7/10/24 at 9:30 a.m.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. 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 one of two trash receptacles and one of one biohazard container were placed/stored appropriately, to prevent cross contamination; and six of six oxygen cylinders were securely stored, to ensure the health and safety of all staff and nine patients. Findings were: During a tour with the Facility Administrator (FA) on 7/10/24 at 9:35 a.m., the following was observed in the treatment area: - A large gray trash receptacle filled with trash was pushed against (was actually touching) a clean sink in the treatment area. - A large red biohazard container filled with small red sharps/biohazard containers was stored in the treatment area. - Six used oxygen cylinders (two small and four medium size), were found unsecured on a window sill in the treatment area that had the potential to cause injury to a person nearby as the cylinders were not restrained and can easily fall or be knocked over. The FA confirmed the above findings on 7/10/24 at 9:35 a.m. and offered no explanation.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 03383 Based on a review of records, staff interviews, and review of policy, it was determined that the facility failed to provide nutrition services to the patients and/or the patients’ families and caregivers, which were designed to maximize the patient’s nutritional status in four of five sampled patients (P#1, P#2, P#3, and P#4). The facility census was nine. Findings were: P#1: - P#1’s most recent CIPA (Comprehensive Interdisciplinary Patient Assessment) and Plan of Care was dated 6/16/23. - Dietitian Evaluation Report Comprehensive (IDT - Interdisciplinary Team) Supervision Rounding (Monthly) dated 9/5/23, and 11/23/23 were provided by the facility to show Registered Dietitian’s (RD) documentation from 7/1/23 to 7/11/24 as requested by this surveyor. A review of the Dietitian Evaluation Report Comprehensive (IDT) Supervision Rounding (Monthly) dated 11/23/23 showed the following albumin results: 4.1 g/dL (grams per decilitre) on 7/18/23; 3.8 g/dL on 8/31/23; 3.7 g/dL on 9/12/23 and 3.7 g/dL on 11/9/23. The report showed the following under Comments: Pt (Patient) non-compliant, have not seen pt; talked to daughter over phone, pt in hospital, daughter at work and said would call back. This was the last report provided. - There was a lack of documentary evidence that an RD provided P#1’s evaluation of nutritional status, patient’s body weight trend, and other nutritional markers from 11/24/23 to 7/11/24. P#2: P#2 was admitted to the facility on 6/13/24. - A review of P#2’s laboratory report dated 6/11/24 showed an albumin of 2.5 g/dL. According to Measures Assessment Tool (MAT), Centers for Medicare and Medicaid Services - Vesion 2.5, the professionally-accepted clinical standard target for albumin was 4.0 g/dL. - There was a lack of documentary evidence that an RD provided an evaluation of P#2’s nutritional status since she was admitted to this facility on 6/13/24. During an interview on 7/11/24 at 6:52 a.m., P#2 stated she has not been seen by the dietitian. P#3: P#3 was admitted to the facility on 6/23/23. A review of Dietitian Evaluation Report Comprehensive (IDT) Supervision Rounding (Monthly) dated 11/21/23 showed P#3’s albumin results on 7/13/23 and 7/15/23 were 3.7 g/dL; 3.3 g/dL on 8/3/23; 3.6 g/dL on 9/12/23; 3.7 on 10/5/23; and 4.3 on 11/2/23. The report showed the nutrition related labs (laboratory results) reviewed and abnormal: goals not met on 11/21/23. This was the last RD report that was provided by the facility. A review of laboratory report from 4/9/24 to 7/9/24 showed the following: - P#3’s albumin dropped from 3.7 g/dL on 5/2/24 to 3.3 g/dL on 6/6/24; and had further dropped down to 2.2 g/dL on 7/4/24. - There was a lack of documentary evidence that an RD provided evaluation of nutritional status since 11/22/23, that addressed P#3’s declining albumin levels, patient’s body weight trend, and other nutritional markers such as sodium, calcium, phosphorus,, and potassium. During an interview on 7/11/24 at 6:12 a.m., P#3 stated he has not been seen by the dietitian. P#4: A review of laboratory report showed that P#4’s albumin was 3.6 g/dL on 5/2/24 and had dropped to 3.3 g/dL on 6/6/24. A review of the Patient Notes under “Note Type” Progress Notes - RD, lacked documented evidence that an RD provided evaluation of nutritional status since 2/20/24, that addressed P#4’s declining albumin levels, patient’s body weight trend, and other nutritional markers such as sodium, calcium, phosphorus,, and potassium. During an interview on 7/11/24 at 7:42 a.m., P#4 stated she has only been seen by the RD once since she started dialysis treatment at this facility on 10/28/23. The above findings were reviewed with the Charge Nurse and the Facility Administrator (FA) on 7/11/24 at 2:30 p.m. The FA stated that she would look into RD concerns and provide additional information. However, no additional information was provided.”

“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: 03383 Based on a review of medical records and staff interview, it was determined that the interdisciplinary team (IDT) failed to ensure that the target weight or estimated dry weight (EDW) and/or blood pressure (BP) of three of five sampled patients (P#1, P#2, and P#5), were monitored and adjusted/addressed when necessary to prevent complications related to excess fluid accumulation (such as cardiovascular (heart and blood vessels) complications and hospitalizations). Findings were: P#1: A review of P#1’s CIPA (Comprehensive Interdisciplinary Patient Assessment) and Plan of Care dated 6/16/23 revealed the following: Fluid Status: Adequate; Recommended Daily Fluid: 1500 ml; Adherence: Good. A review of Flowsheets from 3/9/24 to 6/15/24 showed the following: EDW: 52 kg. 3/9/24: Pre weight: 60.5 kg (kilogram) / Post weight: 58.3 kg was 8.5 kg over target weight; ideal weight gain: 0.4 kg. 3/12/24: Pre weight: 58.7 kg / Post weight: 57.3 kg and was 6.7 kg over target weight; ideal weight gain: 0.4 kg. 3/14/24: Pre weight: 58.7 kg / Post weight: 57.5 kg and was 6.7 kg over target weight; ideal weight gain: 1.4 kg. 3/16/24: Pre weight: 59.3 kg / Post weight: 58.3 kg and was 7.3 kg over target weight; ideal weight gain: 1.8 kg. 3/23/24: Pre weight: 60.7 kg / Post weight: 59.1 kg and was 8.7 kg over target weight; ideal weight gain: 2.4 kg. 4/9/24: Pre weight: 58 kg / Post weight: 57.3 kg and was 6 kg over target weight; ideal weight gain: -1.1 kg. 4/11/24: Pre weight: 57.8 kg / Post weight: 58.3 kg and was 5.8 kg over target weight; ideal weight gain: 0.5 kg. 4/13/24: Pre weight: 59.4 kg / Post weight: 58.5 kg and was 5.8 kg over target weight; ideal weight gain: 0.7 kg. 5/23/24: Pre weight: 59.9 kg / Post weight: 57.7 kg and was 7.9 kg over target weight; ideal weight gain: 1.4 kg. 5/30/24: Pre weight: 59.8 kg / Post weight: 57.8 kg and was 7.9 kg over target weight; ideal weight gain: 2.1 kg. 6/15/24: Pre weight: 57.5 kg / Post weight: 55.2 kg and was 7.9 kg over target weight; ideal weight gain: - 0.3 kg. In addition, on 5/23/24, P#1’s BP ranged between 174/91 mmHg (millimeters of mercury) - 249/166 mmHg during dialysis treatment. On 5/30/24, P#1’s BP ranged between 170/90 mmHg - 206/96 mmHg throughout dialysis treatment. And on 6/15/24, P#1’s BP ranged between 170/95 mmHg - 239/141 mmHg during the entire treatment. A review of the Nephrologist Rounding Report dated 4/9/24 through 6/15/24 showed the following: Rx (Prescribed) Target Wt (Weight) of 52 kg and showed Target Weight Achieved. Interdisciplinary Evaluation Actions Recap: Target Weight Increased per RN on 5/23/24. However, P#1’s dialysis treatment flowsheet dated 5/23/24 - 6/15/24 (last treatment flowsheet available for review) had a target weight of 52 kg. Moreover, P#1’s elevated BP readings on 5/23/24, 5/30/24, and on 6/15/24 were not addressed. There was a lack of documented interventions done for the excessibly high BP measurements during treatment. P#2: Treatment Plan: EDW - 145.5 kg. A review of treatment flowsheets from 6/18/24 - 7/9/24 showed the following: On 6/18/24, P#2’s pre treatment weight was 148.0 kg and post treatment weight was 140 kg. On 6/20/24; 6/22/24; 6/25/24; 6/27/24; 6/29/24; 7/2/24; 7/4/24; 7/6/24; and on 7/9/24, P#2’s pre and post treatment weight were not taken and the flowsheet showed that dry weight was unknown. Nephrologist Rounding Report dated 6/11/24 through 6/18/24 showed the following: Rx Target Wt (kg) on 6/11/24 through 6/18/24 was 145.5 kg; Weight (kg), Post-treatment ranged from 142.5 kg to 145 kg; Weight Gain (kg), Interdialytic, Treatment ranged from 3 kg to 6 kg; and showed Target Weight Achieved. There was a lack of documentation that indicated where P#2’s weight came from on 6/13/24 and 6/18/24 when the patient was not weighed pre or post treatment at the facility. There was a lack of documented plan of care for obtaining P#2’s pre and post treatment weight. P#5: Treatment Plan: EDW - 82 kg. A review of treatment flowsheets from 6/18/24 - 7/9/24 showed the following: On 6/18/24: - Pre weight was 87.9 kg and post weight was 84.2 kg. On 6/20/24: - Pre weight was 86.9 kg and post weight was 84.2 kg. On 6/22/24: - Pre weight was 88.5 kg and post weight was 84.1 kg. On 6/25/24: - Pre weight was 86.6 kg and post weight was 84.8 kg. On 6/27/24: - Pre weight was 87.2 kg and post weight was 84.2 kg. On 6/29/24: - Pre weight was 86.8 kg and post weight was 84.4 kg. On 7/2/24: - Pre weight was 88.2 kg and post weight was 85.2 kg. On 7/4/24: - Pre weight was 87.6 kg and post weight was 85.8 kg. On 7/6/24: - Pre weight was 88.7 kg and post weight was 86.9 kg. On 7/9/24: - Pre weight was 87.6 kg and post weight was 85.1 kg. The last CIPA and Plan of Care dated 7/4/23 showed the patient was admitted to the facility on 6/19/23; and stated the following: Adequacy Goal: Patient able to achieve target weight or net UF volume Total Treatments (Prior 90 Days) 7 treatments; Rx Target Wt/UF Not Achieved: 4 - 57%; Goal Met? Yes A review of the Nephrologist Rounding Report dated 4/9/24 through 7/9/24 showed the following: Rx Target Wt (kg) from 4/2/24 through 7/9/24 was 82 kg; Weight (kg), Post-treatment ranged from 84.2 kg to 84.8 kg; Weight Gain (kg), Interdialytic, Treatment ranged from 2.3 kg to 5.4 kg; and showed Target Weight Achieved. - There was a lack of documented acknowledgement that P#3’s target weight was not attained for 10 of last 10 treatments, with an assessment of the reason for not attaining it, and a plan to correct this issue. - There was no documentation that the patient’s EDW was re-evaluated after repeated failure to get the patient down to his/her EDW. The above findings were discussed and reviewed with the Charge Nurse (CN) and the Facility Administrator on 7/11/24 at 2:15 p.m.”

“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, staff interview, and review of Policy and Procedure, it was determined that the medical director failed to ensure that all staff adhered to facility policy relative to hypertension (high blood pressure) management of one of one patient (P#1) sampled, who experienced high BP readings during dialysis treatment. This deficient practice can lead to higher hospitalization rates and cardiovascular (heart and blood vessels) disease. The facility census was nine. Findings were: A review of P#1’s treatment flowsheets showed the following: P#1’s prescribed duration of dialysis treatment was for three hours. On 5/23/24: - The initiation of P#1’s dialysis treatment began at 6:11 a.m. - P#1’s BP was 249/166 mmHg (millimeters of mercury) at 6:11 a.m.; 241/139 mmHg at 6:30 a.m.; 225/128 mmHg at 7:00 a.m.; 206/110 mmHg at 7:30 a.m.; 174/91 mmHg at 8:00 a.m.; 187/102 mmHg at 8:30 a.m.; 196/106 mmHg at 9:00 a.m.; 196/106 mmHg at 9:05 a.m. - There was a lack of documentary evidence that the nurse notified the physician of P#1’s high BP readings. - There was a lack of interventions done for the extremely elevated BP readings during dialysis treatment. On 5/30/24: - The initiation of P#1’s dialysis treatment began at 6:58 a.m. - P#1’s BP was 205/106 mmHg at 6:58 a.m.; 184/91 mmHg at 7:30 a.m.; 171/94 mmHg at 8:00 a.m.; 170/90 mmHg at 8:30 a.m.; 199/105 mmHg at 9:00 a.m.; 194/108 mmHg at 9:30 a.m.; 206/96 mmHg at 10:00 a.m. - There was a lack of documentary evidence that the nurse and the physician were notified of P#1’s high BP readings. - There was a lack of interventions done for the elevated BP readings during dialysis treatment. On 6/15/24: - The initiation of P#1’s dialysis treatment began at 6:15 a.m. - P#1’s BP was 239/141 mmHg at 6:15 a.m.; 234/140 mmHg at 6:30 a.m.; 188/102 mmHg at 7:00 a.m.; 170/95 mmHg at 7:30 a.m.; 189/101 mmHg at 8:00 a.m.; 192/93 mmHg at 8:30 a.m.; 206/120 mmHg at 9:00 a.m.; 199/105 mmHg at 9:22 a.m. - There was a lack of documentary evidence that the nurse and the physician were notified of P#1’s high BP readings. - There was a lack of interventions done for the elevated BP readings during dialysis treatment. A review of P#1’s physician order dated 7/8/23 showed Clonidine 0.1 mg (milligram) PRN (as the need arises) for essential (primary) hypertension. The above findings were discussed and reviewed with the Charge Nurse (CN) and the Facility Administrator on 7/11/24 at 2:15 p.m. The CN stated that the patient did not like to take Clonidine. However, CN agreed that the flowsheets did not show that Clonidine was offered or any other interventions were offered or provided to address P#1’s high BP readings. A review of Policy titled, “Hypertension Management” revised 3/18/09 showed the following: Goal is to keep post dialysis BP < (less than) 140/90 at all times but to avoid immediate complication in the dynamic disease, Post Dialysis BP of > (greater than) 180/100 to be treated on immediate basis. Procedure: 1. Check the patient’s blood pressure with the appropriate size cuff. If the reading is elevated reposition the cuff and check again. 2. If blood pressure is consistently greater than 180/100 during and/or after dialysis, a. Pt (Patient) must make appointment with their physician to be evaluated. b. Instruct patient to take prescribed BP medications at this time. c. Offer patient to take Clonidine 0.1 mg PO, and repeat dose after one hour if BP is still 180/90 if no obvious contraindications. d. Inform patient’s PMD (Primary Medical Doctor) and obtain order for further management.”