Davita North Carrollton Dialysis

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on a review of patient’s (P#1’s) records, staff interviews and a review of facility Policies and Procedures (P&P), it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This deficient practice negatively affected the health and safety of P#1 who experienced an exsanguination (severe blood loss) incident which could have contributed to P#1’s death due to cardiac arrest. The facility’s in-center hemodialysis census was 34. Cross reference: V 715 - Failure of the Medical Director to ensure that one of one Registered Nurse (RN AA) and one of one Patient Care Technician (PCT AA), adhered to facility P&P relative to intradialytic (during dialysis) monitoring and assessment which resulted in an exsanguination incident of one of one sampled patient (P#1).”

“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: 50523 Based on a review of facility records, staff interviews, and a review of facility Policy and Procedures (P&P), it was determined that the Medical Director failed to ensure that one of one Registered Nurse (RN AA), and one of one Patient Care Technician (PCT AA) sampled, adhered to facility P&P relative to intradialytic (during dialysis) monitoring and assessment which resulted in an exsanguination (severe blood loss) incident of one of one patient (P#1), sampled. This deficient practice negatively affected the health and safety of P#1, which may have contributed to P#1’s death due to cardiac arrest. During exsanguination, the body rapidly loses critical blood volume, leading to catastrophic drop in blood pressure, insufficient oxygen delivery (hypoxia) to organs, and severe shock, causing the heart to fail, brain damage, organ shutdown, and ultimately death, typically after losing 40% or more of blood, unless bleeding is stopped and fluid/blood replaced quickly. The facility census was 34. Findings include: A review of the facility’s “Risk Event Management” (REM) records dated January 12, 2026, revealed that a patient (P#1), at this facility experienced a blood loss greater than (>) 500 milliLiters (mL). A review of P#1’s “Treatment Details Report”, dated 1/12/26, revealed the following: - P#1 had a left upper arm (LUA) Arteriovenous Fistula (AVF - a surgically created connection between an artery and a vein as an access point for hemodialysis), access. The access was located in the inner side of the LUA. - P#1’s prescribed Blood Flow Rate (BFR - the speed at which blood is pumped from the patient through the dialysis circuit, usually measured in milliliter per minute [ml/min.]), was 350 ml/min. - Patient Care Technician (PCT AA), initiated hemodialysis treatment for P#1 at 8:25 a.m. According to PCT AA’s documentation, P#1 was alert and reported no complaints. P#1’s BFR was 200 ml/min with a Venous Pressure (VP-acts as a critical monitoring parameter during hemodialysis, for the resistance in the venous return line when the cleaned blood returns to the heart. Ideally, VP should remain within the +60 to +200 millimeters of mercury [mmHg] range), of 137 mmHg. - At 8:25 a.m., P#1’s Blood Pressure (BP) reading was 154/75 mmHg. - At 8:33 a.m., P#1 was “awake and alert”. The BFR was 315 mL/min, and the VP was 225 mmHg. BP reading was 178/77 mmHg. - At 9:02 a.m., P#1 was “tolerating treatment well”. The BFR was 200 mL/min, and the VP was 259 mmHg. BP reading was 165/74 mmHg. - At 9:33 a.m., P#1 was “awake and alert”. The BFR was 0 mL/min, and the VP was 245 mmHg. PCT AA updated P#1’s chart at 11:01 a.m., and documented: “face; vascular access; and blood line connections were visible”. BP reading was 174/70 mmHg. - At 10:02 a.m., P#1 was “resting with eyes closed”. The BFR was 200 mL/min, and the VP was 103 mmHg. PCT AA again updated P#1’s chart at 11:01 a.m. (same time as above), and documented: “face; vascular access; and blood line connections were visible”. BP reading was 166/75 mmHg. . - At 10:32 a.m., PCT AA documented: “patient appeared to be tolerating treatment well”. The BFR was 350 mL/min, and the VP was 190 mmHg. BP reading was 156/66 mmHg. - At 10:51 a.m., P#1’s VP alarm sounded, P#1 was found with venous needle dislodged. RN AA was at chairside administering normal saline while P#1 was laid back. The BFR was 0 mL/min, and the VP was 461 mmHg. BP reading was 126/77 mmHg. Heart rate (HR) was 147 beats/minute. NOTE: Prior to this time, P#1’s HR was between 64 beats/minute to 68 beats/minute. - At 5:17 p.m., RN AA updated P#1’s chart and documented: “patient was placed in a modified Trendelenburg (feet elevated higher than the head) position due to unresponsiveness. The venous needle was reinserted, and 1,000 cc (cubic centimeter) of normal saline was administered. Patient’s pulse remained stable with a normal heart rate. Oxygen was administered at 2 liters per minute, and 911 was called”. - At 10:54 a.m., P#1’s VP was 458 mmHg and EMS (Emergency Medical Services) was called. BP reading was 79/46 mmHg with a HR of 80 beats/minute. - At 10:57 a.m., P#1’s VP was 456 mmHg. BP reading was 154/76 mmHg. HR was 125 beats/minute. - At 11:16 a.m., P#1 was discharged from the facility with EMS and was transported to the hospital. Based on the above records, P#1’s BP reading dropped from 156/66 mmHg at 10:32 a.m., to 126/77 mmHg at 10:51 a.m., with a HR of 147 beats/minute. At 10:54 a.m., BP reading further dropped to 79/46 mmHg with a HR of 80 beats/minute, then at 10:57 a.m., P#1’s HR was 125 beats/minute. - RN AA documented that she verified P#1’s prescription at 4:12 p.m.; a pre-assessment was documented at 4:25 p.m., and a post-assessment was documented at 5:15 p.m. The intradialytic monitoring and assessment did not address the increasing VP which could have been caused by obstructions in the venous return line, which could include but not limited to: a clotted dialyzer, kinked tubing or clotted needles etc., and arm positioning which could affect the needle alignment. Also, there was no documented reason why P#1 did not dialyze at her prescribed BFR. There was also a delay in RN AA’s documentation of her assessment or lack of assessment of P#1. A review of P#1’s “Hospital Admission Records”, dated 1/12/26, revealed the following: - At 11:30 a.m., P#1 presented to the Emergency Department intubated (a tube placed into a person’s airway - the trachea, through the mouth or nose to keep the airway open and help them breathe), following respiratory arrest (a life-threatening condition in which a person stops breathing or breathes inadequately) while in route. P#1 was pronounced “expired” on 1/12/26 at 10:57 p.m. - A review of P#1’s Hemoglobin (Hgb - protein in red blood cells that carries oxygen) lab results revealed that P#1’s blood was drawn for hemoglobin on 1/12/26 at 8:02 a.m., (prior to the initiation of P#1’s hemodialysis treatment), which resulted at 11.1 g/dL (grams/deciliter). - At approximately 11:30 a.m., on the same date (1/12/26), at the Emergency Department, P#1’s Hgb was drawn again and resulted at 7.1 g/dL. P#1’s Hgb drastically decreased by 4.0 g/dL following the exsanguination. Normal hemoglobin range is 12-14 g/dL, with 10 g/dL being considered low for dialysis patients. During staff interviews on 1/15/26, between 10:34 a.m. and 11:26 a.m., the following was revealed: - At 10:34 a.m., PCT BB stated that P#1’s AVF access was located at the inner side of her LUA. PCT BB added that P#1 usually extended and rested her left arm on top of the side table to expose her access. PCT BB stated that when she went to address P#1’s VP alarm, she discovered that P#1’s left arm was not resting on top of the side table (to expose the access), but her left arm was resting at her side (wedged between her body and the edge of the side table). PCT BB also added that, that’s when she found out that P#1’s venous needle was out and blood was pooling on the floor under P#1’s hemodialysis chair. - At 11:26 a.m., RN AA acknowledged her delayed assessments and documentation. RN AA stated that she usually verified patient prescriptions and conducted assessments within the first hour of a patient’s hemodialysis treatment. RN AA also added that on 1/12/26, she was attending to other patients during the change of shift, and before she could verify and document care for P#1, the exsanguination incident occurred. - A telephonic interview was conducted on 11/20/26 at 11:33 a.m., with the Medical Director (MD). The MD acknowledged the above findings and stated that the facility will implement in-services to ensure that all patients are properly monitored. A review of Policy: 1-04-11 titled, “Vascular Access Monitoring and Surveillance”, dated October 2020, showed the following: 2. Increasing or decreasing venous pressure changes within a treatment or over time could indicate inflow or outflow problems and should be evaluated. 3. Pressures in excess of 260 mmHg indicate inadequate inflow from the vascular access. A review of Policy: 1-03-08, titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, dated April 2024, showed the following: Pre-Treatment Data Collection/Assessment: 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN): a. The assessment included the following components: i. Review of patient reports, data collection, complaints and response to treatment ii. Verification that machine safety checks have been completed and documented iii. Verification of prescription including machine parameters iv. Verification that the patient access is visible and face is not covered. 3. Patient identity, prescription, and machine settings are verified by the teammate prior to initiation of treatment with the exception of the 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 the treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: f. Blood flow rate, h. All accesses evaluated”