Davita Shenandoah Dialysis

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 44475 Based on review of policy, medical record review, observation and interview, the facility failed to label a syringe containing medication when the medication was not immediately administered for 1 of 3 observations of medication administration (Patient #1). The facility reported a census of 30 in center hemodialysis patients at the time of the survey. Findings include: 1. The facility policy titled “Central Venous Catheter (CVC) Locking Solutions” last revised October 2024 directed, in part, that catheter locking solutions containing heparin are prepared/administered by licensed nurse teammates or patient care technicians (PCTs), if allowed by state regulations. The syringes are labeled with: patient name, locking solution type and concentration, date and time prepared, initials of teammate preparing/administering the catheter lock solution. 2. Review of Patient #1’s clinical record showed an order for heparin pork (medication used to prevent blood from clotting) every dialysis treatment, arterial: 1,600 units, venous: 1,600 units signed by the Medical Director with a start date of 11/11/24. 3. In a concurrent observation and interview on 5/12/25 at 12:50 PM showed two unlabeled syringes containing clear fluid on Patient #1’s chairside table. Patient #1 reported not knowing what was inside the syringes. 4. In an observation on 5/12/25 at 1:11 PM, Staff D, PCT, administered the fluid from the two syringes into each lumen (port) of Patient #1’s dialysis catheter. 5. In an interview on 5/12/25 at 1:14 PM, Staff D reported that the two syringes contained heparin because the patient had orders for a heparin lock for the CVC and that Staff B, PCT, prepared the medication. 6. In an interview on 5/12/25 at 1:18 PM, Staff B reported that she prepared the two syringes with heparin for Patient #1. When asked about the process for labeling syringes containing heparin, Staff B replied that she usually puts the label on the syringes. Staff B went on to report that she thought she had labeled the syringes in question.”

“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: 36083 Based on documents review, observations, and staff interview, the facility did not ensure the correct sodium composition of the dialysate for 1 of 4 patients (Patient #2) observed for verification of dialysis prescription. Findings include: 1. The document titled, Priming a Single Use Dialyzer Utilizing B Braun Dialog+ Dialysis Delivery Systems and Streamline Blood Lines, procedure #1-03-06M, dated April 2025, directs staff members to verify dialysis prescription when setting up patients’ dialysis treatments. 2. During observation on 5/12/25 at 1:09 PM, registered nurse (RN) A showed Patient #2’s dialysis prescription including the dialysate with sodium (Na) at 135 milliequivalents per liter (mEq/L). However, Patient #2’s ongoing treatment setting showed Na at 138 mEq/L. Patient #2’s dialysis machine showed 1 hour and 16 minutes remaining of the 3 hours ordered treatment time, which indicated Patient #2 received incorrect Na for 1 hour and 44 minutes. 3. The document titled, Patient Details Report, showed that Patient #2’s dialysis treatment started at 11:22 AM on 5/12/25, with base Na ordered at 135 mEq/L. The document also showed prescription verifications by multiple staff members as follows: patient care technician (PCT) B at 10:46 AM, licensed practical nurse (LPN) C at 11:46 AM, RN A at 11:48 AM, and LPN C at 11:49 AM. The document further showed Patient #2 weighed 0.5 kilograms above the target weight at the end of treatment. 4. On 5/14/25 at 3:00 PM, RN A said the dialysis machines default to Na at 138 mEq/L but it should have been changed/lowered to 135 mEq/L as ordered for Patient #2, but that it was missed. RN A and the facility administrator (FA) acknowledged the importance of providing patients’ treatments as ordered.”