Davita Green Country Dialysis

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36083 Based on documents review, and staff interviews, the facility failed to assess the circumstances related to an emergency room (ER) visit for 1 of 2 patients (Patient #6) who were transported to the hospital after dialysis treatment. The facility reported a census of 43 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” with latest revision date of April 2024, provides for its purpose to obtain and document baseline and ongoing information about the patient before, during, and after dialysis treatment, which will be used in planning, documenting, monitoring during treatment, and reviewing the patient’s response to the treatment and status prior to discharge. The policy directs nurses to complete assessments including illnesses, conditions/complications or other problem patient has experienced since the last dialysis treatment. 2. The pre assessment comments section of Patient #6’s treatment details report dated 3/3/25, indicated Patient #6’s first day of treatment back after hospitalization related to a diagnosis of “Acute on Chronic Respiratory Failure” from 2/24/25 through 3/2/25. The post assessment comments noted “Patient reports he feels like he is going to pass out.” The comments added that Patient #6 was observed for 10-15 minutes with vital signs within facility parameters and then was assisted in a wheelchair going out from the facility treatment floor at 4:33 PM. 3. The “Addendum” document dated 3/3/25, noted Patient #6 complained of “going to pass out post treatment.” The document also noted Patient #6 called 911 while at the facility lobby and emergency medical services (EMS) arrived to take Patient #6 to the ER (emergency room). 4. The assessment documentation on the treatment details report dated 3/5/25, noted “No” to indicate that Patient #6 did not have a hospital or ER visit “since last treatment” even though staff documented that Patient #6 was taken to the ER on 3/3/25. There was a lack of evidence to show any follow-up assessment regarding Patient #6’s ER visit on 3/3/25, which was the last treatment date. 5. During interview on 3/24/25 at 1:22 PM, Patient #6 could not give specific dates of ER visits but confirmed “multiple trips” to the ER during the “past weeks” after dialysis treatments because of weakness and dizziness. 6. During interview on 3/25/25 at 8:42 AM, the medical director (MD) stated awareness regarding Patient #6’s ER visits. The MD acknowledged the importance of following-up on patients’ hospitalizations and ER visits to know if there had been significant changes that could potentially affect the patients’ dialysis treatments.”

“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 I. Based on documents review, observation, and interviews, the facility failed to evaluate prescription related to oxygen administration flow rate for 1 of 5 in-center hemodialysis patients (Patient #6) in the sample reviewed for medical records. The facility reported a total census of 43 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy # 1-02-04, titled, “USE OF OXYGEN CONCENTRATORS” dated October 2023, identifies oxygen as a medication and to be administered by nurses and used by trained teammates. The policy indicates verification of physician/non-physician practitioner order for a patient’s use of oxygen. 2. The document titled, “Patient Summary Report” printed on 3/19/25, showed an order for Patient #6’s oxygen at 3 L (liters)/min (per minute) via nasal cannula with a start date of 3/12/25 and with no end date. However, the document titled, “Patient Details Report” showed that the oxygen administration notes and the nurses’ notes were inconsistent with the order during the applicable dates reviewed, as follows: a. On 3/12/25, the medications section showed oxygen was administered at 3 L/min, but the post treatment assessment noted use of 4 L/min. b. On 3/14/25, the medication section showed administration of oxygen at 3 L/min, but the pre and post treatment assessment noted use of oxygen at 4 L/min. c. On 3/17/25, the medication section showed administration of oxygen at 3 L/min, but the pre treatment assessment notes showed use of oxygen at 4 L/min. d. On 3/19/25, the medication section showed administration of oxygen at 3 L/min, but the pre and post treatment assessment notes showed use of oxygen at 4 L/min. Additional assessment notes and comments also showed use of 4 L/min oxygen. 3. During observation on 3/24/25 at 1:22 PM, Patient #6 had an ongoing treatment at station #9, with oxygen at 3.5 L/min. Patient #6 reported his oxygen was “always set at 4 L” even at home. 4. On 3/24/25 at 3:49 PM, the manager of clinical services (MCS) verified the inconsistencies of the oxygen administration and assessment notes with the ordered flow rate. 5. On 3/25/25 at 8:42 AM, the medical director (MD) stated expectation that staff members follow prescribed medication orders. II. Based on documents review, observation, and interviews, the facility did not ensure administration of heparin (blood thinner) according to facility policy for 1 of 4 patients (Patient #6) in the sample observed for prescription verification. The facility reported a total census of 43 in-center hemodialysis patients at the time of the survey. Findings include: 1. The document titled, “Heparin Protocol 25 U/kg [units/kilogram]” dated 6/14/2016, notes the treatment goals to include minimizing gross or subclinical red blood cell loss or destruction, and reduce the potential for persistent post-dialysis systemic anticoagulation or medication error. The protocol indicates a signed and dated physician’s order for dose administration, and intravenous dosage administration by constant infusion or hourly injection to be discontinued according to venous access in use, as follows: AVF (arteriovenous fistula) - discontinue infusion 1 hour (60 minutes) before end of treatment, and CVC (central venous catheter) - discontinue at end of treatment (0 minute). 2. The policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” with latest revision date of April 2024, directs nurses to complete assessments including verification of prescription. The policy also directs staff to verify patient identity, prescription, and machine settings prior to initiation of treatment and to be confirmed by a license nurse within one (1) hour of treatment initiation. The policy lists prescription components to be verified and confirmed to include heparin administration or heparinization including intradialytic infusion setting, and target weight. 3. During observation on 3/19/25 at 1:30 PM, Patient #6 had an ongoing treatment at station #9, where registered nurse (RN) B reviewed Patient #6’s prescription including heparin 1500 units hourly dose at 0 minute stop time. Patient #6 had an AVF as dialysis access. RN B showed Patient #6’s heparin infusion dose administration, which revealed it was set at 60 minutes stop time before the end of treatment. RN B explained that the heparin administration setting was based on heparin protocol for AVF use, but Patient #6’s prescription should have been changed to reflect the protocol. RN B acknowledged there was a discrepancy between the protocol and Patient #6’s current prescription. RN B then reset Patient #6’s heparin dose infusion to “0 minute stop time” that was in accordance with the current prescription. RN B also stated Patient #6’s heparin prescription should have been changed first before changing the infusion setting. 4. Following the above observation, or on 3/19/25 at 2:43 PM, the document titled, “Patient Note” revealed Patient #6’s hourly heparin dose was changed “from 0 stop time to 60 min stop time” due to the use of AVF. 5. The document titled, “Treatment Details Report” for 8 of 8 treatments, dated from 3/3/25 to 3/19/25, also showed Patient #6 used AVF as access site but the hourly dose of heparin 1500 units was administered at 0 minute stop time. 6. On 3/25/25 at 8:42 AM, the medical director (MD) said the heparin dose administration stops an hour before the end of treatment when the patient has an AVF versus no stop time when the patient has a CVC. The MD stated this is the facility’s protocol and an order should be entered according for its implementation. The MD also stated staff members are expected to follow patients’ prescriptions.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 36083 Based on documents review, observations, and staff interviews, the facility did not ensure correct dialysate for 1 of 4 patients (Patient #6) in the sample for verification of prescriptions. The facility reported a census of 43 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” with latest revision date of April 2024, provides for its purpose to obtain and document baseline and ongoing information about the patient before, during, and after dialysis treatment, which will be used in planning, documenting, monitoring during treatment, and reviewing the patient’s response to the treatment and status prior to discharge. The policy directs nurses to complete assessments including verification of prescription. The policy also directs staff to verify patient identity, prescription, and machine settings prior to initiation of treatment and to be confirmed by a license nurse within one (1) hour of treatment initiation. The policy enumerates the prescription components to be verified and confirmed including correct dialysate composition such as potassium (K) and settings. 2. On 3/19/24 at 1:30 PM, Patient #6 was observed with an ongoing dialysis treatment at station #9. Registered Nurse (RN) B dictated from reading Patient #6’s dialysis prescription programmed in the machine, which identified a dialysate of 2 K (potassium) and 2.5 Ca (calcium). However, RN B showed Patient #6’s ongoing treatment connected to the port that delivered a dialysate of 3 K and 2.5 Ca (higher potassium concentration). RN B then disconnected the dialysate line from the 3 K and 2.5 Ca port, and moved it to the 2 K 2.5 Ca port. RN B acknowledged that Patient #6 did not receive the prescribed dialysate (2 K and 2.5 Ca) from the start of treatment until the observation. 3. The document titled, “Patient Details Report” dated 3/19/25, showed Patient #6 started treatment at 10:41 AM and ended treatment at 2:42 PM, documenting a dialysate of 2 K and 2.5 Ca. The document showed Patient #6’s prescription was verified on 3/19/25 at 11:10AM. However, observation on 3/19/25 at 1:30 PM (2 hours and 49 minutes after the start of treatment), showed that Patient #6 was on a 3 K and 2.5 Ca dialysate. 4. The document titled, “Patient Summary Report” with a print date of 3/19/25, showed Patient #6’s active treatment orders including a dialysate bath of 2 K and 2.5 Ca. 5. On 3/25/25 at 8:42 AM, the medical director (MD) confirmed that Patient #6 was hospitalized in February (2/25) and had ER visits before and after hospitalization. The MD also stated expectations that staff members deliver correct dialysis treatments according to patients’ prescriptions.”

“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: 36083 Based on documents review, observation, and interviews the facility failed to update goal for target weight as ordered for 1 of 5 in-center hemodialysis patients (Patient #6) reviewed for medical records. At the time of the survey, the facility reported a census of 43 in-center hemodialysis patients and 19 peritoneal dialysis patients. Findings include: 1. The policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” with latest revision date of April 2024, directs nurses to complete assessments including verification of prescription. The policy also directs staff to verify patient identity, prescription, and machine settings prior to initiation of treatment and to be confirmed by a license nurse within one (1) hour of treatment initiation. The policy lists prescription components to be verified and confirmed to include heparin administration or heparinization including intradialytic infusion setting, and target weight. 2. Review of Patient #6’s “Treatment Details Report” dated 3/11/25, showed a nurse’s note indicating a pattern of Patient #6 “coming and leaving under TW [target weight]” where a verbal order was noted with regard to changing the TW to 125.2 kg (kilograms). 3. The document titled, Target Weight Assessment” dated 3/11/25, also showed the order to change Patient #6’s target weight as noted, “Verbal orders to change TW to post weight of 125.2kg.” 4. However, Patient #6’s treatment details reports dated 3/12/25, 3/14/25, 3/17/25, and 3/19/25, did not show update or change in the target weight as ordered on 3/11/25. 5. On 3/25/25 at 8:42 AM, the medical director (MD) reported staff members are expected to follow patients’ prescriptions. 44475”