Davita Wayne County 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: 39025 Based on observation, document review, and staff interview, it was determined the Facility failed to ensure prepared syringes of medications were labeled per policy. Findings include: 1. During a tour of the Facility conducted on 01/28/25 at 10:00 AM, two syringes labeled for Pt (Patient) #1 were observed laying on the medication counter in the treatment room. One syringe contained Heparin 2,000 U (units) 1:1000 loading dose; and the other syringe contained Heparin 1,800 U 1:1000 hourly dose. Also observed at this same time were two additional syringes labeled for Pt#6, with one syringe containing Heparin 800 U 1:1000 loading dose; and the other syringe contained Heparin 1,400 U 1:1000 hourly dose. These four syringes did not document a time or initials of when or who drew the Heparin. 2. The Facility policy titled “Medication Policy” (Revised October 2023) was reviewed. It indicated “ ... 20. ... If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication ...” 3. During a staff interview with the Registered Nurse (E#4 - Employee) on 01/28/25 at 10:14 AM, it was verbalized that syringes were to be labeled with the time and initials of who drew up the medication as listed in the policy.”

“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: 51190 Based on document review and staff interview, it was determined for 5 of 6 (Pt #1, Pt #2, Pt#3, Pt#5, and Pt #6) patient’s records reviewed for BFR (Blood Flow Rate), the ESRD (End Stage Renal Disease) Facility failed to ensure the patient’s BFR was achieved and maintained in accordance with the dialysis prescription. Findings include: 1. On 1/29/25, Pt #1’s record was reviewed. Pt #1 was admitted for in-center hemodialysis on 9/22/23 with a diagnosis of ESRD. Pt #1’s clinical record contained a physician order that prescribed a BFR of 350. Pt #1’s treatment sheets dated 12/05/24, 12/28/24, 1/2/25, 1/7/25, 1/16/25, and 1/18/25 failed to achieve the prescribed BFR of 350. The record lacked documentation of notification to the physician and a physician order to change BFR. 2. On 1/29/25, Pt #2’s record was reviewed. Pt #2 was admitted for in-center hemodialysis on 1/10/24 with a diagnosis of ESRD. Pt #2’s clinical record contained a physician order that prescribed a BFR of 400. Pt #2’s treatment sheets dated 12/23/24, 12/31/24, 1/8/25, and 1/22/25 failed to achieve the prescribed BFR of 400.The record lacked documentation of notification to the physician and a physician order to change BFR. 3. On 1/29/25, Pt #3’s record was reviewed. Pt #3 was admitted for in-center hemodialysis on 6/20/22 with a diagnosis of ESRD. Pt #3’s clinical record contained a physician order that prescribed a BFR of 400. Pt #3’s treatment sheets dated 12/23/24, 1/20/25, and 1/22/25 failed to achieve the prescribed BFR of 400. The record lacked documentation of notification to the physician and a physician order to change BFR. 4. On 1/29/25, Pt #5’s record was reviewed. Pt #5 was admitted for in-center hemodialysis on 7/21/23 with a diagnosis of ESRD. Pt #5’s clinical record contained a physician order that prescribed a BFR of 350. Pt #3’s treatment sheets dated 12/09/24, 12/30/24, and 1/07/25 failed to achieve the prescribed BFR of 350. The record lacked documentation of notification to the physician and a physician order to change BFR. 5. On 1/29/25, Pt #6’s record was reviewed. Pt #6 was admitted for in-center hemodialysis on 1/16/25 with a diagnosis of Acute Kidney Failure. Pt #6’s clinical record contained a physician order that prescribed a BFR of 400. Pt #2’s treatment sheets dated 1/16/25 and 1/18/25 failed to achieve the prescribed BFR of 400. The record lacked documentation of notification to the physician and a physician order to change BFR. 6. On 1/29/25, the policy titled, “In-center Hemodialysis Policies & Procedures” (Effective 1/3/08) was reviewed. It states, “ ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ... The licensed nurse notifies the physician as needed of changes in patient status.” 7. On 1/29/25 at 2:15 PM, an interview was conducted with the Clinic Service Manager (E#12). E#12 confirmed that there were no notifications to the physician when above BFR orders were changed.”