Davita Topeka Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 50873 Based on observation, interview, and policy review, the facility failed to ensure 3 of 4 observed staff (Staff M, Registered Nurse (RN), Staff T, Patient Care Technician (PCT) and Staff CC, PCT) performed hand hygiene before they touched patient care supplies and patient care equipment, after they removed their gloves, after patient contact, and prior to cannulation (insertion of needles). Failure to perform hand hygiene provided a mode of cross-contamination with the potential spread of pathogens (microorganism that can cause diease), which could negatively impact the health and well-being of the 133 patients who received dialysis treatments at the facility. Findings include: Review of a policy titled, “Infection Control For Dialysis Facilities,” revised April 2023, showed, “...1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g., before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...” Observations of the dialysis treatment area on 02/11/25 showed the following: At 10:31 AM, Staff CC, (PCT) entered patient treatment station #9. Staff CC applied a clean pair of gloves without first performing hand hygiene, then gathered clean supplies. Staff CC performed direct patient care then removed gloves and applied a clean pair of gloves without performing hand hygiene. Staff CC then disconnected the patient’s arterial line, flushed the lumen, then removed gloves and typed on the computer. Staff CC did not perform hand hygiene at any point during the observation. At 10:39 AM, Staff CC, PCT, rechecked the patient’s blood pressure at station 9, removed gloves and applied a clean pair of gloves without performing hand hygiene. At 11:11 AM, Staff T, PCT, entered patient treatment station #25 to initiate dialysis. Staff T failed to perform hand hygiene between glove changes when performing Central Venous Catheter Care (CVC) [a flexible tube inserted in to a large vein to access the bloodstream]. Failing to adhere to hand hygiene policies while accessing a CVC increases the risk of infection. Observations of the dialysis treatment area on 02/13/25 showed the following: At 10:27 AM, Staff M, RN, entered patient treatment station #23 to initiate dialysis. Staff M palpated the patient’s first access site with gloved hands, applied antiseptic, then cannulated the access without changing gloves, performing hand hygiene, or reapplying antiseptic to the patient’s access site. Staff M then palpated the second access site and cannulated the site without changing gloves, performing hand hygiene, or reapplying antiseptic to the access site. During an interview on 02/13/25 at 11:59 AM, Staff N, RN, stated that the expectation was for staff to perform hand hygiene when entering and leaving the treatment floor, when hands were visibly soiled, when going between patients, when going from the machine to the patient, when changing gloves, and before going to the computer. During an interview on 02/11/25 at 11:03 AM, Staff A, Facility Administrator (FA), confirmed the facility expectation was for staff members to perform hand hygiene prior to putting on, changing, or removing gloves. During an interview on 02/14/25 at 1:04 PM, Staff B, Medical Director (MD), confirmed the facility expectation was for staff to perform hand hygiene between glove changes, after patient contact, and prior to cannulation.”

“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: 50873 Based on interview, record review, and policy review, the facility failed to report abnormal findings to the licensed nurse according to their policy for 3 (Patients 2, 11, and 13) of 15 sampled patients. Failure to report patients’ abnormal findings according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact their care. Findings included: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed, “ ...11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to ‘Abnormal Findings’ section in this policy)...Abnormal Findings Unless other abnormal parameters are established by the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ...Post-treatment: If patient is above or below 1 kg [kilogram] from the target weight Blood pressure: Pre-dialysis: Systolic [top number of a blood pressure reading] greater than 180 mm/Hg [millimeters mercury] or less than 90 mm/Hg. Diastolic [bottom number of a blood pressure reading] greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Blood Pressure-Intradialytic [during dialysis]: Systolic greater than 180 mm/Hg or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat [sic] ...” Patient 2 Review of a document titled, “Treatment Details Report,” dated 12/26/24, showed the patient’s blood pressure (BP), documented by Staff X, Patient Care Technician (PCT), at 11:56 AM, was 216/115. There was no documentation to indicate the nurse was notified of Patient 2’s elevated BP. During an interview on 02/12/25 at 11:15 AM, Staff K, Manager of Clinical Services (MCS) stated that Staff X, PCT, should have notified the registered nurse (RN) of Patient 2’s blood pressure and the RN should have followed-up with an assessment and notified the physician if needed. Patient 11 Review of a document titled, “Treatment Details Report,” dated 01/28/25, showed the patient’s blood pressure (BP), documented by Staff Z, PCT, at 8:03 AM, was 88/58. The Treatment Details Report further showed that Patient 11 complained of not feeling well. There was no documentation to indicate the nurse was notified of Patient 11’s low BP. During an interview on 02/12/25 at 3:18 PM, Staff K, MCS, confirmed there was no evidence of RN notification of the low blood pressure reading. Patient 13 Review of a document titled, “Treatment Details Report,” dated 02/07/25, showed the patient’s heart rate, documented by Staff AA, PCT at 12:33 PM, was 127. There was no documentation to indicate the nurse was notified of the patient’s elevated heart rate. Additionally, Patient 13’s “Post Treatment Weight,” showed the patient’s target weight was 104.5 kilograms (kg) and their post weight was 106.2 kg, a difference from target calculation of 1.7 kg. There was no documentation to indicate the RN addressed the patient leaving the facility above their target weight. During an interview on 02/12/25 at 4:02 PM, Staff K, MCS, confirmed there was no evidence of RN notification of Patient 13’s elevated heart rate or post-dialysis weight being 1.7 kg above their target weight. Staff K stated the RN was expected to notify the provider of Patient 13’s heart rate and of Patient 13 being above their target weight. Staff K stated that the notification should also have been documented. During an interview on 02/13/25 at 11:59 AM, Staff N, RN stated that the PCTs should report any patient heart rate below 60 or above 100, any blood pressure above 180/90 or below 100/60, or any patient symptoms such as cramping, fever, lightheadedness, or dizziness. During an interview on 02/14/25 at 1:04 PM, Staff B, Medical Director, confirmed the PCTs were expected to report to the RNs based on facility policy.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview, document review, and policy review, the facility failed to include a review of contributing factors when tracking, trending, and analyzing quality indicators for patient deaths. This failure had the potential to impact all 133 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Continuous Quality Improvement Program,” revised April 2021, showed, “...7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following: Patient Safety, including Review of sentinel events. Review of trends of adverse patient occurrences including falls and blood loss. Review of product, equipment, or medication notices or recalls...Mortality - review of deaths...” A document titled, “Dashboard Home: December 2024,” showed a “mortality” graph that included measurement data for deaths. The document included information regarding the causes of deaths including cardiac, infection, gastrointestinal (GI), as well as the total number of deaths and the gross mortality rate but failed to include possible contributing factors such as missed treatments, abnormal lab values, or ultrafiltration rates. A document titled, “Mortality Improvement Plans - December 2024,” revealed one death was recorded during the month of December 2024 with the cause unknown; three deaths were recorded in October 2024 with the causes being one cardiac, one other, and one not available; three deaths recorded in September 2024 with the causes being one cardiac and two not available; and two deaths recorded in August 2024 with the causes being one gastrointestinal and one not available. During an interview on 02/14/25 at 9:10 AM, Staff A, Facility Administrator (FA), confirmed that the facility was not tracking, trending, or analyzing potential contributing factors to the patient deaths, such as missed treatments, relevant laboratory values, or ultrafiltration rates. Staff A stated the only data being reviewed by the facility was the number of deaths, causes of death, and the gross mortality rate. During an interview on 02/14/25 at 1:04 PM, Staff B, Medical Director, confirmed the facility reviewed patient deaths but did not look at contributing factors.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 50873 Based on interview, document review, and policy review, the facility failed to revise a phosphorous performance improvement plan despite the plan having shown no improvement in performance. This failure had the potential to impact all 133 patients who received dialysis treatments at the facility. Findings include: Review of a policy titled “Continuous Quality Improvement Program,” revised in April 2021, showed, “...7. The facility will measure, analyze, and track quality indicators or other aspects of performance...8. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained...” Review of a document titled, “Comprehensive Report - [facility name]” dated 06/19/24, showed that the Centers for Medicare and Medicaid Services (CMS) goal for phosphorous was 12.6% and the facility’s phosphorous percentage was at 30.5%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE [End-Stage Renal Disease Core Survey]. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” Review of a document titled, “Comprehensive Report -facility name” dated 07/23/24 showed that the CMS goal for phosphorous was 12.6% and the facility phosphorous percentage was at 34.8%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” Review of a document titled, “Comprehensive Report - [facility name]” dated 08/21/24 showed that the CMS goal for phosphorous was 12.6% and the facility phosphorous percentage was at 36%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” Review of a document titled, “Comprehensive Report -[facility name]” dated 09/10/24 showed that the CMS goal for phosphorous was 12.6% and the facility phosphorous percentage was at 33.1%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” Review of a document titled, “Comprehensive Report - [facility name]” dated 10/29/24 showed that the CMS goal for phosphorous was 12.6% and the facility phosphorous percentage was at 32.2%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” Review of a document titled, “Comprehensive Report - [facility name]” dated 11/21/24 showed that the CMS goal for phosphorous was 12.6% and the facility phosphorous percentage was at 37%. The report showed, “Action(s) and Interventions: 1) Review pt [patient] population in CORE. 2) Work with patients who need help obtaining binders to get on pt assistance program if eligible. 3) Review pt labs with them bi-monthly as drawn and continue to educate pts on importance of PO4 [phosphorous] control and side effects of prolonged high PO4. 5) [sic] Review and continuously educate on the importance of taking binders and when to take them.” During an interview on 02/14/25 at 9:10 AM, Staff A, Facility Administrator, confirmed there had been no changes to the phosphorous action plan from June 2024 to December 2024, despite the plan having shown no improvement in performance. During an interview on 02/14/25 at 11:13 AM, Staff I, Regional Home Manager, confirmed the facility expectation would be for an action plan to be updated if it failed to demonstrate improvements in performance. During an interview on 02/14/25 at 1:04 PM, Staff B, Medical Director, confirmed the facility expectation was to make adjustments to action plans when the plans were not working.”