Davita Gardenside 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: 35697 Based on observation, interview, and facility policy review, the facility failed to ensure that 2 out of 4 staff performed hand hygiene after removing their gloves between each patient or station. The findings include: Review of the facility policy titled, “Infection Control for Dialysis Facilities,” revised in April 2023, revealed under the section titled, “HAND HYGIENE” that “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...d. after patient and dialysis delivery system contact...” During an observation on the dialysis treatment floor on 05/01/2024 at 9:50 AM, Registered Nurse (RN) #4 stepped out of a treatment area, took off her gloves, and did not perform hand hygiene as required before putting on a new pair of gloves. During an interview on 05/01/2024 at 10:00 AM, RN #4 stated she failed to perform hand hygiene, as per the observation at 9:50 AM. During an observation on the dialysis treatment floor on 05/01/2024 at 11:00 AM, Patient Care Technician (PCT) #6 was observed to take off her gloves after coming away from a patient treatment station. Further observation revealed PCT #6 began typing on a computer keyboard without performing hand hygiene. During an interview on 05/01/2024 at 11:05 AM, PCT #6 stated she failed to perform hand hygiene after taking off her gloves and before using the computer keyboard. During an interview on 05/01/2024 at 12:00 PM, the Manager of Clinical Services stated it was her expectation for staff to complete appropriate hand hygiene after taking off their gloves.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to complete an initial comprehensive assessment within 30 calendar days or 13 dialysis treatment sessions as required for 1 of 1 sampled patients (Patient #1) who was new to dialysis and admitted to the facility within the last 90 days. The findings include: Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” with a revision date of July 2023, noted, “...4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” Review of the facility’s “Patient Summary Report” for Patient #1 revealed the facility admitted the patient on 01/30/2024. Review of the facility’s, “Hospitalizations and Treatment Behaviors Log: February 2024” and the “Hospitalizations and Treatment Behaviors Log: March 2024” revealed the 13th dialysis treatment for Patient #1 occurred on 03/05/2024. Review of the facility’s, “Comprehensive Encounter” dated 03/21/2024 revealed Patient #1’s physician, as a member of the IDT, completed the initial comprehensive assessment on 03/21/2024. During an interview on 04/30/2024 at 1:04 PM, the Manager of Clinical Services stated she was unable to produce an initial comprehensive assessment completed by Patient #1’s physician within 30 days or 13 dialysis treatment sessions of the patient’s admission. The Manager of Clinical Services stated the facility’s process was to follow its policy, and she did not know why Patient #1’s physician had not completed the patient’s comprehensive initial assessment within 30 days or 13 dialysis treatment sessions as required. During an interview on 05/02/2024 at 10:17 AM, the Medical Director stated the facility’s policy was to be followed, and an initial comprehensive assessment was to be completed within 30 days or 13 dialysis treatment sessions as per the facility policy. The Medical Director stated Patient #1’s physician was from an outside “group” that had patients receiving dialysis treatments at the facility; however, the physician was “still expected to follow [the facility’s] policy.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to complete a monthly comprehensive re-assessment for 1 of 1 sampled patients, (Patient #2) who had been deemed as unstable due to frequent hospitalizations, missed treatments, and shortened treatment duration. The findings include: Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised in July 2023, revealed, “A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least annually for stable patients or semiannually when required by State Regulation, at least monthly for unstable patients, including, but not limited to, patients with the following: Extended or frequent hospitalizations, marked deterioration in health status, significant changes in psychosocial needs, concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.” Review of the facility’s, “Comprehensive Assessment Report” for Patient #2 revealed the IDT had completed a comprehensive assessment on 03/18/2024 of the patient, and based on the completed comprehensive assessment, the patient was deemed as “unstable.” During an interview on 04/30/2024 at 3:10 PM, the Manager of Clinical Services stated the IDT had not completed a monthly comprehensive re-assessment of Patient #2 after the unstable assessment completed on 03/18/2024, for patient hospitalizations, missing treatments, and not staying for prescribed treatment duration. The Manager of Clinical Services stated she did not know why the comprehensive re-assessment had not been completed monthly as required, and stated monthly was interpreted by the facility as every 30 days. During an interview on 05/02/2024 at 10:17 AM, the Medical Director stated Patient #2 should have been re-assessed “monthly,” which was every “30 days,” as per the facility’s policy. The Medical Director stated the facility’s process for comprehensive re-assessments for patients deemed as unstable was to follow the facility’s policy and complete a comprehensive monthly follow-up re-assessment. The Medical Director further stated Patient #2 chronically missed treatments and might not have been available for a comprehensive follow-up re-assessment by the IDT.”

“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: 35697 Based on interview, record review, and facility policy review, the facility failed to ensure policies and procedures relative to patient care were followed for 1 of 11 sampled patients (Patient #7). Review of facility’s policy revealed nursing staff were to notify the physician or non-physician practitioner (NPP) of any concerns that might preclude the initiation of dialysis. However, review of Patient #7’s medical record revealed the patient’s pretreatment blood pressure was 76/41 millimeters of mercury (mm/Hg) with no documented evidence the physician was notified. The findings include: Review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in April 2021, revealed “6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner (NPP) if applicable) will be notified of any concerns that may preclude the initiation of dialysis.” Continued review of the policy revealed, “Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time.” Further review of the policy revealed the conditions or concerns included “Blood pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg.” Review of the facility’s, “Admit [admission]/Discharge History” report for Patient #7 revealed the patient was admitted to the facility on 04/16/2019 and discharged on 11/29/2019. Review of a “Kardex” report for Patient #7 revealed the patient’s primary diagnosis for dialysis was end-stage renal disease (ESRD). Review of the facility’s dialysis “Post Treatment” flowsheet dated 08/14/2019, revealed Patient #7’s blood pressure at 2:21 PM was 76/41 mm/Hg at the initiation of dialysis. Continued review of the flowsheet revealed Patient #7 was dialyzed from 2:21 PM to 5:05 PM, and at 5:01 PM, the patient was noted as unresponsive with a blood pressure of 53/38 mm/Hg. Per review, 400 cubic centimeters (cc) of normal saline was administered to Patient #7, and at 5:03 PM, the patient’s blood pressure improved and was 97/43 mm/Hg. Review of the flowsheet revealed Patient #7 was still obtunded (dulled or reduced level of alertness or consciousness), and had no response to painful stimuli with an additional 200 cc of saline administered. Further review revealed at 5:04 PM, Patient #7’s remained intermittently lethargic, and at 5:05 PM, the dialysis treatment was terminated and the patient sent to an emergency room for further evaluation. Further review of Patient #7’s medical record revealed no documented evidence the physician was notified of the patient’s pretreatment blood pressure. During an interview on 05/02/2024 at 9:30 AM, the Manager of Clinical Services stated the physician should have been contacted when Patient #7’s blood pressure was low prior to starting the dialysis treatment on 08/14/2019. During an interview on 05/02/2024 at 10:00 AM, the Medical Director stated he was not sure if the physician was called prior to starting the dialysis treatment for Patient #7 (on 08/14/2019). The Medical Director confirmed there was no documentation in the patient’s medical record indicating a physician was contacted prior to the initiation of Patient #7’s dialysis treatment.”