Davita Springhurst Dialysis

“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 facility policy review, the facility failed to monitor patients’ vital signs according to their policy for 4 (Patients #1, #3, #4, and #5) of 5 sampled patients. Failure to monitor patients’ vitals 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 the care provided to the 33 patients who received dialysis treatments at the facility. The findings include: Review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated “Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. Per the policy, “Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT [patient care technician] or licensed nurse includes: a. Vital signs and treatment monitoring.” The policy revealed, “Post-Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. Per the policy, 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.” The policy specified, abnormal findings included “Blood Pressure-Intradialytic [during dialysis treatment]: * Systolic greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg.” The policy indicated “Blood Pressure-Intradialytic: * Systolic greater than 180 mmHg or less than 90 mmHg * Diastolic greater than or equal to 100 mmHg or less than 50 mmHg” and “Heart or Pulse Rate Pre/Intra/Post: * Less than 60 beats per minute [bpm] or greater than 100 beats per minute and/or an irregular heart beat.” Review of facility records for Patient #1’s, “Treatment Details Report,” dated 09/24/2025 indicated the patient’s post-treatment heart rate was listed as 49 bpm and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. Review of Patient #3’s “Treatment Details Report” dated 09/26/2025 indicated the patient’s pre-treatment heart rate was listed as 39 bpm and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. Additionally, Patient #3’s “Treatment Details Report” dated 09/22/2025 indicated the patient’s heart rate during treatment was listed as 42 bpm at 11:51 AM, 43 bpm at 12:21 PM, 104 bpm at 12:51 PM and 1:21 PM, 105 bpm at 1:51 PM, and 107 bpm at 2:21 PM and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. Review of Patient #4’s”Treatment Details Report,” dated 09/15/2025, indicated the patient had a pre-treatment blood pressure reading of 209/91 mmHg, a standing heart rate of 103 bpm, and a seated heart rate of 103 pm and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure or heart rate. Additionally, review of Patient #4’s “Treatment Details Report” dated 09/19/2025 indicated the patient had a pre-treatment blood pressure reading of 192/111 mmHg and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Review of facility records revealed Patient #5’s “Treatment Details Report” dated 09/15/2025 indicated during treatment the patient had a blood pressure reading of 115/42 mmHg at 12:01 PM, 124/36 mmHg at 12:29 PM, 132/43 mmHg at 12:59 PM, 90/43 mmHg at 1:31 PM, 112/29 mmHg at 2:01 PM, 120/39 mmHg at 2:29 PM, and 107/43 mmHg at 2:38 PM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Additionally, review of Patient #5’s “Treatment Details Report” dated 09/17/2025 indicated during treatment the patient had a blood pressure reading of 118/46 mmHg at 12:30 PM, 130/49 mmHg at 12:59 PM, 128/47 mmHg at 1:59 PM, 118/43 mmHg at 2:29 PM, and 119/49 mmHg at 2:38 PM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. During an interview on 10/01/2025 at 4:44 PM, Patient Care Technician #6 stated the facility expected PCTs to report a patient’s low blood pressure readings to the RN and document the notification. During an interview on 09/30/2025 at 10:02 AM, the Manager of Clinical Services confirmed the facility expected PCTs would first recheck any out-of-range vital signs for a patient and then if the vital sign was still out of range, to notify the RN per the facility policy. During an interview on 12/05/2025 at 12:34 PM, the Medical Director stated the facility expectation was for staff to report patients’ out-of-range vital signs to the RN per the facility policy and document the notification.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to provide vascular access monitoring per facility policy for 2 out of 2 observations of initiation of dialysis for patients with an arteriovenous fistula (AVF). The findings include: Review of facility policy titled, “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care,” revised 04/2025, indicated “Purpose: To reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize blood loss and to maximize the lifetime of each access.” On 10/01/2025 at 10:25 AM, Patient Care Technician (PCT) #5 was observed initiating treatment for a patient with an AVF at Treatment Station 9. PCT #5 was observed to clean the patient’s access with a wipe, alcohol, and an antiseptic. PCT #5 then removed her gloves, performed hand hygiene, donned clean gloves, went to the computer, changed gloves and performed hand hygiene, applied a tourniquet, cannulated the access, then taped the needles. PCT #5 failed to auscultate (listen with a stethoscope) the access prior to cannulation. On 10/01/2025 at 11:02 AM, PCT #6 was observed initiating dialysis treatment for a patient with an AVF at Treatment Station 1. PCT #6 was observed to apply antiseptic to the patient’s access, changed her gloves and performed hand hygiene in between gloves, applied a tourniquet, palpated the cannulation site on the access, applied numbing spray, and cannulated. PCT #6 failed to reapply antiseptic after she touched the patient’s access and prior to cannulation. During an interview on 10/01/2025 at 2:58 PM, Registered Nurse (RN) #1 stated the process to assess an AVF included lifting the arm, looking for any issues, listening to the access, and feeling the access. RN #1 stated that if a staff member were to touch the access after applying the antiseptic, the antiseptic should be reapplied before cannulation. During an interview on 10/01/2025 at 4:44 PM, PCT #6 stated that when assessing an access, the PCT would look, listen, and feel the access. PCT #6 stated that if the access was touched after antiseptic was applied, the staff member would need to reapply antiseptic prior to cannulating. During an interview on 12/05/2025 at 12:34 PM, the Medical Director (MD) confirmed that auscultation was an expected part of assessing patients’ accesses prior to every cannulation, and stethoscopes were provided if needed. The MD confirmed that antiseptic would need to be reapplied if the access was touched prior to cannulation.”