Davita Chestertown Dialysis Center

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 36839 Based on observations, and interviews with the patients and staff, the facility’s administration failed to ensure an environment free from hazards in order to maintain safety and functionality. This failure placed the well being and safety of patients, staff, and visitors at potential risk for harm and possible exposure to infectious diseases. Findings include: The Centers for Disease Control and Prevention (CDC) defines a “sanitary environment” as an environment that meets the “Standard Precautions” and stricter hemodialysis guidelines due to higher contamination risks. Dialysis facilities must be defect-free, with intact, clean surfaces to ensure effective cleaning and disinfection, preventing microbial growth. 1. During observations in the clinical treatment room on 5/21/2024, the following were noted: a. The dialysis recliner at station #9 had a tear on the back rest measuring approximately 1 x 1.5 inches. b. The dirty sink located at the laboratory area had a green stain and the drain was surrounded with a red-brown substance. 2. During an inspectional tour of the patient’s waiting room on 5/22/2024, it was noted that one of the chairs located nearest to the door of “Treatment Area 3” had yellow crusty stains around it. The Occupational Safety and Health Administration (OSHA) defines an exit route as “a continuous and unobstructed path of exit travel from any point within a workplace to a place of safety. These exit routes must be permanent and always free from any form of obstruction. 3. The emergency exit located in the supply room adjacent to the acid tank was obstructed with a floor polisher, a wheeled trolley, 4 empty boxes, a rolling white trash bin, and a gray rectangular lid. These findings were discussed with the facility administrator and the assistant facility administrator during the exit conference on 5/22/2024.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 36839 Based on observations, the governing body failed to ensure that the contact information for the State Survey Agency and Renal Network were current and accurate. This failure denied the patients their rights. Findings Included: The Centers for Medicare and Medicaid Services (CMS) requires that all in-center dialysis facilities post the current contact information for the applicable End-Stage Renal Disease (ESRD) Network and State Survey Agency (SSA) and the current complaint telephone numbers for each. The purpose of this posting is to ensure that patients are aware of their rights and have access to important contact information should they need to file a complaint or report a concern. However, it is important to note that this posting is meant to supplement, not replace, individual communication with each patient about their rights in a way that they can understand. During observations at the patient’s waiting room, it was noted that the contact information of the Office of Health Care Quality (OHCQ) and Quality Insights Renal Network 5 were not up to date. This finding was discussed with the facility administrator and the assistant facility administrator during the exit conference on 5/22/2024.”

“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: 36839 Based on a review of the dialysis patients’ treatment flowsheets, the facility’s administration and clinical staff failed to ensure that the dialysis prescriptions were the same as what the patients received. The failure to ensure that the dialysis prescription was implemented according to the doctor’s orders placed the patients at potential risk of harm or injury. Patients: #1, #2, #3, #4 Findings included: In order to have an effective dialysis treatment, the prescription order must be followed. The Blood Flow Rate (BFR), heparin order, treatment time, as well as the frequency of the patient assessment based on each facility’s policy must all be completed and documented. The reason being, an appropriate hemodialysis prescription is individualized to meet the dialysis needs of the patient. Through data collection and nursing assessment, providers can review the patient’s response to the treatment and make changes accordingly. A review of the sampled patients’ treatment flowsheets on 5/22/2024 revealed that 4 out of 4 sampled patients’ prescribed BFRs were not followed, and were not supported by any documentation explaining why they the clinical staff deviated from the patients’ BFR prescription. 1. On treatment date 5/16/2024, Patient #1’s BFR ran at 300 mL/minute instead of 350 mL/minute. 2. On treatment date 5/20/2024, Patient #2’s BFR ran at 325 mL/minute instead of 350 mL/minute. 3. On treatment date 5/15/2024, Patient #3’s BFR ran at 300 mL/minute instead of 350 mL/minute. 4. On treatment date 5/18/2024, Patient #4’s BFR ran at 300 mL/minute instead of 350 mL/minute. These findings were discussed with the facility administrator and the assistant facility administrator during the exit conference on 5/22/2024.”

“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: 36839 Based on patient record review, the governing body, and the interdisciplinary team (IDT) failed to ensure that a Plan of Care (PoC) has been conducted on all new patients within the latter of 30 calendar days, or 13 treatments beginning with the first outpatient dialysis session. This failure placed the affected patient at potential risk of harm and denied the patients their rights. Patient #2 Findings included: The Centers for Medicare and Medicaid Services (CMS) require a PoC to be completed for each new dialysis patient within 30 days or 13 treatments, whichever comes first, starting from the first dialysis session. The purpose of this assessment is to provide a comprehensive evaluation of the patient’s physical, psychosocial, and medical status, which is used to develop an individualized care plan for the patient. A review of Patient #2’s PoC on 5/22/2024 showed that the first dialysis treatment at the facility was on 2/9/2024 with an initial PoC completed on 3/21/2024 which was greater than 30 days from the patient’s first dialysis session. This finding was confirmed by the facility administrator upon reveiw of the patient’s medical record, and again discussed with the administrative team during the exit conference on 5/22/2024.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36839 Based on review of the patients’ plans of care (PoC), the governing body failed to ensure that the facility’s interdisciplinary team (IDT) completed the 90-day follow-up comprehensive assessment. This failure placed the affected patient at risk for receiving inadequate health care and denied the patient his/her rights. Patients: #4 Findings included: According to the facility’s policy (1-14-01, page 2, #5), “A follow-up 90-day reassessment will be completed to evaluate the patient’s status and provide information to adjust the patient’s plan of care.” Upon review of the sampled patients’ medical records on 5/22/2024, it was noted that Patient #4, who was admitted to the facility on 5/11/2023, had an initial PoC completed on 6/22/2023. However, the 90-day PoC was not found. This finding was verified with the administrative team during the exit conference on 5/22/2024.”

“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: 36839 Based on observations and a review of the facility’s policies and procedures, the facility’s administration failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access prior to cannulation, and practiced the correct infection control protocol. This failure placed the safety and well being of the patients at potential risk of harm in maintaining their vascular access. Findings included: The facility’s policy on Arteriovenous Fistula (AVF) or Graft (AVG) Cannulation (1-04-01E) states: “Do not palpate insertion site once the area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” During observations on the dialysis treatment floor on 5/22/2024 at 9:50 a.m., Staff #1 touched the vascular access of the patient at station #9 immediately before needle insertion after it had already been prepped. This observation was discussed with the administrative team during the exit conference on 5/22/2024.”