Davita Seton Drive Dialysis

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 47759 Based on record review and staff interview, the facility’s governing body failed to maintain a current copy of all of the patients’ treatment orders and medication list. This failure placed the safety and wellbeing of the patients at potential risk of harm in the event of an emergency evacuation. Patients C, L, R, S,T,U and V Findings Included: According to the facility’s policy Facility Emergency Management Plan (Policy 04-07-01) page 17 number 6 “Each evacuation kit(s) should contain: a copy of each patient’s treatment orders and medication list. The Facility Administrator (FA) or designee will then verify patient information is updated and replaced at least monthly.” On 01/23/2024 at 11:30 a.m., during inspection of the facility’s emergency evacuation kit, the surveyor observed that the facility’s emergency patient list was last updated on 08/2023. Since 08/2023, (seven) 7 patients have been admitted to the facility. [Patients C, L, R, S,T,U and V]. This information was corroborated by Staff #2.”

“ENVIRONMENT-ACCESS TO PORTS/METERS CFR(s): 494.40(a) 8 Environment: access to ports/meters The layout of the water purification system should provide easy access to all components of the system, including all meters, gauges, and sampling ports used for monitoring system performance. This Standard is not met as evidenced by: 47759 Based on observations and staff interviews, the facility’s governing body failed to ensure easy access to all components of the system such as: (1) water pressure gauges (2) water valves and (3) sample ports. This failure placed the water system at risk for possible damage that may affect patient care. Findings Included: According to the American National Standards Institute (ANSI/AAMI RD52:2004), the layout of the water purification system should provide easy access to all components of the system, including all meters, gauges and sampling ports used for monitoring system performance. On 01/22/2023 from 01:30 p.m.- 02:00 p.m., during observations of the water room, the surveyor observed the following: 1. Several air filters and a yellow rectangular containers among other items were observed blocking valve L1, first water out sample port and the ultrafiltration meter. 2. A black vacuum blocking valve H1 and H2 3. A white 100 liter opaque drum with several different hoses inside was found blocking gauge G6 and the secondary chlorine sample. 4. Two Acid concentrate barrels blocking the water heater. On 01/22/2023 at 01:40 p.m., during interviews with the assistant facility administrator (AFA), the AFA corroborated that all components of the water system should be easily accessible and not blocked by any items.”

“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: 47759 Based on record review, observations, staff and patient interviews, the facility’s governing body failed to maintain an environment that is constructed, equipped and maintained to provide dialysis patients and the public a safe, functional, and comfortable treatment environment Findings Included On 01/24/2024 at 02:00 p.m., during review of the facility’s policies and procedures titled “Physical Environment” (Policy: 08-04-01) page 1 number 1 states “The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates and the public safe, functional, and comfortable treatment environment.” Number 2 states “The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates, and the public.” 1. On 01/22/2024 at 09:40 a.m.,, upon arrival to the vicinity of the facility, the surveyor observed that the outside entrance to the dialysis facility was icy. Interview with the assistant facility administrator (AFA) corroborated that the outside entrance to the dialysis facility was icy and was a concern for patient and staff safety. a. On 01/22/2024 from 11:15-12:30 p.m., interviews with patients I and C revealed concerns about patient safety related to the icy outside entrance way as well as the wet waiting room floor. According to the patients, they were informed that facility #2 was responsible for the outside maintainance. b. On 01/25/2024 at 10:00 a.m., review of the dialysis facility and facility #2’s agreement did not show a clear division of responsibility on outside maintenance. 2. On 01/22/2024 at 01:45 p.m., during observations of the water room, the surveyor observed the following: a. Peeling white wall near the acid tank container b. A hole on the wall near the Reverse Osmosis System approximately 3 inches by 3 inches on the wall c. A hole to the right of the water heater approximately 3 inches by 1 inch i. The Bio-Medical Technician corroborated that the facility was aware of the peeling walls and the 2 holes on the wall. 3. On 01/23/2024 at 09:50 a.m., during observations of the treatment floor, the surveyor observed the following: a. Torn cushion on the stool near station #9. b. Cracked plastic containers located across station #2, #4 and #10. i. The AFA corroborated that the plastic containers will need to be replaced. c. Peeling paint on the wall between stations #1 and #2; #3 and #4; #5 and #6. i. The AFA corroborated that the walls have to be repainted d. Brown stain on one of the ceiling tiles near station #4 i. The AFA corroborated that there had been a leak at one point and that the tiles do need to be replaced.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47759 Based on record review, observations, patient and staff interviews, the facility ’ s governing body failed to properly assess patients’ fluid status by failing to (1) perform the patient’s comprehensive assessment in a timely manner, (2) intervene in abnormal findings in a prompt manner and (3) document abnormalities. This failure places the affected patients at potential harm and denies the patient the opportunity to have their care re-evaluated in a prompt manner. Findings Included: On 01/24/2024 at 02:05 p.m., during record review of the facility’s Pre-Intra-Post treatment data collection, monitoring, and nursing assessment (policy 1-03-08) page 1 number 2 states “The Nursing assessment will be performed and documented by a licensed nurse ... a. The assessment includes the following components: ...VI(2). Auscultation of the lungs.” Page 3 number 8 states “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.” Page 4 number 11 states “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse.” Page 4 number 12 states “The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status.”Page 4 number 13 states “All findings, interventions and patient response will be documented in the patient ’ s medical record.” Page 5 states “the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ’ s medical record” Under Post-treatment it states “If patient is above or below 1 kg from the target weight” On 01/22/2024 from 10:00 a.m. -11:15 a.m., during observations of the clinical treatment floor, the surveyor observed that Staff #2 had not performed [his/her] nursing assessment on patients on the second shift (treatment put on time of 09:45-10:15 a.m.). To confirm this observation, from 11:16 a.m.-12:30 p.m., the surveyor interviewed [Patients B,C, H, and I], all of whom had a put on time schedule before 10:15 a.m., and asked if Staff #2 had listened to their lungs today. Patients B, C, H, and I all said “no, not yet” but assured the surveyor that the nurse always does, just not immediately. On 01/23/2024 from 10:20 a.m. - 11:30 a.m., during observations of the clinical treatment floor, the surveyor observed that from 10:20 a.m. through 11:25 a.m., [Patient G] ’ s mean arterial pressure (MAP) were the following: 1. 10: 26 a.m. 88mmHg/32mmHg (MAP: 51mmHg) ---Ultrafiltration Rate (UFR): 580mL/kg 2. 11:00 a.m. 84mmHg/38mmHg (MAP:53mmHg) --UFR: 580mL/kg 3. 11:25 a.m. 80mmHg/36mmHg (MAP: 51mmHg)----UFR: 0mL/kg On 01/23/2024, at 10:50 a.m., the surveyor interviewed Staff #1 about Patient G. According to Staff #1, the patient was not feeling well and therefore contacted the provider. According to the provider, “the patient must still get dialysis with the MAP goal greater than 60mmHg. If the patient ’ s MAP declines below 60mmHg, then the UFR must be decreased or turned off.” However, no intervention was witnessed by the surveyor despite being able to verbalize the provider’s parameters until 11:25 a.m. In summary, Staff #1 failed to follow the provider’s order promptly. On 01/24/2024 at 10:20 a.m., during record review of the sampled patient’s treatment flowsheet, the surveyor observed that on treatment date 01/18/2024, Patient D was discharged with the weight of 110.3 kg, which is 10.3 kg over the ordered target weight (100kg). Interview with the manager of clinical services on 01/26/2024 corroborated that there should have been a note stating that the patient’s target goal was not achieved that treatment date.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the facility’s implemented infection control protocol. This failure placed the safety and wellbeing of the patients at potential risk of harm in maintaining their vascular access. Staff: #5, #6, #7 and #9 Findings included: According to the facility’s policies and procedures titled “AV Fistula or Graft Cannulation with Nipro Or Medsystems Safety Fistula Needles (SFN) And Administration of Heparin Loading Dose” page 3 number 13 states “Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” On 01/22/2024, during observations of the treatment floor, the surveyor observed the following: 1. At 10:15 a.m., Staff #7 disinfected the access site of [Patient J] at station #5, then touched the patient’s skin prior to cannulation without disinfecting the access site again. 2. At 10:20 a.m., Staff #6 disinfected the access site of [Patient K] at station #3, then touched the patient’s skin prior to cannulation without disinfecting the access site again. 3. At 10:30 a.m., Staff #9 disinfected the access site of [Patient C] in the isolation room, then touched the patient’s skin prior to cannulation without disinfecting the access site again. On 01/23/2024, the surveyor asked the Assistant Facility Administrator (AFA) to observe the floor with the surveyor. At 11:03 a.m., the surveyor observed Staff #5 disinfected the access site of [Patient L] at station #11, then touched the patient’s skin prior to cannulation without disinfecting the access site again. The AFA corroborated that Staff #5 should have disinfected the access site of Patient L again.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 47759 Based on record review and staff interview, the facility’s governing body failed to conduct a quality of life assessment survey at regular intervals, or more frequently on an as-needed basis on 2 out of the 6 selected patients (33%). This failure decreases the interdisciplinary team’s ability to address the patient’s psychosocial needs and “achieve and sustain” an appropriate psychosocial status Patients A and D Findings Included: On 01/24/2024 at 02:10 a.m. during record review of the facility’s Quality of Life Assessment Survey (03-01-10), page 1 number 1 states “The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter.” Number 2 states “If a patient refuses to complete the KDQOL-36 at any time, the Social Worker needs to document the refusal in the KDQOL Psychosocial condition in the electronic medical record.” On 01/23/2024 at 01:30 p.m., during reviews of the selected patients’ medical charts, the surveyor observed that 2 out of the 6 selected patients (33%) did not have an updated-2023 KDQOL completed or refusal documentation [Patient A and Patient D]. Patient A’s last KDQOL was 01/20/2022. Patient D’s last KDQOL was 07/05/2022. On 01/23/2024 at 01:45 p.m., during staff interviews, the Assistant Facility Administrator corroborated that Patient A and D did not have an updated KDQOL for the year 2023.”

“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: 47759 Based on review of Quality Assessment and Performance Improvement (QAPI) meeting minutes and interviews with staff, the facility’s governing body failed to (1) ensure that the facility incorporated mortality data in QAPI meetings, (2) tracked mortality data accurately in QAPI, and (3) analyzed each data to identify potential problems and opportunities for improving care. This failure placed patients at potential risk of harm by failing to utilize the data gathered to identify potential problems in the facility resulting in delay in interventions aimed at improvement. Findings Included: On 01/24/2024 at 01:20 p.m.,, during record review of the facility’s Continuous Quality Improvement Program (Policy 12-16-06) page 1 number 7 states “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: mortality (review of deaths); hospitalizations. Number 8 states “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 ensure improvements are sustained.” On 01/25/2024 at 11:23 a.m., According to the Assistant Facility Administrator (AFA), the data on the Facility Health Records (FHR) measurement data trend was inaccurate and corroborated that the facility’s interdisciplinary team were not documenting all the mortality data on FHR accurately as well as not documenting the analysis and actions taken to identify potential problem and to identify opportunities for improving care. On 01/26/2024 at 03:55 p.m., during interviews with the Manager of clinical services, when asked the question “Based on the FHR meeting documentation provided, is the facility ’ s interdisciplinary team (IDT) comparing mortality data with community, state, and national based standards?” According to the MCS, no, the facility’s IDT was not. On 01/25/2024 at 11:30 a.m., during record review of the facility’s mortality review and FHR meetings, the surveyor noted the following: 1. In the year 2022, 18 patients were reported to the End Stage Renal Disease Quality Reporting System (EQRS). Yet only 14 patients were recorded on the facility’s FHR measurement data trend (5 patients were unaccounted for on the data provided). To add on, 3 out of the 18 (16%) patients reviewed did not have a completed mortality review documented-Patients M,N,and O. 2. In the year 2023, 5 patients were reported to the End Stage Renal Disease Quality Reporting System (EQRS). Yet only 3 patients were recorded on the facility’s FHR measurement data trend (2 patients were unaccounted for on the data provided). To add on, 2 out of the 5 patients reviewed did not have a completed mortality review documented.-Patients P and Q.”