Davita Saginaw Dialysis

“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: 48030 Based on observation, record review and interview, the facility failed to identify two (P-3, P-5) of five patients as unstable and failed to conduct a monthly Comprehensive Interdisciplinary Assessment (CIA). Findings include: On 3/5/2024 at 1430 interview the Facility Administrator (Staff B) revealed that the facility Dietician (Staff H) and the Social Worker (Staff E) are responsible for maintaining the Unstable Patient List and she does not participate in the decision to make a patient unstable. Staff B stated patients are made unstable when they have been hospitalized longer than 15 days with a discharge within the last 30 days. On 3/6/2024 at 1205 an interview occurred with P-3 during dialysis services at the facility. P-3 stated she moved from the Detroit area in September or October of last year, she did not remember when, and received dialysis at another facility in Detroit prior to moving. P-3 stated she has been in and out of the hospital several times since moving, mostly for fluid on her lungs. P-3 stated she was discharged from the hospital yesterday to a rehabilitation facility, but she normally lives at home alone. When queried whether the facility has updated her Plan of Care following her recent hospitalizations, P-3 stated the dietician has recommended changes in her diet. On 3/6/2024 at 1450 an interview occurred with the facility dietician (Staff H) which revealed in his role he reviews the status of patients at the facility by reviewing bloodwork. When queried what criteria is used to determine if a patient is considered unstable, Staff H stated he makes recommendations at the weekly Interdisciplinary Team (IDT) meeting and “most of the time when patients are made unstable it is due to the length of hospitalizations” and only includes patients that have been admitted “longer than 15 days with discharge within the last 30 days”. Staff H stated the facility uses the Falcon system and CWOW to generate a list of patients that may trigger them as unstable by the automated system. Upon request to review of the facility’s Unstable Log, Staff H stated the facility does not keep an Unstable Log. Staff H stated IDT will schedule Plan of Care discussions by using handwritten calendar titled “Assessment Calendar” with patient names on them, which will list the reason for the Plan of Care discussion. On 3/7/2024 at 1030 during document review of P-3’s Hospitalizations and Treatment Behaviors Log reveals in-center dialysis was not completed due to hospitalizations on 11/29/23 through 12/12/2023 with 6 missing in-center dialysis treatments, 1/20/2024 through 1/24/2024 with 2 missed in-center dialysis treatments, 2/7/2024 through 2/11/2024 with 2 missed in-center dialysis treatments, 2/27/24 through 3/5/204 with 3 missed in-center dialysis treatments. Review of the Assessment Calendars from 12/2023 through 3/2024 reveals P-3 was not listed as unstable during that time. Review of the Plan of Care for P-3 reveals an initial assessment was completed and a 90-day assessment and was not listed as unstable on either Plan of Care. On 3/7/2024 at 1045 review of records and the Annual Patient Plan of Care dated 12/13/2023 for P-5 revealed he was deemed stable, no other Plans of Care were provided. Review of the documentation from the facility nurse practitioner revealed the following comments were revealed regarding P-5 on: 11/28/2023-Central venous catheter (CVC) out, sent to the emergency department, 12/7/2023-Non-compliance with medications and fluid restrictions, blood pressure (BP) elevated, 12/12/2023-Elevated BP, fluid overload, 1/2/2024-Elevated BP, fluid overload, 10 kg over target weight, removed 4 L during treatment due to missed treatments, mother declined to bring in for treatment after provider and staff educated on risks, 2/1/2024-Improved compliance after meeting with family and APS (Adult Protective Services). Comments from the notes from nursing revealed: 10/7/2023-Called off for treatment, advised to come in for at least 2 hours but declined, advised to go to ER if he becomes symptomatic, 10/19/2023-Unable to have a conference with mother to discuss an appointment for mapping and placing of a fistula or graft, educated about fluid restrictions, continues to miss treatments during the week, 11/24/2023-Trouble with transportation, unable to come for dialysis, 11/28/2023-Educated numerous times about fluid restriction, continues to miss treatments during the week, 11/29/2023-Patient does not have a ride for treatment today, 12/15/2023-Extensive discussion regarding poor health choices, poor personal hygiene, infection prevention and importance of adhering to medications and treatments, patient unable to retain information due to mental capacity, attempted to contact mother without success, facility administrator (FA), social worker and another nurse coordinated care with Nephrology team in an attempt to focus on patient care coordination and improve pt condition. Comments from the notes from Staff E reveal: 12/21/2023-Discussed issues that clinical staff had brought to MSW attention, including missing or shortening treatments and hygiene, reports roof leak and no bedroom, going to live with his dad, no contact info available for dad, 12/22/2023-Spoke with father, stated P-5 cannot move in because mom is not agreeable, expressed concerns, discussed APS (adult protective services) referral is being considered, 12/28/2023-Nurse states hair not clean, access is clotted and could not run dialysis, spoke with mother who stated money is tight, less money for groceries, provided resources. 12/29/2023-Missed dialysis because stomach was upset, mother stated she is not going to make him come, 1/5/2024-Met with FA, RN and a call placed to APS for repeated concerns, case will be reviewed and assigned to someone at APS, 1/11/2024-Attempts to call mother, contacted Saginaw County Department of Health and Human Services regarding APS referral, 1/19/2024-Patient returned for treatment with high blood pressure and fluid overload, 1/24/2024-Meeting held with APS, father, mother, FA and nephrologist regarding concerns, 1/30/2024-No call, no show for dialysis, 2/15/2024-Called and said transportation was canceled due to weather, did not want to come because of roads, 2/23/2024-APS notified patient missed labs and treatments, 2/27-discussion with APS regarding pt’s status. Comments from registered dietician (RD) revealed: 2/27/2024-High phosphorus, continued to provide ongoing education. During an interview with facility social worker (Staff E) on 03/06/24 at 1100, Staff E was questioned if any patients were currently ‘unstable.’ Staff E responded ‘no’. Staff E was next questioned who can deem patients unstable? Staff E replied, “any of us can, but Staff H has that umbrella.” An interview was conducted with Medical Director (Staff G) on 03/06/24 at 1534. Staff G stated that he has been a practicing Nephrologist for 13 years. Staff G was questioned, if in his experience, it was normal to have some ‘unstable patients’ at any given time. Staff G responded that it was not normal to have ‘unstable’ patients, and added that the facility ‘goes many months with no unstable.’ Staff G was next questioned how patients are made ‘unstable?’ Staff G responded, “I only know the clinical triggers, I determine stability by the criteria that I use.” Staff G, was next queried if patient’s social factors could make them unstable and responded, “We have not discussed ‘unstable’ regarding Social Work or social issues.” On 3/7/2024 at 1100 a review of the policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy number 1-14-01, with the revision date of July 2023, was conducted. According to the policy it states under subtitle Assessment, number 7, “A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted...frequent hospitalizations...significant changes in psychosocial needs.” 28042 In an interview on 03/06/2024 at 1500, Staff A stated as the clinical coordinator at the facilitiy, she did not have a say about whether a patient is stable or unstable for their plan of care. Staff A stated she goes into the electronic medical record system, does their assessment for the plan of care, and if the interdisciplinary team meeting is held on the treatment floor, at the patient’s chair side, she does attend the meeting. Staff A stated she worked the floor six days a week and did not have time to do much more. In an interview on 03/06/2024 at 1430, Staff B stated she was the facility administrator and was not familiar with the plan of care process.”

“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: 28042 Based on observation, interview, and record review, the medical director failed to ensure staff followed facility policy and removed expired items from use, resulting in the potential for poor patient outcomes for all patients receiving treatment in the facility. Findings include: On 03/06/2024 at 1000, while touring the treatment floor, the lab station was observed to have one carton and four tubes of green lab tubes with expiration dates of 01/31/2024, three clear lab tubes with expiration dates of 12/31/2023, three blood culture collection kits with expiration dates of 3/5/2024, one culture swab kit with expiration date of 12/05/2023, and four saliva collection kits with expiration dates of 09/30/2023. On 03/06/2024 at 1010, the expired lab supplies were shown to Staff A who stated, “Oh, that’s not good. Our facility administrator obtained the green lab tubes from another facility because we were out.” Staff A stated there wasn’t a clear designated process for checking supplies for expiration dates. The nurses check medications for outdates when they do the daily counts. Staff A stated she thought the Administrative Assistant checked for outdates. On 03/06/2024 at 1030, Staff B was informed of the above observation and given the expired lab supplies. She stated, “Oh no, those should not be out there.” Staff B stated there was not clear documented process for checking for outdated supplies. On 03/06/2024 at 1530, Medical Director Staff G stated it was his expectation that staff follow the policies and procedures of the facility. Staff G stated the expired supplies should not be in the facility. Review of facility policy titled “Infection Control for Dialysis Facilities” dated April, 2023 states, “8. Supplies will be stored in a manner that maintains their integrity.” and “8. a. Expiration date and integrity will be verified prior to use.” 39083 On 3/5/24 at 10:45 AM, during an inspection of the water treatment room, the Minncare HD disinfectant test strips were observed to be expired with the expiration date of 1/16/2024. At this time, Biomed “F” proceeded to locate new test strips but stated that they are all expired. According to the facilities policy, “RESIDUAL MINNCARE HD TESTING USING RESIDUAL MINNCARE HD ACID TEST STRIPS,” revision date April 2021, it notes, “Procedure 1. Put on PPE. 2. Verify that the test strip vial has been tightly capped and is not beyond the expiration date...Rationale 1. PPE is worn for teammate protection. 2. Test strips stored in open vials or used beyond their expiration date may give inaccurate test results.” During an interview on 3/5/24 at 1:30 PM, Biomed “F” stated that Minncare disinfecting occurs weekly. During an interview on 3/5/24 at 1:40 PM, Facility Administrator “B” stated that they have a new staff member that is doing the testing, “But it’s on me.””