Davita Bowles Avenue Dialysis

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 36473 Based on interview, record review and policy review the facility failed to ensure staff viewed one patient’s vascular access site and bloodline connections (#1) throughout dialysis treatment to ensure patient safety. (refer to V407) The deficient practice resulted in the facility’s non-compliance with specific requirements found under the Condition of Participation (CoP): Physical Environment. The facility census was 48 in-center hemodialysis (the process of purifying the blood of persons whose kidneys were not working) and 13 peritoneal dialysis (PD, a treatment of kidney failure using the lining of your abdomen or belly to filter your blood) patients. The severity of this practice resulted in the death of one patient (#1) and placed all patients at risk for their health and safety, and resulted in Immediate Jeopardy (IJ). The facility provided an acceptable plan of correction and implemented the following corrective actions to remove the IJ and prevent further risk to the patients: - Immediate inservicing 100% clinical teammates: Nurses, PCTs, MSW, and RD on Policy and Procedure 1-03-08: Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment emphasizing: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to: Vascular access status.The Nursing assessment will be performed and documented by a licensed nurse.The assessment includes the following components including Verification that the patient access is visible and face is not covered.Vital signs and treatment monitoring are completed at least every thirty (30) minutes. At a minimum, obtain and document the following including Vascular access visible and line connections intact. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. All findings, interventions and patient response will be documented in the patient’s medical record. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. 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. - Facility Administrator (FA) or designee will complete daily observational audits on each patient, twice each shift x 1 week to verify compliance, then once a shift daily x 1 week, then decrease to daily x 2 weeks, then weekly x 4 weeks, then minimum of monthly for sustained compliance of 95% or greater. Any instances of noncompliance will be addressed immediately. Charge Nurse will continue to be responsible for daily observational monitoring to verify compliance. - Teammates also educated on policy 1-04-02 Central Venous Catheter (CVC) Care with emphasis on but not limited to: PURPOSE: To reduce the risk of infection in the patient and to reduce trauma to the catheter and exit site while minimizing blood loss. CVC lumen and blood tubing connections will be verified for accurate, patent and secure connections, and remain visible throughout the treatment. Document findings and interventions in patient’s medical record. - The FA or designee will complete daily observational audits on each patient, twice each shift x 1 week to verify compliance, then once a shift daily x 1 week, then decrease to daily x 2 weeks, then weekly x 4 weeks, then minimum of monthly for sustained compliance of 95% or greater. Any instances of noncompliance will be addressed immediately. Charge Nurse will continue to be responsible for daily observational monitoring to verify compliance. - Teammates are also being educated on Policy 1-10-01 Medical Emergency with emphasis on but not limited to: In the event of a medical emergency, the charge nurse will: Initiate emergency treatment according to signs and symptoms shown by the patient. Monitor the patient. Contact the patient ’ s nephrologist. If the situation warrants, contact emergency medical system: 911. When the paramedics arrive, assist EMS as necessary. The paramedics will manage the patient according to orders received from the doctor at their base station. Document events in the patient’s medical record. - The FAor designee will complete daily observational audits on each patient, twice each shift x 1 week to verify compliance, then once a shift daily x 1 week, then decrease to daily x 2 weeks, then weekly x 4 weeks, then minimum of monthly for sustained compliance of 95% or greater. Any instances of noncompliance will be addressed immediately. Charge Nurse will continue to be responsible for daily observational monitoring to verify compliance. - Teammate education also included a review of “Venous Needle Dislodgement, How to Minimize Risks”, and a Homeroom lesson on Needle Dislodgement. Attendance of in-service evidenced by TMs signature on clinical in-service form. Any teammate not present for today’s in-service will get in-serviced on their next scheduled workday before starting patient care. - The FA or designee will complete daily observational audits on each patient, twice each shift x 1 week to verify compliance, then once a shift daily x 1 week, then decrease to daily x 2 weeks, then weekly x 4 weeks, then minimum of monthly for sustained compliance of 95% or greater. Any instances of noncompliance will be addressed immediately. Charge Nurse will continue to be responsible for daily observational monitoring to verify compliance. - 100% of patients will be educated on keeping access sites uncovered, utilizing “Prevent Blood Loss During Treatment” which includes tips for staying comfortable and using a light colored blanket for comfort and safety beginning 5/10/2024. Documentation of education placed in medical record. Any patient not able to be educated today will be educated on their next dialysis treatment. - The FA or designee will complete daily observational audits on each patient, twice each shift x 1 week to verify compliance, then once a shift daily x 1 week, then decrease to daily x 2 weeks, then weekly x 4 weeks, then minimum of monthly for sustained compliance of 95% or greater. Any instances of noncompliance will be addressed immediately. Charge Nurse will continue to be responsible for daily observational monitoring to verify compliance.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36473 Based on interview, record review and policy review the facility failed to ensure the staff viewed one patient’s vascular access site and bloodline connections (#1) of one reviewed, throughout the patient’s hemodialysis (the process of purifying the blood of persons whose kidneys were not working) treatment to ensure patient safety. These failures resulted in the death of Patient #1 and had the potential for negative outcomes of all patients that presented to the facility for hemodialysis. The facility census was 48 in-center hemodialysis and 13 peritoneal dialysis (PD, a treatment of kidney failure using the lining of your abdomen or belly to filter your blood) patients. Findings included: Staff & Patient Interviews 1. During an interview on 05/14/24 at 12:14 PM, Staff A, PCT, stated they worked on 05/08/24 and were assigned to Patient #1 (89 year old female hemodialysis patient that presented to the facility for outpatient treatment) the day the patient expired. They also shared the following process prior to the patient passing: - Patient #1’s daughter brought the patient to the chair and Staff A assisted transferring the patient from the wheelchair to the hemodialysis chair. - Staff A took the patient’s blood pressure and started charting. - Staff A removed the patient’s cardiovascular catheter (CVC, a thin, flexible tube inserted into a vein and used for hemodialysis treatment) dressing, cleaned the site and applied a new dressing. - Staff A removed the caps, cleaned with alcohol and flushed the lines with saline. - Staff A administered a Heparin bolus, attached the lines and unclamped the Heparin infusion. - Staff A took the patient’s blood pressure and continued charting while sitting at the computer next to the patient’s chair. - Staff A gave Patient #1 a blanket and the patient placed it over the CVC. - Staff A started the dialysis treatment and five minutes after, the patient told them their blood sugar was low. - Staff A asked Staff B, RN, Charge Nurse, to come over to look at the patient. - During Staff B’s assessment, Patient #1 went unresponsive and Staff B started compressions. - Staff G, Facility Administrator (FA), brought the crash cart (a wheeled container carrying medicine and equipment for use in an emergency resuscitation) over and they continued the code until the Emergency Medical Technician’s (EMT’s) arrived to take over. - Staff A stated they were sitting so close to the patient the blood under the chair was not visible. 2. During an interview on 05/15/24 at 10:28 AM, Staff B, Charge Nurse, stated Staff A, PCT, called out to them to assess Patient #1’s blood sugar and during his assessment the patient went unresponsive and pale. Staff B performed a chest rub with no response and started cardiopulmonary resuscitations (CPR, certified procedure performed when the heart stops beating) in the chair. When Staff G, FA, brought the crash cart over, they lifted the patient to the floor and continued CPR until the EMTs arrived. Staff B also stated they hadn’t performed a nursing assessment or prescription verification prior to the code and they had one hour to complete per facility policy. The code with Patient #1 happened in the first five minutes of treatment. 3. During an interview on 05/14/24 at 10:00 AM, Staff G, FA, stated they were at the medication area on 05/08/24 when Patient #1 went unresponsive. Staff G assisted Staff B, pulled back the patient’s blanket and saw the venous dialysis line not connected. They then clamped the line, started normal saline wide open, started CPR and retrieved the crash cart. When they retrieved the crash cart and walked back to the patient’s chair, they saw blood under the patient’s chair. They assisted with CPR until the EMTs arrived. 4. During an interview on 05/15/24 at 1:09 PM, Staff F, PCT, stated they worked near Patient #1 on 05/08/24 and recalled the patient complained about their blood sugar being low and then their face color went to grey in seconds. 5. During an interview on 05/14/24 at 12:30 PM, Staff D, Peritoneal Dialysis (PD) Technician, stated they took turns performing chest compressions on Patient #1 and when the staff lifted the patient from the chair to the floor, there was a large amount of coagulated (changed to a semi-solid state) blood under the dialysis machine, in and under the patient’s chair. 6. During an interview on 05/15/24 at 1:30 PM, Patient #2, stated they saw Patient #1 sit down in the dialysis chair and Staff A, PCT gave Patient #1 a blanket, then the patient pulled the blanket up to their chin. 7. During an interview on 05/14/24 at 12:20 PM, Patient #3, stated they sat next to Patient #1 and recalled the patient told Staff A, PCT, their blood pressure dropped and then all staff responded. 8. During an interview on 05/15/24 at 1:57 PM, Staff C, Director of Clinical Services, stated the annual education titled, “How to Prevent Blood Loss,” and “In-Center Hemodialysis (ICHD) Policies and Procedures,” showed the direction for staff to keep the site uncovered at all times. 9. During an interview on 05/15/24 at 2:16 PM, Staff H, Manager of Clinical Services, stated they expected staff to have better documentation and adhere to the facility’s policies and procedures related to access care. Facility’s Documentation 10. Review of Patient #1’s treatment flowsheet dated 05/08/24 showed the patient’s hemodialysis treatment started at 1:50 PM and showed documentation by Staff A, PCT, stating the patient’s access site was visualized. 11. Review of the Staff B, Charge Nurse’s notes, dated 05/09/24, late entry at 2:59 PM, showed: - Staff B, called to Patient #1’s chairside by Staff A, PCT for low blood sugar; - They performed an accu check (a procedure to check blood sugar) and resulted a reading of 122 (normal range 70 - 100); - At time of Staff B’s arrival to the patient’s chair, the patient went unresponsive and pale. - They performed a chest rub with no response; - They started Cardiopulmonary Resusitation (CPR) and staff called 911. - They placed an automated external defibrillator (AED) on patient and continued CPR until paramedics arrived; - They stated there was approximately three to four feet of blood on the floor; and - At 1:56 PM, Patient #1’s blood pressure was 64/50 (normal range 120/80) with a pulse of 100 (normal range 70-100). 12. Review of the facility’s annual education log for Staff A, (PCT), showed they completed an online class titled, “How to Prevent Blood Loss,” on 04/29/24. 13. Review of the facility’s annual education log for Staff B, Registered Nurse (RN), showed they completed an online class titled, “In-Center Hemodialysis (ICHD) Policies and Procedures,” on 03/23/24. 14. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last reviewed on 04/2024, showed the direction for the PCT or licensed nurse, to ensure the vascular access site, blood line connections and the patient’s face was visible throughout the dialysis treatment. 15. Review of the facility’s policy titled, “Central Venous Catheter (CVC) Care,” last reviewed on 10/2022, showed the direction for staff to verify CVC lumen and blood tubing connections for accurate, patent and secure connections, and ensure visibility throughout the treatment. Hospital and EMT Documentation 16. Review of the EMT’s documentation dated 05/08/24 showed they arrived at the scene at 1:57 pm and Patient #1’s vital signs were 0 pulse, 0 respirations and a glascow coma scale (tool used to score loss of consciousness with the highest 15 and the lowest is three) score of three. 17. Review of the receiving hospital’s emergency room (ER) medical record showed Patient #1 arrived at 2:14 PM unresponsive, asystole (no heart rate) with post cardiac arrest post dialysis. The ER record also showed the ER disposition was deceased.”