Davita Sedc Wilmington Dialysis Center

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 26622 Based on policy review, medical records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 7 of 7 (Patients #1, #2, #3, #4, #5, #6 and #7) in-center hemodialysis patients at the prescribed Blood Flow Rate (BFR)/Dialysate Flow Rate (DFR) and/or treatment duration. Findings include: Review on 12/11/2025 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed “INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 9. ... b. At a minimum, obtain and document the following: ... iii. Blood and dialysate flows, arterial and venous pressures ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” 1. Review of the medical record for Patient #1 revealed a 56-year-old female admitted for In-Center Hemodialysis treatments on 11/03/2025. Review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 11/24/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1843 and ended at 2229 (221 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 341, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/01/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1842 and ended at 2218 (214 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 338 and DFR average was 500, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/03/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1840 and ended at 2215 (212 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 350, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #1’s blood flow rate was decreased in 3 of 6 treatments and dialysate flow rate was decreased in 1 of 6 treatment, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 3 of 6 treatments and a decreased DFR in 1 of 6 treatment, with no documentation for the decreased BFR/DFR and Registered Nurse notification. 2. Review of the medical record for Patient #2 revealed an 89-year-old female admitted for In-Center Hemodialysis treatments on 03/28/2017. Review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 11/28/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0701 and ended at 1025 (195 minutes). Review of the Flowsheet revealed Patient #2’s DFR average was 700, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/01/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0709 and ended at 1011 (180 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 292, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #2’s BFR was decreased in 1 of 4 treatment and DFR was decreased in 1 of 4 treatment, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #2 had a decreased BFR in 1 of 4 treatment and a decreased DFR in 1 of 4 treatment, with no documentation for the decreased BFR/DFR and Registered Nurse notification. 3. Review of the medical record for Patient #3 revealed a 76-year-old female admitted for In-Center Hemodialysis treatments on 06/22/2023. Review of the Physician orders revealed Patient #3’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 12/04/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0646 and ended at 1002 (194 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 414, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/06/2025 revealed Patient #3’s hemodialysis treatment was initiated at 0640 and ended at 0944 (181 minutes). Review of the Flowsheet revealed Patient #3’s BFR average was 433, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #3’s blood flow rate was decreased in 2 of 6 treatments, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #3 had a decreased BFR in 2 of 6 treatments, with no documentation for the decreased BFR and Registered Nurse notification. 4. Review of the medical record for Patient #4 revealed a 62-year-old female admitted for In-Center Hemodialysis treatments on 11/14/2023. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 11/26/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0712 and ended at 1111 (225 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 350 and DFR average was 500, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 11/29/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0902 and ended at 1300 (225 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 340 and DFR average was 500, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/02/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0702 and ended at 1032 (225 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 350 and DFR average was 683, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/04/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0722 and ended at 1110 (225 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 390, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #4’s blood flow rate was decreased in 4 of 5 treatments and dialysate flow rate was decreased in 3 of 5 treatments, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #4 had a decreased BFR in 4 of 5 treatments and a decreased DFR in 3 of 5 treatments, with no documentation for the decreased BFR/DFR and Registered Nurse notification. 5. Review of the medical record for Patient #5 revealed a 51-year-old male admitted for In-Center Hemodialysis treatments on 09/09/2022. Review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 11/25/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0724 and ended at 1022 (177 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 328, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 11/28/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0743 and ended at 1134 (227 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 304 and DFR average was 689, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/01/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0721 and ended at 0932 (116 minutes). Review of the Flowsheet revealed Patient #5’s DFR average was 550, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/05/2025 revealed Patient #5’s hemodialysis treatment was initiated at 0803 and ended at 0941 (87 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 300 and DFR average was 720, with no documentation for the decreased BFR /DFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #5’s blood flow rate was decreased in 3 of 4 treatments and dialysate flow rate was decreased in 2 of 4 treatments, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #5 had a decreased BFR in 3 of 4 treatments and a decreased DFR in 2 of 4 treatments, with no documentation for the decreased BFR/DFR and Registered Nurse notification. 6. Review of the medical record for Patient #6 revealed a 79-year-old female admitted for In-Center Hemodialysis treatments on 04/02/2025. Review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 11/25/2025 revealed Patient #6’s hemodialysis treatment was initiated at 1252 and ended at 1550 (171 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 336, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/05/2025 revealed Patient #6’s hemodialysis treatment was initiated at 0846 and ended at 1157 (157 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 325 and DFR average was 522, with no documentation for the decreased BFR and increased DFR, with no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #6’s blood flow rate was decreased in 2 of 5 treatments and dialysate flow rate was increased in 1 of 5 treatments, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR and increased DFR during the patient treatments. The interview confirmed the medical record findings that patient #6 had a decreased BFR in 2 of 5 treatments and an increased DFR in 1 of 5 treatments, with no documentation for the decreased/increased BFR/DFR and Registered Nurse notification. 7. Review of the medical record for Patient #7 revealed a 49-year-old female admitted for In-Center Hemodialysis treatments on 09/19/2022. Review of the Physician orders revealed Patient #7’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 11/26/2025 revealed Patient #7’s hemodialysis treatment was initiated at 1200 and ended at 1610 (240 minutes). Review of the Flowsheet revealed Patient #7’s BFR average was 350, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/06/2025 revealed Patient #7’s hemodialysis treatment was initiated at 1211 and ended at 1609 (237 minutes). Review of the Flowsheet revealed Patient #7’s BFR average was 413, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #7’s blood flow rate was decreased in 2 of 4, with no notification of the registered nurse. Interview on 12/11/2025 at 1330 with the Manger of Clinical Services revealed the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. The interview further revealed that the nursing staff should have assessed and documented the reason for the decreased BFR and increased DFR during the patient treatments. The interview confirmed the medical record findings that patient #7 had a decreased BFR in 2 of 5 treatments and an increased DFR in 1 of 5 treatments, with no documentation for the decreased/increased BFR/DFR and Registered Nurse notification.”