Davita Sedc Kenansville Dialysis Center

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 26622 Based on policy review, observation and interview, the patient care staff failed to disinfect the CVC exit site with 2 % Chlorhexidine Gluconate/70 % Isopropyl alcohol and allow to dry for 60 seconds per facility policy for 1 of 2 observed CVC exit sites disinfected with Chlorhexidine (PCT #2, Station #2). Findings include: Review on 02/11/2025 of the facility policy/procedure titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” effective October 2024 revealed “... 8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for minimum of 30 seconds... Then wait 60 seconds for air dry time.” Observation on 02/10/2025 at 1100 in the patient treatment area revealed PCT #2 entered Station #2 and initiated CVC exit site care for dialysis treatment with a CVC. PCT #2 cleansed the CVC exit site and area around site with 2% Chlorhexidine for 20 seconds and allowed to dry for forty-five (45) seconds. Observation revealed that the PCT failed to disinfect the CVC exit site for thirty (30) seconds and allow the exit site to dry for sixty (60) seconds per facility policy. Interview on 02/10/2025 at 1120 with PCT #2 revealed that the CVC exit site should be disinfected for 30 seconds. The interview confirmed that PCT #2 did not follow the facility policy. Interview on 02/11/2025 at 1500 with the Manager of Clinical Services and the Facility Administrator revealed the staff were expected to disinfect the CVC catheter exit site with Chlorhexidine swabs for 30 seconds and allow the site to dry for 60 seconds prior to applying new dressing per facility policy. Interview revealed the staff failed to follow the facility policy.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 26622 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to ensure machine prescription verifications were performed by a nurse within one hour of initiation of hemodialysis treatment in 2 of 6 (Patients #2 and #3, ) sampled in-center hemodialysis records reviewed. Findings include: Review on 02/11/2025 of the facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed “Policy .... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation ...” 1. Review of the medical record for Patient #2 revealed a 41-year-old female admitted for In-Center Hemodialysis treatments on 05/21/2024. Review of the Treatment Flowsheet dated 12/20/2024 revealed Patient #2’s treatment was initiated at 1342. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1547 (2 hours and 5 minutes after initiation of treatment). Interview on 02/11/2025 at 1500 with the Manager of Clinical Services and Facility Administrator revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy. 2. Review of the medical record for Patient #3 revealed a 71-year-old female admitted for In-Center Hemodialysis treatments on 02/07/2023. Review of the Treatment Flowsheet dated 02/06/2025 revealed Patient #3’s treatment was initiated at 0954. Review of the Flowsheet revealed the Registered Nurse Machine Verification was performed at 1205 (2 hours and 11 minutes after initiation of treatment). Interview on 02/11/2025 at 1500 with the Manager of Clinical Services and Facility Administrator revealed the Registered Nurse was expected to document the machine verification within one (1) hour of the patient dialysis treatment initiation time. Interview revealed the Registered Nurse failed to follow the facility policy.”

“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 record review, and staff interview the facility staff failed to follow the adequacy plan of care by failing to dialyze 5 of 6 (Patient #1, #2, #4, #5 and #6) patients at the prescribed BFR/DFR and/or treatment duration. Findings included: Review on 02/11/2025 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 22-year-old male admitted for In-Center Hemodialysis treatments on 01/28/2025. 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 01/28/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1154 and ended at 1501 (187 of 240 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 367, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/30/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1027 and ended at 1429 (234 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 361 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/06/2025 revealed Patient #1’s hemodialysis treatment was initiated at 1148 and ended at 1556 (240 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 335 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 with no notification of the registered nurse. Interview on 02/11/2025 at 1500 with the Manger of Clinical Services and Facility Administrator 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 during the patient treatments. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 2. Review of the medical record for Patient #2 revealed a 41-year-old female admitted for In-Center Hemodialysis treatments on 05/21/2024. Review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 12/18/2024 revealed Patient #2’s hemodialysis treatment was initiated at 1328 and ended at 1601 (153 of 210 minutes). Review of the Treatment Flowsheet dated 12/20/2024 revealed Patient #2’s hemodialysis treatment was initiated at 1342 and ended at 1708 (199 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 289 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 12/23/2024 revealed Patient #2’s hemodialysis treatment was initiated at 1449 and ended at 1701 (131 of 210 minutes). Review of the treatment sheets revealed that Patient #2’s blood flow rate and/or treatment duration was decreased in 3 of 5 treatments with no documented reason for decreased BFR and/or treatment duration and no notification to the registered nurse. Interview on 02/11/2025 at 1500 with the Manger of Clinical Services and Facility Administrator 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 during the patient treatments. The interview confirmed the medical record findings that patient #2 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. The nurse should be notified if the patients are unable to complete the prescribed duration of the treatment and an against medical advice leave form should be completed and signed by the patient. 3. Review of the medical record for Patient #4 revealed an 81-year-old male admitted for In-Center Hemodialysis treatments on 10/11/2022. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 01/27/2025 revealed Patient #4’s hemodialysis treatment was initiated at 1121 and ended at 1418 (133 of 180 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 377, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/03/2025 revealed Patient #4’s hemodialysis treatment was initiated at 1111 and ended at 1416 (181 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 361 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 2 of 6 treatments with no notification of the registered nurse. Interview on 02/11/2025 at 1500 with the Manger of Clinical Services and Facility Administrator 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 during the patient treatments. The interview confirmed the medical record findings that patient #4 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 4. Review of the medical record for Patient #5 revealed a 65-year-old male admitted for In-Center Hemodialysis treatments on 10/26/2023. Review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 500. Review of the Treatment Flowsheet dated 02/06/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1035 and ended at 1409 (215 of 240 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 317, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/08/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1035 and ended at 1303 (136 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 313 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #5’s blood flow rate was decreased in 2 of 6 treatments with no notification of the registered nurse. Interview on 02/11/2025 at 1500 with the Manger of Clinical Services and Facility Administrator 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 during the patient treatments. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification. 5. Review of the medical record for Patient #6 revealed a 79-year-old female admitted for In-Center Hemodialysis treatments on 07/09/2024. Review of the Physician orders revealed Patient #6’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 600. Review of the Treatment Flowsheet dated 01/29/2025 revealed Patient #6’s hemodialysis treatment was initiated at 1136 and ended at 1436 (175 of 180 minutes). Review of the Flowsheet revealed Patient #6’s DFR average was 500, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 01/31/2025 revealed Patient #6’s hemodialysis treatment was initiated at 1127 and ended at 1425 (169 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 333, with no documentation for the decreased BFR and no documental of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/03/2025 revealed Patient #6’s hemodialysis treatment was initiated at 1120 and ended at 1428 (183 minutes). Review of the Flowsheet revealed Patient #6’s DFR average was 500, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 02/05/2025 revealed Patient #6’s hemodialysis treatment was initiated at 1112 and ended at 1332 (119 of 180 minutes). Review of the Flowsheet revealed Patient #6’s BFR average was 286 and DFR average was 575, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #6’s BFR/DFR was decreased in 4 of 6 treatments with no notification of the registered nurse. Interview on 02/11/2025 at 1500 with the Manger of Clinical Services and Facility Administrator 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 during the patient treatments. The interview confirmed the medical record findings that patient #1 had a decreased BFR in 3 of 6 treatments with no documentation for the decreased BFR and Registered Nurse notification.”

“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: 26622 Based on policy and procedure review, observations, and staff interviews, the facility failed to ensure staff performed skin antisepsis per policy before cannulation of 1 of 2 Arterio-venous fistula/graft (AVF/AVG) cannulation procedures observed (Station #10, PCT #1). Findings included: Review on 02/11/2025 of the facility policy titled “AV (Arterio-venous) Fistula or Graft Cannulation ...” revised October 2022 revealed “ ... Skin Antiseptic: Povidone Iodine; Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site; Effective Contact Time: 30 seconds; Air Drying Time: 2 minutes ...” Observation on 02/10/2025 at 0948 in the patient treatment area revealed PCT #1 entered Station #10 and initiated access of an Arterio-venous fistula/graft (AVF/G) for hemodialysis treatment. PCT #1 performed hand hygiene and applied clean gloves. The PCT #1 cleansed the arterial and venous access sites simultaneously with one Povidone Iodine pad for 30 seconds. PCT #1 allowed the access sites to dry for 2 minutes before cannulation. Observation revealed PCT #1 failed to disinfect each access site with Povidone Iodine for 30 seconds per the facility policy. Interview on 02/10/2025 at 1155 with PCT #1 revealed that each site should be disinfected for 30 seconds. Interview revealed that PCT #1 disinfected the access sites at the same time using only one (1) Povidone Iodine pad. Interview revealed PCT #1 failed to disinfect the access sites per facility policy. Interview on 02/11/2025 at 1500 with the Manager of Clinical Services and the Facility Administrator revealed the staff were expected to disinfect each access site for 30 seconds when using Povidone Iodine pads and allow each site to dry for 2 minutes, prior to cannulating. Interview revealed the staff failed to follow the facility policy.”