Davita Sedc Elizabethtown 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 record review, and staff interview the facility staff failed to follow the adequacy plan of care by failing to dialyze 3 of 5 (Patient #1, #2 and #4) in-center hemodialysis patients at the prescribed BFR/DFR and/or treatment duration. Findings included: Review on 08/20/2025 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 66-year-old male admitted for In-Center Hemodialysis treatments on 06/12/2025. Review of the Physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 07/29/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0858 and ended at 1259 (241 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 344 and DFR average was 763, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 07/31/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0917 and ended at 1307 (230 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 311, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/02/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0856 and ended at 1254 (238 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 364 and DFR average was 633, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/07/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0858 and ended at 1258 (240 minutes). Review of the Flowsheet revealed Patient #1’s BFR average was 310, 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 4 of 6 treatments and dialysate flow rate was decreased in 2 of 6 treatments, with no notification of the registered nurse. Interview on 08/20/2025 at 1030 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 4 of 6 treatments and a decreased DFR in 2 of 6 treatments, with no documentation for the decreased BFR/DFR and Registered Nurse notification. 2. Review of the medical record for Patient #2 revealed a 78-year-old female admitted for In-Center Hemodialysis treatments on 05/25/2023. 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 07/29/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0645 and ended at 0946 (181 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 313, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 07/31/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0646 and ended at 0949 (183 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 217 and DFR average was 543, with no documentation for the decreased BFR/DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/02/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0640 and ended at 0936 (175 minutes). Review of the Flowsheet revealed Patient #2’s DFR average was 763, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/07/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0641 and ended at 0941 (180 minutes). Review of the Flowsheet revealed Patient #2’s DFR average was 733, with no documentation for the decreased DFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/09/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0635 and ended at 0930 (175 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 400 and DFR average was 500, with no documentation for the increased BFR and decreased DFR and no documentation of the Registered Nurse notification. Review of the treatment sheets revealed that Patient #2’s blood flow rate was decreased in 2 of 6 treatments and increased in 1 of 6 treatment, with no notification of the registered nurse. Patient #2’s dialysate flow rate was decreased in 4 of 6 treatments, with no notification of the registered nurse. Interview on 08/20/2025 at 1030 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 increased/decreased BFR/DFR during the patient treatments. The interview confirmed the medical record findings that patient #2 had a decreased BFR in 2 of 6 treatments, increased BFR in 1 of 6 treatment and a decreased DFR in 4 of 6 treatments, with no documentation for the increased/decreased BFR/DFR and Registered Nurse notification. 3. Review of the medical record for Patient #4 revealed a 55-year-old male admitted for In-Center Hemodialysis treatments on 03/03/2023. Review of the Physician orders revealed Patient #4’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 07/30/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0615 and ended at 0955 (220 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 329 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 08/01/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0713 and ended at 1043 (209 minutes). Review of the Flowsheet revealed Patient #4’s BFR average was 344, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 08/04/2025 revealed Patient #4’s hemodialysis treatment was initiated at 0635 and ended at 1043 (205 minutes). Review of the Flowsheet revealed Patient #4’s DFR average was 500, with no documentation for the decreased DFR 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 and dialysate flow rate was decreased in 2 of 6 treatments, with no notification of the registered nurse. Interview on 08/20/2025 at 1030 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 2 of 6 treatments and a decreased DFR in 2 of 6 treatments, with no documentation for the decreased BFR/DFR and Registered Nurse notification.”