Davita Dialysis Care of Hoke County

“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: 51294 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to monitor a patient at a minimum of every 30 minutes during hemodialysis treatments for 4 of 6 sampled in-center hemodialysis records reviewed (Patients #1, #2, #3, and #4). Findings included: Review on 12/03/2025 of the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” revised April 2024 revealed, “INTRADIALYTIC DATA COLLECTION/ASSESSMENT ...9. Intradialytic treatment monitoring and data collection...includes: a. Vital signs and treatment monitoring...iii. For non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures iv. Fluid removal and/or replacement v. Vascular access visible and line connections intact vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints.” 1. Open medical record review on 12/03/2025 for Patient #1 revealed a 47-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 11/13/2023. Review of the treatment sheet dated 11/17/2025 revealed the treatment started at 0936 and ended at 1254 for a duration of 193 minutes. Review of the monitoring documentation dated 11/17/2025 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 1033 and monitored next by staff at 1119 (46 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 11/17/2025. Interview on 12/03/2025 at 1600 with the Clinical Manager revealed the staff were expected to monitor the patients every 30 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 11/17/2025 for Patient #1. 2. Open medical record review on 12/03/2025 for Patient #2 revealed a 56-year-old patient admitted to the facility for ICHD (In Center Hemodialysis) treatments on 09/08/2025. Review of the treatment sheet dated 11/10/2025 revealed the treatment started at 1143 and ended at 1559 for a duration of 235 minutes. Review of the monitoring documentation dated 11/10/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1153 and monitored next by staff at 1253 (60 minutes later). Review of the treatment sheet dated 11/12/2025 revealed the treatment started at 1147 and ended at 1534 for a duration of 217 minutes. Review of the monitoring documentation dated 11/12/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1205 and monitored next by staff at 1243 (38 minutes later). Review of the treatment sheet dated 11/14/2025 revealed the treatment started at 1103 and ended at 1535 for a duration of 233 minutes. Review of the monitoring documentation dated 11/14/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1235 and monitored next by staff at 1327 (52 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 11/10/2025, 11/12/2025, and 11/14/2025. Interview on 12/03/2025 at 1600 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 11/10/2025, 11/12/2025, and 11/14/2025 for Patient #2. 3. Open medical record review on 12/03/2025 for Patient #3 revealed a 60-year-old female admitted to the facility for ICHD (In Center Hemodialysis) treatments on 02/28/2025. Review of the treatment sheet dated 11/14/2025 revealed the treatment started at 1126 and ended at 1427 for a duration of 178 minutes. Review of the monitoring documentation dated 11/14/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1230 and monitored next by staff at 1306 (36 minutes later). Review of the treatment sheet dated 11/19/2025 revealed the treatment started at 1101 and ended at 1520 for a duration of 259 minutes. Review of the monitoring documentation dated 11/19/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1405 and monitored next by staff at 1520 (75 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 11/14/2025 and 11/19/2025. Interview on 12/03/2025 at 1600 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 11/14/2025 and 11/19/2025 for Patient #3. 4. Open medical record review on 12/03/2025 for Patient #4 revealed an 86-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 09/08/2025. Review of the treatment sheet dated 11/12/2025 revealed the treatment started at 1050 and ended at 1409 for a duration of 178 minutes. Review of the monitoring documentation dated 11/12/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1254 and monitored next by staff at 1354 (60 minutes later). Review of the treatment sheet dated 11/21/2025 revealed the treatment started at 1051 and ended at 1430 for a duration of 186 minutes. Review of the monitoring documentation dated 11/21/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1153 and monitored next by staff at 1243 (47 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatments on 11/12/2025 and 11/21/2025. Interview on 12/03/2025 at 1600 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy on 11/12/2025 and 11/21/2025 for Patient #4.”