Davita Surf City Dialysis

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to obtain a post-treatment weight for 1 of 3 patients treatment termination observed (Patient #9). Findings included: A review on 05/10/2024 of the facility’s policy and procedure, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” revised 04/2024 revealed “...POLICY: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: ...iv. Patient weight...” An observation on 05/10/2024 at 1030 revealed Patient #9’s dialysis treatment was complete. The patient walked unassisted from the dialysis station to the weight scale. Once at the scale, the patient obtained and printed a slip detailing the post-treatment weight. The observation revealed the patient returned to the station, handed the slip to the RN, and exited the treatment area. The observation revealed the facility staff failed to verify the post-treatment weight of the patient. An interview on 05/10/2024 at 1035 with RN #2 confirmed that the patient obtained his weight unsupervised by the staff. The interview revealed obtaining the patient’s weight before and after the treatment was the responsibility of the PCTs and the nurses to ensure that the weight was accurate. RN #2 stated an accurate weight was necessary to assess the patient’s fluid status. An interview on 05/10/2024 at 1350 with the clinic FA and the visiting FA revealed that if patients were stable and ambulatory enough to go to the scale, they were allowed to obtain their weight independently. After a review of the facility policy, the FAs stated that staff should have monitored the patient while taking the weight to ensure its accuracy. The interview confirmed that the policy was not followed.”

“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: 38766 Based on facility policy review, medical record review, and staff interview, the facility patient care staff failed to notify the nurse of a patient’s abnormal vital signs in one (1) of eight (9) in-patient records reviewed (Patient #5). Findings included: A review on 05/09/2024 of the facility’s policy and procedure, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” revised 04/2024 revealed “...Intradialytic Data Collection/Assessment... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to ‘abnormal Findings’ section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary... Abnormal Findings... 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... Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg (milliliter of mercury) or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” An open medical record review on 05/09/2024 for Patient #5 revealed a 59-year-old male admitted to the facility for ICHD treatments on 12/04/2023. Review of the treatment sheet dated 04/19/2024 revealed the treatment started at 0620 and ended at 1023 for a duration of 243 minutes. Review of the treatment flowsheet revealed Patient #5’s blood pressures were as follows: at 0923 BP of 91/61, at 0953 BP of 88/55, at 0954 BP of 70/40 and 200 ml (milliliter) of normal saline was given, at 0959 BP of 81/30, and at 1000 BP of 102/55. The review revealed no documentation of the nurse’s notification of the low blood pressures. An interview on 05/10/2024 at 1350 with the FA and the visiting FA revealed the staff were expected to monitor the patients and notify the nurse of any abnormal findings such as low blood pressure. Interview revealed the staff failed to notify the nurse of abnormal values per facility policy.”

“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: 38766 Based on facility policy review, observations, medical record reviews, and staff interviews, the facility staff failed to ensure that there was documentation of a patient’s request to pull both needles, one after the other, at the end of the patient’s hemodialysis treatment in 1 of 3 discontinuations of AVF/AVG observations (Sta. #2). Findings include: A review on 05/08/2024 of the facility policy titled “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” revised 04/2023 revealed, “... 9. ...One needle should be pulled at a time. However, if the patient requests and they are able to hold both cannulation sites, then both needles may be removed...” An observation on 05/08/2024 at 1255 in the patient treatment area revealed PCT #1 entered Sta. #15 and prepared to discontinue the patient’s AVF/AVG. Observation revealed PCT #1 pulled both the arterial and venous needles one after the other and allowed the patient to hold both sites simultaneously. An open medical record review on 05/08/2024 revealed Patient #2 was admitted to the in-center facility on 02/03/2023. The review of the medical record for Patient #2 revealed no available documentation of the patient’s request for staff to pull both needles at the same time. An interview on 05/08/2024 at 1300 with PCT #1 during observation revealed that Patient #2 always had both needles pulled at the same time and held pressure on both sites at the same time. The interview revealed PCT #1 did not know if the patient had an order to hold pressure on both sites at the same time, but “I always do it like that.” An interview on 05/08/2024 with the FA and the visiting FA revealed that patients were allowed to hold pressure on both access sites at the same time if they requested to do so. An interview on 05/10/2024 at 1055 with Patient #2 revealed that they (the clinic staff) were using vascular access clamps to apply pressure to the access sites after treatments. The interview revealed that Patient #2 requested to hold pressure on his access sites, but he did not make a request to hold pressure on both sites at once. A follow-up interview on 05/10/2024 at 1350 with the FA and the visiting FA revealed that the request should have been documented in the patient’s medical record. The interview confirmed that there was no documentation of the patient’s request in the chart.”