Davita Fayetteville Road Dialysis

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 38766 Based on policy and procedure review, post-carbon waterlogs, and staff interview, the facility staff failed to promote the health and safety of dialysis patients by not ensuring a minimum of 18 minutes lapsed before determining the chlorine color comparison for 16 of 52 days. findings included: A review on 06/05/2024 of the facility’s policy, “Daily Water System Total Chlorine Monitoring “revised in 10/2023 revealed, “...Policy: ...3. Total Chlorine testing is done on a daily basis prior to the first patient treatment... All samples are to be drawn only after the water system has been operating for at least 15 minutes. Document results on Routine Total Chlorine Testing Log... 5. For direct feed systems, the RO (Reverse Osmosis) must have been operating for at least 15 minutes. For indirect feed systems (holding tanks), observations and readings will be obtained while the RO is operating continuously for a minimum of 15 minutes and continues to operate while testing is being completed....” A review on 06/15/2024 of the Routine Total Chlorine Testing Log from 03/01/2024 through 04/30/2024 revealed that the RO was on at 0430 daily. The review revealed that on the following dates: 03/5/2024, 03/8/2024, 03/9/2024, 03/18/2024, 03/20/2024, 03/21/2024, 04/06/2024, 04/08/2024, 04/09/2024, 04/12/2024, 04/16/2024, 04/20/2024, 04/24/2024, 04/25/2024, 04/29/2024, and 04/30/2024), the sample was collected and read in less than 15 minutes from the time the RO was on. An interview on 06/05/2024 at 1400 with the Biomedical staff revealed that the system turned on at 0430 daily. The interview revealed that the staff had been instructed to visualize the water running for a minimum of 15 minutes before the first water sample was collected for the total chlorine check. An interview on 06/06/2024 at 1230 with the Facility Administrator (FA) and the Manager of Clinical Services (MCS) revealed that the clinic managers verified and agreed with the survey findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 38766 Based on policy review, record review, and staff and patient interview, the facility staff failed to ensure a patient without documented photosensitivity to light did not wear sunglasses during dialysis per policy for 1 of 1 patient observed wearing sunglasses (Patient #4, Station #11). Findings included: A review on 06/04/2024 of the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” revised in 04/2024 revealed, “...Intradialytic Data Collection/Assessment... c. The vascular access site, bloodline connections, and the patient’s face should be visible throughout the dialysis treatment...” Observation on 06/04/2024 from 1200-1525 (85 minutes) revealed Patient #4 dialyzing in Station #11 wearing dark sunglasses. The observation revealed the patient did not remove the sunglasses and that staff did not ask for the sunglasses to be removed during the 85 minutes of observation. Observation revealed the facility staff failed to ensure the patient did not wear sunglasses during treatment. An interview on 06/04/2024 at 1320 with the staff nurse during the observation revealed that Patient #4 did not have an order to wear sunglasses during treatment. The nurse added that patients were not supposed to have any part of their faces covered during treatment. During the interview, the nurse approached the patient and asked about the sunglasses, and the patient acknowledged having them on the entire treatment. A medical record review on 06/06/2024 revealed Patient #4 was admitted for ICHD on 01/01/2020. The record review failed to reveal documented photosensitivity to light or an order for the patient to wear sunglasses during treatment. An interview on 06/06/2024 at 1230 with the Facility Administrator (FA) and the Manager of Clinical Services (MCS) revealed that documentation for wearing sunglasses would not be found in the patient’s chart because the patient did not have an order for face covering during treatment. The interview revealed that the staff should also ask the patient to remove the glasses so they can visually see their eyes during every 30-minute assessment per policy. The interview revealed that the clinic managers verified and agreed with the survey findings.”

“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 changes in a patient’s blood pressure during treatment in one (1) of eight (6) in-patient records reviewed (Patient #4). 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 judgment 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 06/06/2024 for Patient #4 revealed an 86-year-old male admitted to the facility for ICHD treatments on 01/01/2020. A review of the treatment sheet dated 05/25/2024 revealed the treatment started at 1100 and ended at 1530 for 244 minutes. The review of the treatment flowsheet revealed Patient #4’s blood pressures were as follows: ...at 1243 B/P of 89/62 with the comment of “retake B/P was low”, at 1243 B/P of 92/62 with the comment of “retake B/P was low and turn UF off “, at 1244 B/P of 95/52 with the comment of “patient B/P low”, at 1305 B/P of 97/47 with the comment of “lower goal 3.3”, at 1343 B/P of 80/48 with the comment of “rechecking B/P”, and at 1416 B/P of 86/48 with the comment of “B/P low UF off and 200 NS given...” The review revealed no documentation of the nurse’s notification of the low blood pressure. An interview on 06//06/2024 at 1155 with PCT #3 revealed that the PCT had been an employee at the clinic for the past 7 years. The interview revealed a systolic blood pressure of less than 100 would be considered low and require the UF to be turned off to assist the patient in bringing the blood pressure back up. The interview revealed if the low blood pressure persisted, the patient would need normal saline and the PCT would notify the nurse. An interview on 06/06/2024 at 1230 with the Facility Administrator (FA) and the Manager of Clinical Services (MCS) revealed the staff were expected to notify the nurse of any abnormal findings such as low blood pressure. The interview revealed the staff failed to inform the nurse of abnormal values per facility policy.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to ensure adherence to policies and procedures by failing to date and place their initials on opened multi-dose vials in 1-of-1 observation of the treatment area. Findings included: A review on 06/04/2024 of the facility’s policy, “Medication Policy” revised on 10/2023 revealed, “...Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications. Policy: ...29. ...Each vial is labeled with the initials of the person opening the vial and the expiration date...” Observation on 06/04/2024 between 1200 and 1325 of the treatment areas revealed a locked medication drawer in the nursing station area. The observation revealed three (3) opened bottles of Cinacalcet (medication used to treat high levels of calcium in the blood) and two (2) opened bottles of Calcitriol (medication used to treat low calcium levels caused by kidney disease) were stored in the medication drawer without the initials and the date that the bottles were opened. An interview on 06/04/2024 at 1320 during the observation with the staff nurse confirmed that the opened vials should have been marked with the nurse’s initials and the date of opening. An interview on 06/05/2024 at 1600 with the Facility Administrator (FA) and the Manager of Clinical Services (MCS) revealed that the staff had been educated on this requirement but failed to comply with the policy.”