Davita Sorensen Park Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, staff schedules, record review, and staff interviews, the facility failed to ensure sufficient staffing for continuity of operations to ensure patient needs were met for 5 of 24 patients (Pt-1, Pt-2, Pt-3, Pt-4, and Pt-5) who failed to receive In Center Hemodialysis (ICHD) treatments at the facility as scheduled on 5-9-25 and the facility failed to have policies and procedures to ensure compliance with this requirement at Title 175 Nebraska Administrative Code (NAC) Chapter 7-006.03. The patient census was 37. This failed practice had the potential to negatively impact the health and safety of all patients who have physician orders to receive ICHD treatments at this facility. Findings are: A. Nebraska Title 175 NAC 7-006.03 Staff Requirements: Each health clinic must maintain a sufficient number of staff with the qualifications, training, and skills to meet operational and patient needs. B. Review of the facility staff schedule for 5/9/25 revealed the sole scheduled Registered Nurse (RN-C) was unable to work their scheduled shift resulting in a facility closure on 5/9/25. C. Review of the facility patient treatment records for 5/9/25 revealed that 5 of 24 patients (Pt-1, Pt-2, Pt-3, Pt-4, and Pt-5) declined receiving ICHD treatment at another facility or dialyzing at the facility as an alternative ICHD treatment day on 5/10/25. D. During staff interview on 6/16/25 at 12:37 PM, the Facility Administrator (FA) confirmed that RN-C was the sole scheduled RN for 5/9/25. The FA confirmed that they were unable to find a replacement RN for RN-C resulting in the facility closure on 5/9/25. The FA revealed it is the facility practice to assign one sole RN to work the entire day that patients are receiving ICHD treatments. The FA confirmed a policy and procedure did not exist for scheduling an RN as a back-up or on call RN in the event the sole scheduled RN is unable to work.”

“GOV-ADM RESP FOR FISCAL OPERATIONS CFR(s): 494.180(a)(2) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (2) Fiscal operations; This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, staff schedules, record review, and staff interviews, the facility failed to have policies and procedures for maintaining the fiscal operations for the hiring of sufficient staff to maintain operations of the dialysis facility. This failed practice had the potential to negatively impact the health and safety of all patients who have physician orders to receive In Center Hemodialysis (ICHD) treatments at this facility. The patient census was 37. Findings are: A. Review of the facility staff schedule for 5/9/25 revealed the sole scheduled Registered Nurse (RN-C) was unable to work their scheduled shift resulting in a facility closure on 5/9/25. B. Review of the facility patient treatment records for 5/9/25 revealed that 5 of 24 patients (Pt-1, Pt-2, Pt-3, Pt-4, and Pt-5) declined receiving ICHD treatment at another facility or dialyzing at the facility as an alternative ICHD treatment day on 5/10/25. C. During staff interview on 6/16/25 at 12:37 PM, the Facility Administrator (FA) confirmed that RN-C was the sole scheduled RN for 5/9/25. The FA confirmed two nurses are assigned to this facility, RN-C and RN-D. The FA revealed RN-D was on vacation on 5/9/25 and would not have been available to come in and work in the event that RN-C was unable to work as scheduled. The FA revealed it is the facility practice to assign one RN to work the entire day that patients are receiving ICHD treatments. The FA confirmed policies and procedures did not exist for scheduling an RN as a back-up or on call RN in the event the sole scheduled RN is unable to work. D. During staff interview on 6/17/25 at 10:00 AM, the FA confirmed policies and procedures did not exist for maintaining the fiscal operations for the hiring of sufficient staff to maintain operations of the dialysis facility.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interviews, the Registered Nurses (RN-A and RN-B) failed to identify and remove expired emergency lab tubes from the Emergency Cart (where emergency medications and supplies are stored). This failed practice had the potential to affect lab results of all 29 patients on census if emergency labs were ordered by the physician. Findings are: A. Review of the policy titled Emergency Equipment Checks, dated 10/2024, revealed the expiration dates of emergency supplies are to be checked weekly by the facility nurses. B. Review of the procedure titled Emergency Equipment Checklist, 2/2025, revealed the weekly Emergency Cart review was completed and contained no expired supplies by nurses for the following weeks: 1. RN-A completed weekly checks of the Emergency Cart on: 2/1/25, 2/5/25, and 2/8/25. 2. RN-B completed weekly checks of the Emergency Cart on: 2/3/25, 2/10/25, 2/17/25, and 2/24/25. C. Observation of the facility Emergency Cart, on 2/27/25 at 9:30 AM with the Facility Administrator (FA), revealed 3 red clear lab tubes with an expiration date of 1/31/2025. D. During staff interview on 2/27/25 at 9:40 AM, the FA confirmed the 3 red lab tubes were expired and confirmed RN-A and RN-B failed to identify and remove the 3 expired red lab tubes during the weekly checks of the Emergency Cart for expired supplies.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interviews, the facility failed to maintain the outer metal panel covering of the reverse osmosis (RO) machine (the primary method for purifying water for hemodialysis (HD) treatments) to prevent corrosion of the RO outer metal covering. This failed practice had the potential to affect the facility’s ability to provide uninterrupted HD treatments to all 29 patients on census. Findings are: A. Review of the facility policy and procedure titled Physical Environment, dated 4/2018, revealed the facility will be maintained for a safe and functional environment. B. Observation of the facility Water Room on 2/26/25 at 9:20 AM with the Facility Administrator (FA), revealed rust colored debris and corrosion of the back lower left outer metal panel of the RO machine. C. During staff interview on 2/27/25 at 12:40 PM, the Biomed Technician (BMT) confirmed the presence of rust colored debris and corrosion of the back lower left outer metal panel of the RO machine and confirmed this metal panel was in need of repair or replacement. The BMT confirmed the biomed staff are responsible for maintaining the RO machine. The BMT confirmed the biomed staff failed to maintain the outer metal panel of the RO machine. D. During staff interview on 2/27/25 at 1:00 PM, the FA confirmed the presence of rust colored debris and corrosion of the RO’s back lower left outer metal panel and confirmed this outer metal panel was in need of repair or replacement. The FA confirmed the biomed staff are responsible for maintaining the RO machine. The FA confirmed the biomed staff failed to maintain the outer metal panel covering of the RO machine.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interviews, the facility failed to secure the file cabinets where historical patient records were stored. This failed practice had the potential to affect the privacy and confidentiality of dialysis patients by not safeguarding patient medical records against unauthorized use. The patient census was 29. Findings are: A. Review of the facility policy and procedure titled Medical Records Custodian (MRC) and Maintenance, dated 10/2019, revealed the MRC is responsible for safeguarding the privacy and confidentiality of patient medical records against unauthorized use. B. During observation of the open, unattended Medical Records room on 2/26/25 at 9:00 AM with the Facility Administrator (FA), 4 unlocked file cabinets containing patient medical records were identified. C. During staff interview on 2/26/25 at 10:00 AM, the Facility Administrator (FA) confirmed it is the expectation of the MRC to safeguard the privacy and confidentiality of patient medical records against unauthorized use. The FA further confirmed it is the expectation that patient medical records are stored in the Medical Records room and locked in the file cabinets designated for patient records. The FA confirmed the MRC failed to lock the 4 file cabinets containing patient medical records.”