Davita Omaha Harrison Dialysis

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 47269 Based on review of facility checklists, policies, and procedures, observations, and staff interviews, the facility failed to identify and remove expired emergency evacuation supplies/medications from the Emergency Evacuation Kit (EEK, a kit containing non-expired emergency evacuation supplies/medications, including site dressings, saline, IV tubing, available to accommodate evacuated hemodialysis patients). This failed practice had the potential to expose all 42 patients on census to expired medications during a facility evacuation. Findings are: A. Review of the facility policy titled Medication Policy, dated 10/2023, revealed all medications are checked monthly for expiration dates and expired medications are removed from the treatment and inventory areas and disposed of per state/local regulations. B. Review of the facility policy titled Facility Emergency Management Plan, dated 4/2023, revealed the EEK was to be checked monthly by a designated staff member who, by utilizing the EEK Checklist (a list containing all the expiration dates of the supplies/medications located in the EEK), would confirm the EEK contents and expiration dates by dating and initializing the EEK Checklist. C. Observation of the Emergency Evacuation Kit with the Manager of Clinical Services (MCS), on 12/6/23 at 1:45 PM, revealed seven 1-liter Normal Saline bags with the expiration date of 6/2023 along with seven 1-liter Normal Saline bags with the expiration date of 8/2024. The MCS confirmed the EEK Checklist, located in the EEK, was dated and initialed by Staff C on 12/5/23. D. Review of the EEK Checklists, on 12/6/23 at 2:45 PM, for 5/2023 thru 12/2023, revealed Staff C had updated the checklist in 7/2023 to show seven 1-liter Normal Saline bags with the expiration date of 8/2024, but failed to remove the expired seven 1-Liter Normal Saline bags from the EEK. E. During staff interview on 12/6/23 at 3:00 PM, the Facility Administrator (FA) and MCS, confirmed Staff C was the designated staff member responsible for checking the EEK supplies/medications monthly by utilizing the EEK Checklist. The FA and MCS both confirmed it is the expectation that Staff C would remove any expired supplies/medications from the EEK and update the EEK Checklist to reflect accurate expiration dates of supplies/medications located in the EEK.”

“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: 48995 Based on review of records, policies, and procedures, and staff interviews, the facility staff failed to follow the facility’s policy and procedure for notification of a Registered Nurse (RN) when Blood Pressure (BP) readings were not within the facility policy’s parameters, during hemodialysis (HD) treatment, for 2 of 5 sampled patients (Patients 4 and 8). This failed practice provided for a lack of intervention by the RN to prevent negative patient outcomes associated with blood pressure changes. The facility census was 42. Findings are: A. Review of the policy and procedure titled Pre-intra-post data collection monitoring and nurse assessment, dated 10/23, revealed the facility may allow implementation of revised abnormal BP parameters established by the facility Governing Body and documented in the Governing Body Meeting minutes. The Governing Body Meeting minutes dated 5/30/23, revised the facility’s abnormal BP parameters to be: Systolic BP greater than 190 mm (Millimeters)/Hg (Mercury) or equal to or less than 90 mm/Hg and/or Diastolic BP greater than 110 mm/Hg or less than 50 mm/Hg, or a difference of 20 mm/Hg increase or decrease from the patient’s last intradialytic treatment BP reading. The Governing Body also established these abnormal BP findings were to be reported to the licensed nurse and documented in the patient’s medical record. B. Review of Patient 4’s clinical record, on 12/7/23, revealed the following HD treatment BP readings outside of the facility policy’s parameter, as documented by Patient Care Technicians (PCTs) with failure, by the PCTs, to document RN notification: 1. PCT-D on 11/18/23 at 12:31 PM, BP 191/120, and at 12:32 PM, BP 189/118. 2. PCT-B on 11/18/23 at 1:01 PM, BP 197/122 and at 1:15 PM, BP 212/128, and on 11/21/23 at 12:56 PM, BP 162/111 and at 2:54 PM, BP 182/113. 3. PCT-I on 11/18/23 at 1:45 PM, BP 180/111 and at 3:28 PM, BP 169/113 and on 11/23/23 at 9:05 AM, BP 209/128 and at 11:00 AM, BP 221/134. 4. PCT-O on 11/21/23 at 12:07 PM, BP 213/135, and at 3:24 PM, BP was 185/113. C. Review of Patient 8’s clinical record, on 12/7/23, revealed the following HD treatment BP readings outside of the facility policy’s parameter, as documented by the PCT with failure, by the PCTs, to document RN notification: 1. PCT-E on 11/16/23 at 12:56 PM, BP 108/45 and on 11/28/23 at 1:30 PM, BP 98/40. 2. PCT-I on 11/28/23 at 2:00 PM, BP 93/48. D. During staff interview on 12/12/23 at 10:10 AM, the Facility Administrator (FA) confirmed facility staff failed to follow the facility’s policy and procedure for documentation of RN notification when patient BP readings were outside of policy parameters for Patients 4 and 8.”