Davita N.E. Nebraska Dialysis

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 48995 Based on review of policies and procedures, review of Quality Assurance Performance Improvement (QAPI, a data driven and proactive approach using a systematic, comprehensive, approach for maintaining and improving safety, and to identify areas of opportunity for the improvement in the provision of care, and testing of interventions) monthly meeting minutes, and staff interviews, the facility failed to conduct audits and document QAPI meeting discussions of their Treatment Detail Reports audit findings, as part of the facility’s plan of correction (POC) to correct the deficient practices cited at V504 during a recertification survey with exit date on 4/29/24, in 2 of 2 monthly QAPI meeting minutes (5/23/24 and 6/27/24). This failed practice prevented the staff from being able to take actions that result in performance improvements, and track performance to ensure improvements are sustained over time. The facility census was 58. Findings are: A. Review of the facility policy titled Continuous Quality Improvement Program, dated April 2021, revealed the facility will measure, analyze, and track quality indicators or other aspects of performance. Continuous monitoring of indicators will be reflected in the meeting minutes. Facility Administrators (FAs) conduct periodic Facility Health Meetings (FHM) (also known as QAPI in the CMS Conditions of Coverage) with Continuous Quality Improvement (CQI) committee to review issues and indicators regarding facility’s management and performance. B. During staff interview on 7/11/24 at 7:40 AM, the FA confirmed the facility’s Treatment Detail Reports audits were to be conducted as part of the facility’s plan of correction to ensure the deficient practices cited at V504, during a recertification survey with exit date on 4/29/24, were corrected and remained corrected. Audits were completed for the month of May in 2024. No audits were completed for June and early July in 2024. C. Review of facility monthly QAPI meeting minutes revealed no documentation of reviewing, discussing, or evaluating the facility’s 257 Treatment Detail Reports audits conducted from 5/22/24 through 5/31/24. D. During staff interview on 7/11/24 at 7:50 AM the FA confirmed, there was no documentation included in the 5/23/24 or 6/27/24 monthly QAPI meeting minutes for the review, discussion, or evaluation of the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24. E. During staff interview on 7/11/24 at 10:30 AM, the Medical Director confirmed they were aware of the 4/29/24 recertification survey deficient practice findings cited at V504; but could not confirm survey findings, or the facility’s POC in response to these survey findings, were discussed at the 5/23/24 or 6/27/24 QAPI meetings. The Medical Director further confirmed they were not aware of any specifics regarding the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24.”

“MD RESP-QAPI PROGRAM CFR(s): 494.150(a) Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program. This Standard is not met as evidenced by: 48995 Based on review of policies and procedures, review of Quality Assurance Performance Improvement (QAPI, a data driven and proactive approach using a systematic, comprehensive, approach for maintaining and improving safety, and to identify areas of opportunity for the improvement in the provision of care, and testing of interventions) monthly meeting minutes, and staff interviews, the Medical Director failed to ensure review, discussion, and evaluation of the facility’s Treatment Detail Reports audit findings, as part of the facility’s plan of correction (POC) to correct the deficient practices cited at V504 during a recertification survey with exit date on 4/29/24, was included in 2 of 2 monthly QAPI meeting minutes (5/23/24 and 6/27/24). This failed practice prevented the Medical Director from being involved in adjusting the facility’s POC, if needed, to ensure ongoing correction, by facility staff, of the deficient practices cited at V504 on 4/29/24. The facility census was 58. Findings are: A. Review of the facility policy titled Continuous Quality Improvement Program dated April 2021, revealed the Facility Medical Director is responsible for verifying the execution as well as participation in the Quality Improvement Program including implementation, continuous monitoring, development of action plans and program evaluation. B. During staff interview on 7/11/24 at 7:40 AM, the Facility Administrator (FA) confirmed the facility’s Treatment Detail Reports audits were to be conducted as part of the facility’s plan of correction to ensure the deficient practices cited at V504, during a recertification survey with exit date on 4/29/24, were corrected and remained corrected. The POC also included, the FA would review the audit findings with the Medical Director, during the monthly QAPI meetings, with supporting documentation included in the meeting. C. Review of facility monthly QAPI meeting minutes revealed no documentation of reviewing, discussing, or evaluating the facility’s 257 Treatment Detail Reports audits conducted from 5/22/24 through 5/31/24. D. During staff interview on 7/11/24 at 7:50 AM, the FA confirmed there was no documentation included in the 5/23/24 and 6/27/24 monthly QAPI meeting minutes for the review, discussion, or evaluation of the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24. E. During staff interview on 7/11/24 at 10:30 AM, the Medical Director confirmed they were aware of the 4/29/24 recertification survey deficient practice findings cited at V504; but could not confirm survey findings, or the facility’s POC in response to these survey findings, were discussed at the 5/23/24 or 6/27/24 QAPI meetings. The Medical Director further confirmed they were not aware of any specifics regarding the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24.”

“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: 48995 Based on review of policies and procedures, record review, and staff interviews, the Medical Director (MD) failed to ensure facility staff followed the facility’s policies and procedures for Quality Assurance Performance Improvement (QAPI), as cited at Tag V638 on 7/11/24, and failed to ensure facility Patient Care Technicians (PCTs) followed the facility’s policy and procedure for notification of a Registered Nurse (RN) when patient Blood Pressure (BP) readings, taken during hemodialysis (HD) treatment, were not within the facility policy’s parameters for 4 of 7 sampled patients (Patient 5, 7, 10, 13). These failed practices provided the potential for a lack of interventions by the RN to prevent negative patient outcomes associated with blood pressure changes and prevented the MD from being involved in adjusting the facility’s POC, if needed, to ensure ongoing correction, by facility staff of the deficient practices cited at V504 on 4/29/24. The facility census was 58. Findings are: A. Review of the facility policy titled Pre-intra-post treatment data collection monitoring and nurse assessment, dated April 2024, revealed the facility may allow implementation of revised abnormal BP parameters established by the facility Governing Bodyand documented in the Governing Body Meeting minutes. The Governing Body Meeting minutes dated 6/2/23, approved 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 10’s clinical record revealed Patient Care Technicians (PCTs) failed to document an RN was notified for BP readings outside of policy parameters for the following HD treatments: 1. PCT-J on: 5/15/24 BP 151/132 and 159/116 2. PCT-N on: 6/28/24 BP 126/48 C. Review of Patient 7’s clinical record revealed PCTs failed to document an RN was notified for BP readings outside of policy parameters for the following HD treatments: 1. PCT-K on: 6/3/24 BP 171/114 D. Review of Patient 5’s clinical record revealed PCTs failed to document an RN was notified for BP readings outside of policy parameters for the following HD treatments: 1. PCT-L on: 6/14/24 BP 143/114 6/21/24 BP 185/149 2. PCT-M on: 7/3/24 BP 202/101 and 209/104 E. Review of Patient 13’s clinical record revealed PCTs failed to document an RN was notified for BP readings outside of policy parameters for the following HD treatments: 1. PCT-J on: 5/13/24 BP 163/127 5/15/24 BP 80/42, 89/46 and 98/49 5/22/24 BP 174/120 2. PCT-M on: 5/20/24 BP 174/112, 167/116, 168/124 and 152/110 5/27/24 BP 200/150, 199/133 and 185/124 3. PCT-N on: 6/24/24 BP 163/113 F. During staff interview on 7/11/24 at 9:45 AM, the Facility Administrator confirmed facility PCTs had failed to document an RN was notified when BP readings were outside of policy parameters during HD treatments for Patient’s 5, 7, 10, and 13. G. During staff interview on 7/11/24 at 7:40 AM, the FA confirmed the facility’s Treatment Detail Reports audits were to be conducted as part of the facility’s plan of correction to ensure the deficient practices cited at V504, during a recertification survey with exit date on 4/29/24, were corrected and remained corrected. Audits were completed for the month of May in 2024. No audits were completed for June and early July in 2024. H. Review of facility monthly QAPI meeting minutes revealed no documentation of reviewing, discussing, or evaluating the facility’s 257 Treatment Detail Reports audits conducted from 5/22/24 through 5/31/24. I. During staff interview on 7/11/24 at 7:50 AM the FA confirmed, there was no documentation included in the 5/23/24 or 6/27/24 monthly QAPI meeting minutes for the review, discussion, or evaluation of the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24. J. During staff interview on 7/11/24 at 10:30 AM, the Medical Director confirmed they were aware of the 4/29/24 recertification survey deficient practice findings cited at V504; but could not confirm survey findings, or the facility’s POC in response to these survey findings, were discussed at the 5/23/24 or 6/27/24 QAPI meetings. The Medical Director further confirmed they were not aware of any specifics regarding the facility’s Treatment Detail Reports audits as part of the facility’s POC for V504 cited on 4/29/24.”

“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: 48995 Based on review of facility policies and procedures, observations, and staff interviews, the facility staff failed to comply with Nebraska Title 175 NAC (Nebraska Administrative Code) 7-006.06A Administration of Medications: Each health clinic must establish and implement written policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the Five Rights, which means getting the right drug to the right recipient in the right dosage by the right route at the right time, and in accordance with prevailing professional standards. Facility staff also failed to follow the facility’s Medication Policy which requires the teammate preparing the medication to also be the teammate administering the medication. This failed practice had the potential to affect the health and safety of all patients who receive medications administered by facility staff. Patient census was 61. Findings are: A. Review of the facility policy titled Medication Policy, with a revision date of 10/2023, revealed the policy was to provide guidance for the safe preparation and administration of medications by facility staff to patients and requires the teammate preparing the medication to also be the teammate administering the medication. B. During observations of Patient (PT)-4’s Central Venous Catheter (CVC) dressing change and initiation of hemodialysis (HD), the following occurred: 1. At 1:50 PM, Patient Care Technician (PCT)-F delivered a syringe containing a clear liquid to PT-4’s chair side table. The syringe was labeled as Heparin 3000Units/3mL (milliliter). 2. At 2:05 PM, Registered Nurse (RN)-H administered the syringe containing a clear liquid, labeled Heparin 3000Units/3mL (delivered by PCT-F) into PT-4’s CVC. C. During staff interview on 4/22/24 at 2:30PM, RN-H confirmed she had administered the syringe labeled Heparin 3000Units/3mL to PT-4 but had not prepared the syringe. RN-H further confirmed the syringe had been prepared by PCT-F. D. During staff interview on 4/24/24 at 8:30AM, the Facility Administrator (FA) and Manager of Clinical Services (MCS) confirmed RN-H failed to follow the facility’s Medication Policy and the Five Rights of Medication Administration professional standards.”

“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 facility policies and procedures, record review and staff interviews, the facility staff failed to follow the policies and procedures for notification of an Registered Nurse (RN), when Blood Pressure (BP) readings were not within the facility policy’s parameters, during hemodialysis (HD) treatment for 4 of 7 sampled patients (Patients 3, 11, 14 and 16). This failed practice provided for a lack of intervention by the RN to prevent negative patient outcomes associated with blood pressure changes. Patient census was 61. Findings are: A. Review of the policy and procedure titled Pre-intra-post data collection monitoring and nurse assessment, dated 4/24, 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 6/2/23, approved 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 3’s clinical record 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-I on 3/27/24 at 2:57 PM, BP 166/111; on 3/29/24 at 4:57 PM, BP 159/113; and on 4/12/24 at 1:02 PM, BP 177/122. 2. PCT-Q on 4/1/24 at 3:14 PM, BP 177/112. 3. PCT-C on 4/1/24 at 5:58 PM, BP 167/111, at 6:58 PM, BP 160/122. 4. PCT-P on 4/1/24 at 3:58 PM, BP 168/124, at 6:28 PM, BP 167/112, at 8:28 PM, BP 164/117; on 4/3/24 at 5:28 PM, BP 182/119; and on 4/12/24 at 1:02 PM, BP 168/117. 5. PCT-B on 4/3/24 at 4:28 PM, BP 183/134. C. Review of Patient 11’s clinical record revealed the following HD treatment BP readings outside of the facility policy’s parameter, as documented by PCTs with failure, by the PCTs to document RN notification. 1. PCT-P on 4/10/24 at 10:00 AM, BP 78/50, at 9:01 AM, BP 85/54. 2. PCT-B on 4/10/24 at 9:32 AM, BP 116/22. D. Review of Patient 14 ‘s clinical record revealed the following HD treatment BP readings outside of the facility policy’s parameter, as documented by PCTs with failure, by the PCTs to document RN notification. 1. PCT-C on 4/19/24 at 3:02 PM, BP 173/111. 2. PCT-F on 4/12/24 at 9:03 AM, BP 160/120; on 4/19/24 at 4:03 PM, BP 181/129, at 4:33 PM, BP 180/120. 3. PCT-A on 4/5/24 at 6:48 AM, BP 178/124, at 6:57 AM, BP 176/114, at 7:57 AM, BP 177/115; on 4/8/24 at 8:26 AM, BP 155/113; on 4/12/24 at 6:51 AM, BP 170/122, at 8:02 AM, BP 179/128, at 8:33 AM, BP 174/117; on 4/22/24 at 6:57 AM, BP 174/121, at 7:27 AM, BP 174/124, at 8:27 AM, BP 165/116. 4. PCT-B on 4/10/24 at 9:32 AM, BP 169/117; on 4/22/24 at 7:57 AM, BP 169/111. 5. PCT-P on 4/5/24 at 8:27 AM, BP 163/111, at 10:05 AM, BP 155/113; on 4/8/24 at 9:26 AM, BP 177/116; on 4/10/24 at 7:01 AM, BP 176/127, at 8:31 AM, BP 168/138. 6. PCT-I on 4/8/24 at 7:32 AM, BP 172/123 and at 9:30 AM, BP 175/123. E. Review of Patient 16 ‘s clinical record revealed the following HD treatment BP readings outside of the facility policy’s parameter, as documented by PCTs with failure, by the PCTs to document RN notification. 1. PCT-C on 4/3/24 at 1:58 PM, BP 117/45, at 2:58 PM, BP 118/40; and on 4/15/24 at 1:26 PM, BP 194/161, at 2:57 PM, BP 145/44. 2. PCT-I on 4/5/24 at 2:48 PM, BP 125/44, at 2:58 PM, BP 135/27, at 3:28 PM, BP 120/40; on 4/10/24 at 12:27 PM, BP 134/44; and on 4/15/24 at 12:57 PM, BP 116/46, at 1:05 PM, BP 117/44. 3. PCT-F on 4/5/24 at 12:08 PM, BP 213/66. 4. PCT-T on 4/12/24 at 1:01 PM, BP 139/49, at 2:31 PM, BP 150/49, at 3:01 PM, BP 150/49. 5. PCT-P on 4/17/24 at 1:49 PM, BP 121/42, at 4:07 PM, BP 124/32. F. During staff interview on 4/23/24 at 3:50 PM, the facility Administrator (FA) confirmed facility PCTs 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 3, 11, 14 and 16.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 48995 Based on review of facility policies and procedures, record review, and staff interviews, the dialysis facility failed to document, in the medical record, a change in physician orders for 1 of 7 sampled patients (PT-14). This failed practice had the potential to affect the health and safety of PT-14. Patient census was 61. Findings are: A. Review of the policy and procedure titled Pre-intra-post data collection monitoring and nurse assessment, dated 4/24, revealed the patient identity, prescriptions and machine settings are to be verified by a teammate prior to the initiation of a patient’s treatment. Prescription components include, but are not limited to, correct dialysate composition (potassium, calcium, base sodium, and bicarb) and settings. B. Review of PT-14’s clinical record revealed on 4/15/24, 2K(Potassium/3Ca(Calcium) dialysate was used to dialyze the patient, due to a malfunction of the facility’s water box (frames recessed into the wall at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water and dispose of waste products). The ordered dalysate prescription on the plan of care was 2K/2.5Ca. No physician order was documented to change PT-14’s dialysate to 2K/3Ca on 4-15-24. C. During an interview on 4/24/24 at 12:15 PM, the facility’s Medical Director (MD) confirmed being notified by RN-E of the wall box malfunction on 4-15-24 and the need to a change PT-14’s dialysate order to 2K/3Ca for 4-15-24. D. During an interview on 4/29/24 at 1:45 PM, RN-E confirmed receiving a telephone order on 4-15-24 from the facility’s MD to change PT-14’s dialysate order to 2K/3Ca for 4-15-24, but failed to document this telephone order in PT-14’s medical record. E. During an interview on 4/23/24 at 3:00 PM, the Facility Administrator (FA) confirmed RN-E failed to document, in PT-14’s medical record, the facility MD’s telephone order received 4-15-24 to change PT-14’s dialysate order for 4-15-24.”