Davita Bayonne

“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: 48966 Based on observation, staff interview, and review of facility documentation, it was determined the facility failed to ensure that the emergency evacuation box contained patient treatment orders and were updated monthly for 53 of 53 hemodialysis patients. Findings include: During an observation of the emergency evacuation box on 11/27/23 at 1:12 PM, a binder containing patient treatment orders and medication lists were noted within the box. The treatment orders and medication lists were dated 2/3/23. On 11/27/23 during an interview at 1:34 PM, Staff (S)2, the Clinical Coordinator (CC), stated the patient’s treatment orders and medication lists are updated quarterly by the Administrative Assistant. On 11/27/23 during an interview at 2:33 PM, Staff (S)1, the Facility Administrator (FA), explained that the patient’s treatment orders and medication lists should be updated monthly. S1 provided the emergency evacuation box policy. Review of the facility policy titled, “Facility Emergency Management Plan,” revised in October 2023, stated....”Emergency Evacuation Kit...6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list. FA or designee will verify patient information is updated and replaced at least monthly.” N.J.A.C. 8:43A-15.1(d)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 33557 Based on observation and staff interview on 11/28/23, it was determined that: 1. the ceiling tiles surrounding ten (10) of ten (10) heating and air conditioning discharge louvers, mounted on the ceiling throughout the Hemodialysis Treatment floor, are discolored and stained; and 2. the exhaust fan in the Janitor’s Closet is disconnected and should be remounted. Findings include: 1. During a tour of the Treatment Floor at 11:05 AM, white ceiling tiles surrounding ten (10) of ten (10) heating and air conditioning discharge louvers, mounted on the ceiling of the treatment floor, were visibly dirty and stained gray. During an interview at 11:05 AM, Staff #8 stated, “Those ceiling tiles need to be changed out. They look dirty.” 2. On 11/28/23 at 10:30 AM in the Janitor’s Closet, the exhaust fan that was previously mounted on the ceiling, was found resting on the top shelf on its side, still running. The exhaust fan was no longer connected to the exhaust ductwork which exhausted air to the outside. The frame, which held the fan in place, was still hanging from the ceiling grid. During an interview, Staff #8 confirmed the above finding.”

“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: 33557 Based on observation and staff interview on 11/28/23, it was determined the facility failed to ensure the toilet paper dispenser in the patient toilet is maintained for one of one patient toilets on the treatment floor. Findings include: During a tour of the Treatment Floor at 10:45 AM, the toilet paper dispenser in the patient toilet, on the Treatment Floor, was apart with the front cover lying on the floor. During an interview at 10:45 AM, Staff #8 stated, “That should not be like that.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 39228 Based on medical record review and staff interview, it was determined the facility failed to ensure that one of seven patients (Patient (P) 1) received his/her hemodialysis treatments in accordance with the physician prescribed dialysis order. Findings include: A review of P1’s medical record revealed the following: “Orders,” dated 11/8/23, included an order for a dialysis flow rate (DFR) of “600.” On 11/8/23, the “Treatment Details Report” indicated P1 was dialyzed with a DFR of 500 instead of the prescribed DFR of 600 from the initiation of the treatment at 11:16 AM until the end of the treatment at 14:17 (2:17 PM), three hours and 1 minute later. The medical record lacked documented evidence of a rationale for a lower DFR rate of 500. On 11/13/23, the “Treatment Details Report” indicated that P1 was dialyzed with a DFR of 500 instead of the prescribed DFR of 600 from the initiation of the treatment at 10:59 AM until the end of the treatment at 14:02 (2:07 PM), three hours and three minutes later. The medical record lacked documented evidence of a rationale for a lower DFR rate of 500. “Orders,” dated 11/22/23, included an order for a dialysis flow rate (DFR) of “600.” On 11/22/23, the “Treatment Details Report” indicated that P1 was dialyzed with a DFR of 500 instead of the prescribed DFR of 600, from the initiation of the treatment at 10:56 AM until the end of the treatment at 14:02 (2:02 PM), three hours and six (6) minutes later. The medical record lacked documented evidence of a rationale for a lower DFR rate of 500. During an interview on 11/28/23 at 11:45 AM, the above findings were reviewed with Staff (S) 2, a Registered Nurse. S2 stated that the DFR was ordered at 600 on the above dates and that the staff should be running it at 600 not 500. The above findings are not in accordance with the prescribed orders. A review of facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised April 2023, stated, “... PLAN OF CARE: 8. The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs ... 9. The plan of care will address, but not be limited to, the following: Dose of dialysis which addresses care and services to manage the patient;s volume status; and achieve and sustain the prescribed dose of dialysis ...” N.J.A.C. 8:43A-24.13 (b)”