Davita Willingboro Dialysis

“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: 51040 Based on observation and staff interview on March 5, 2025, it was determined that the facility failed to ensure environmental services are maintained for the safety of the patients, the staff, and the public. Finding include: During a tour conducted at 9:30 AM, in the presence of Staff (S) 3, Biomedical Technician, the shelf in the Janitor’s Closet was peeling which creates an surface that can not be properly cleaned. During a tour of the Treatment Floor at 9:45 AM, in the presence of S3, the drains for both dirty sinks, one located on Side A and one located on Side B, were leaking causing the cabinet to delaminate which exposes a porous surface which cannot be properly cleaned. The following findings were confirmed by interview with S3 at 10:48 AM. N.J.A.C. 8:43A-17.3(a)”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 51227 Based on one of two observations of a central venous catheter (CVC, a type of access used for hemodialysis) initiation, staff interview, and facility policy review, it was determined that the facility failed to ensure each patient’s right to privacy. Findings include: On 3/6/25 at 10:15 AM in Station 4, Staff (S) 10, a Registered Nurse (RN) initiated hemodialysis through the patient’s right chest CVC. The patient’s shirt was opened during the procedure, exposing his/her chest. The curtain was fully drawn to the right of the patient but was only partially open on the left side of the patient, and not fully extended to the front of the patient. The patient’s exposed chest was visible to the patient sitting in Station 9. Staff members were seen walking past the left side of the opening. During an interview at 10:30 AM, S10 stated, “the curtain should be closed all the way, but it doesn’t fully close all the way because it is too short.” Facility policy titled, “Patient’s Rights,” last revised October 2021, stated, “ ... Your Rights As A Patient: ... 4. The right to privacy and confidentiality in all aspects of treatment. The dialysis facility will make accommodations to provide for patient privacy when patients are examined or body exposure is required, for example privacy screens or curtains ...” N.J.A.C. 8:43A-16.2(a)10”

“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: 51227 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that patients receive hemodialysis treatment as ordered by the physician for one of one patient (Patient (P) 9) with an Ultrafiltration Rate above 13 milliliters (mL) per kilogram (kg) per hour (hr) during hemodialysis treatment. Findings include: The medical record for P9 was reviewed and the following was revealed: P9’s last Plan of Care Meeting was held on 2/6/25 and indicated that the patient was meeting his/her goal of fluid and blood pressure management. Hemodialysis treatment orders indicated a target weight of 68.5 kg (kilograms) for 2/11/25 through 3/5/25. The hemodialysis prescription also indicated a treatment time of three hours and 45 minutes with a maximum Ultrafiltration (UF) rate of 13.0 mL/kg/hr for 2/11/25 through 3/5/25. The ‘Treatment Details Reports’ for 2/11/25 through 3/5/25 revealed the following treatments provided to P9 delivered a UF rate above the ordered maximum limit: On 2/11/25, P9’s Pre-Weight was 75.3 kg, 6.8 kg above the ordered target weight of 68.5 kg. After 3,944 mL of fluid was removed, the Post Weight was 71.6 kg. The documented actual UF rate was “13.7 mL/kg/hr,” which is above the ordered maximum rate. On 2/13/25, P9’s Pre-Weight was 72.3 kg, 3.8 kg above the ordered target weight of 68.5 kg. After 4,468 mL of fluid was removed, the Post Weight was 68.1 kg. The documented actual UF rate was “16.4 mL/kg/hr,” which is above the ordered maximum rate. On 2/15/25, P9’s Pre-Weight was 72.2 kg, 3.7 kg above the ordered target weight of 68.5 kg. After 4,502 mL of fluid was removed, the Post Weight was 68.1 kg. The documented actual UF rate was “16.0 mL/kg/hr,” which is above the ordered maximum rate. On 2/18/25, P9’s Pre-Weight was 76.9 kg, 8.4 kg above the ordered target weight of 68.5 kg. After 4,839 mL of fluid was removed, the Post Weight was 72.1 kg. The documented actual UF rate was “17.3 mL/kg/hr,” which is above the ordered maximum rate. On 2/22/25, P9’s Pre-Weight was 74.5 kg, 6.0 kg above the ordered target weight of 68.5 kg. After 3,989 mL of fluid was removed, the Post Weight was 70.7 kg. The documented actual UF rate was “14.3 mL/kg/hr,” which is above the ordered maximum rate. On 3/5/25, P9’s Pre-Weight was 73.8 kg, 5.3 kg above the ordered target weight of 68.5 kg. After 4,471 mL of fluid was removed, the Post Weight was 69.6 kg. The documented actual UF rate was “16.0 mL/kg/hr,” which is above the ordered maximum rate. During an interview on 3/6/25 at 12:40 PM, the above findings were reviewed with Staff (S) 4, the Clinical Coordinator (CC). He/she confirmed P9’s UF rate was above 13 mL/kg/hr. S4 also confirmed that there was no documented evidence of a physician’s order for the patient to receive a UF rate above the maximum of 13 mL/kg/hr for the above dates where the UF rate was above the maximum. Facility Policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024, stated, “ ... 3. Patient identity, prescription and machine settings are verified by teammate prior to the initiation of treatment ... Prescription components include but are not necessarily limited to: ... d. UFR and Max UFR ...” N.J.A.C. 8:43A-24.4(a)”

“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: 49828 Based on medical record review, staff interviews, and review of facility documents, it was determined that the Medical Director failed to ensure that the Early Termination of Treatment Against Medical Advice form is completed for four of nine treatments reviewed for Patient (P) 10. Findings include: A review of P10’s medical record revealed the following: The “Active Treatment Orders” stated, “... Frequency/TX [treatment] time Three times a week, 3hr 0min (180 min [minutes]) ...” On 12/16/24, the “Treatment Details Report” indicated that P10’s initiation of hemodialysis began at 4:10 PM, and that treatment was terminated at 6:33 PM, 37 minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Choice [AMA (against medical advice), feels unwell/cramping, patient behavioral issue].” The medical record lacked documented evidence of a completed Early Termination of Treatment Against Medical Advice form. On 12/20/24, the “Treatment Details Report” indicated that P10’s initiation of hemodialysis began at 3:45 PM, and that treatment was terminated at 5:52 PM, 53 minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Choice [AMA, feels unwell/cramping, patient behavioral issue].” The medical record lacked documented evidence of a completed Early Termination of Treatment Against Medical Advice form. On 12/22/24, the “Treatment Details Report” indicated that P10’s initiation of hemodialysis began at 4:16 PM, and that treatment was terminated at 6:14 PM, one hour and two minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Choice [AMA, feels unwell/cramping, patient behavioral issue].” The medical record lacked documented evidence of a completed Early Termination of Treatment Against Medical Advice form. On 2/24/25, the “Treatment Details Report” indicated that P10’s initiation of hemodialysis began at 4:04 PM and that treatment was terminated at 6:44 PM, 20 minutes earlier than the prescribed treatment time. The “Events and Comments” section of the report stated, “ ... Treatment terminated; pt [patient] requested term tx [termination of treatment] early due to transportation ...” The medical record lacked documented evidence of a completed Early Termination of Treatment Against Medical Advice form. On 3/6/25 at 1:23 PM, Staff (S) 4, the Clinical Coordinator confirmed that if the patient shortens their treatment an Early Termination form should be signed and filed. S4 confirmed that there were no completed Early Termination of Treatment Against Medical Advice forms on 12/16/24, 12/20/24, 12/22/24, and 2/24/25 despite the patient shortening their treatment on those dates. Facility policy and procedure titled, “Prescribed Treatment Time Not Met,” Revised April 2024, stated, “... Policy: A. Completion Of The Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse [RN] will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. ...” N.J.A.C. 8:43A-24.4(a)”