Davita North Plainfield

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 35949 Based on observation, interview, and policy review, it was determined that the facility failed to label as “isolation” all equipment and supplies dedicated for use in 1 of 1 isolation room. Failure to label as “isolation” all equipment and supplies dedicated for use during treatment of patients who receive dialysis that require isolation for bloodborne pathogens have the potential to provide a mode of cross contamination and negatively impact the safety and wellbeing of the 52 patients who received dialysis treatments at the facility. Findings include: Review of the facility policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” revised in April 2024, revealed, “Such supplies will be labeled “isolation” and will remain in the isolation room/area or station and be disinfected after every patient use with a 1:100 (one to one hundred) bleach solution.” During a concurrent interview and observation of the designated isolation room on 04/11/2024 at 2:45 PM with Registered Nurse (RN) #4, revealed the following unlabeled equipment and supplies: one sharps container, one biohazard bin, two personal protective equipment face shields, and one oxygen concentrator machine. RN #4 confirmed the listed items located in the designated isolation room were not labeled as “isolation.” RN #4 stated the current process utilized in the facility was to place a blank piece of red tape on all the equipment and supplies dedicated for use in the isolation room. During an interview on 04/11/2024 at 2:50 PM, the Facility Administrator confirmed the listed items located in the designated isolation room were not labeled as “isolation.” The Facility Administrator stated the current process utilized in the facility was to place a blank piece of red tape on all the equipment and supplies dedicated for use in the isolation room and the process currently used was not per the facility’s policy. N.J.A.C 8:43A-24.4(b)”

“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: 35949 Based on record reviews, interviews, and policy review, it was determined that the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 3 of 7 sampled patients (Patients #2, #5, and #7). Failure to follow the medical providers’ dialysis prescription has the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 52 patients who received dialysis treatments at the facility. Findings include: Review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in October 2023, revealed, “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment.” Further review of the policy revealed, “10. If the dialysis prescription is not being met (including dialysis flow rate or change/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse notified.” 1. Review of Patient #2’s “Patient Summary Report,” section titled “Active Treatment Orders,” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) dated 03/06/2024. Review of Patient #2’s “Treatment Details Report,” dated 03/25/2024, revealed evidence to indicate the patient’s BFR was documented between 270 mL/min and 320 mL/min from 7:46 AM until the treatment was terminated at 9:16 AM. There was no documented objective rationale for the change to the prescribed BFR. Review of Patient #2’s “Treatment Details Report,” dated 03/27/2024, revealed evidence to indicate the patient’s BFR was documented at 300 mL/min from 8:29 AM until the treatment was terminated at 9:44 AM. There was no documented objective rationale for the change to the prescribed BFR. 2. Review of Patient #5’s “Treatment Details Report,” section titled “Dialysis Prescription,” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) dated 03/20/2024. Review Patient #5’s “Treatment Details Report,” dated 03/22/2024, revealed evidence to indicate the patient’s BFR was documented at 300 mL/min from 12:14 PM until the treatment was terminated at 2:17 PM There was no documented objective rationale for the change to the prescribed BFR. Review of Patient #5’s “Treatment Details Report,” dated 03/25/2024, revealed evidence to indicate the patient’s BFR was documented between 300 mL/min and 310 mL/min from 12:26 PM until the treatment was terminated at 1:57 PM. There was no documented objective rationale for the change to the prescribed BFR. Review of Patient #5’s “Treatment Details Report,” dated 03/27/2024, revealed evidence to indicate the patient’s BFR was documented between 250 mL/min and 300 mL/min from 11:31 AM until 1:01 PM. There was no documented objective rationale for the change to the prescribed BFR. 3. Review of Patient #7’s “Treatment Details Report,” section titled “Dialysis Prescription,” revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min) and a prescribed dialysate flow rate (DFR) of 800 mL/min dated 03/13/2024. Review of Patient #7’s “Treatment Details Report,” dated 03/19/2024, revealed evidence to indicate the patient’s BFR was documented between 290 mL/min and 350 mL/min from 10:36 AM until 11:45 AM. There was no documented objective rationale for the change to the prescribed BFR and DFR. Review of Patient #7’s “Treatment Details Report,” dated 03/23/2024, revealed evidence to indicate the patient’s DFR was documented at 500 mL/min during the entire treatment. There was no documented objective rationale for the change to the prescribed BFR and DFR. Review of Patient #7’s “Treatment Details Report,” dated 04/02/2024, revealed evidence to indicate the patient’s BFR was documented at 300 mL/min from 10:50 AM until 11:20 AM and between 300 mL/min and 350 mL/min from 12:22 PM until the treatment was terminated at 1:51 PM. There was no documented objective rationale for the change to the prescribed BFR and DFR. Review of Patient #7’s “Treatment Details Report,” dated 04/04/2024, revealed evidence to indicate the patient’s BFR was documented at 350 mL/min from 12:50 PM until the treatment was terminated at 2:20 PM. There was no documented objective rationale for the change to the prescribed BFR and DFR. Review of Patient #7’s “Treatment Details Report,” dated 04/06/2024, revealed evidence to indicate the patient’s DFR was documented between 500 mL/min and 510 mL/min from 10:33 AM until the treatment was terminated at 2:07 PM. There was no documented objective rationale for the change to the prescribed BFR and DFR. During an interview on 04/11/2024 at 9:15 AM, the Facility Administrator confirmed the treatment sheets were reviewed and lacked documentation regarding why changes occurred to the patients’ prescribed BFRs and DFRs. The Facility Administrator confirmed the staff were trained and expected to document a rationale when the physicians’ prescribed BFRs and/or DFRs were not achieved. During an interview on 04/12/2024 at 12:36 PM, Registered Nurse #4 confirmed staff were trained to document a rationale for changes to the prescribed BFR and/or DFR. During an interview on 04/12/2024 at 1:05 PM, Patient Care Technician #8 confirmed staff were trained to document a rationale for changes to the prescribed BFR and/or DFR. During an interview on 04/12/2024 at 2:19 PM, the Medical Director stated the BFR was changed for a variety of reasons, but they were not aware the facility’s policy required documentation of a rationale. N.J.A.C. 8:43A-24.4(a)”