Davita Elmora

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 35949 Based on interviews and review of the facility’s emergency management plan and emergency phone list, it was determined that the facility failed to update staff contact information throughout the year to ensure they maintained current information and failed to review and update the plan at least every two years. Failure to maintain a current contact list limited the facility’s ability to contact their current staff and provide the necessary personnel and additional resources in the event of an emergency and has the potential to impact the safety and well-being of all 55 patients receiving dialysis treatments at the facility . Findings include: A review of the facility’s “Facility Emergency Management Plan,” revised in April 2024, revealed “6. Emergency contact information will be reviewed QUARTERLY and updated as necessary.” The Facility Emergency Management Plan referred to the “Teammate Emergency Contact List.” A review of the facility’s “Teammate Emergency Phone List,” last updated on 10/30/2019, revealed names and contact information for Clinical Nurse Manager (CNM) #15, Licensed Clinical Social Worker (LCSW) #16, Dietician #17, and Administrative Assistant (AA) #18. A review of the “ESRD [end stage renal disease] Core Survey Facility Worksheet: Personnel File,” completed and signed by the Facility Administrator on 04/17/2024, revealed CNM #15, LCSW #16, Dietician #17, and AA #18 were not listed on the document as current facility personnel. During an interview on 04/17/2024 at 11:35 AM, the Facility Administrator confirmed CNM #15, LCSW #16, Dietician #17, and AA #18 were no longer employed at the facility and the list was not updated to reflect the changes. The Facility Administrator confirmed the emergency contact list was not current and/or accurate and had not been updated quarterly as specified by the “Facility Emergency Management Plan.””

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 35949 Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure 3 (Patient Care Technician [PCT] #9, PCT #11, and Registered Nurse [RN] #7) of 6 staff observed during 5 of 6 handwashing opportunities performed hand hygiene prior to applying clean gloves and prior to touching patients or patient care equipment. Failure to properly perform hand hygiene provides a mode for blood borne pathogens to cross contaminate and impact the health and well-being of the 55 patients receiving dialysis treatments at this facility. Findings include: A review of the facility policy titled, “Infection Control for Dialysis Facilities,” revised in April 2023, revealed “Hand Hygiene” included “1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e. [id est, that is], plugging/unplugging acid/bicarb [bicarbonate] lines form [sic] dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” On 04/18/2024 at 9:46 AM, PCT #9 was observed obtaining a pair of gloves and placing the pair of gloves on a computer desk. PCT #9 opened a supply storage drawer, applied the previously obtained pair of gloves, and entered Station 8. PCT #9 then touched the patient. PCT #9 failed to perform hand hygiene before applying a pair of gloves and before touching the patient. On 04/18/2024 at 10:07 AM, PCT #9 was observed opening a supply storage drawer. PCT #9 obtained and applied a pair of gloves, entered Station 14, and touched a dialysis machine. PCT #9 failed to perform hand hygiene before applying a pair of gloves and before touching patient care equipment. During an interview on 04/18/2024 at 3:15 PM, PCT #9 acknowledged he/she was trained and was expected to perform hand hygiene before putting on gloves and before contact with a patient or patient care equipment. On 04/18/2024 at 10:35 AM, PCT #11 was observed opening a supply storage drawer. PCT #11 obtained and applied a pair of gloves, entered Station 9, and touched a dialysis machine. PCT #11 failed to perform hand hygiene before applying a pair of gloves and before touching patient care equipment. During an interview on 04/18/2024 at 3:48 PM, PCT #11 acknowledged he/she was trained and was expected to perform hand hygiene before putting on gloves and before touching patient care equipment. On 04/18/2024 at 10:50 AM, RN #7 was observed obtaining a pair of gloves. RN #7 applied the gloves, entered Station 17, and touched a dialysis machine. RN #7 failed to perform hand hygiene before applying a pair of gloves and before touching patient care equipment. On 04/18/2024 at 11:02 AM, RN #7 was observed obtaining a pair of gloves. RN #7 applied the gloves, entered Station 16, and touched a dialysis machine. RN #7 failed to perform hand hygiene before applying a pair of gloves and before touching patient care equipment. During an interview on 04/18/2024 at 3:45 PM, RN #7 stated that he/she was trained and was expected to perform hand hygiene before applying a pair of gloves and before touching patient care equipment. During an interview on 04/19/2024 at 8:49 AM, Medical Director (MD) #14 confirmed staff should perform proper infection control by performing hand hygiene before applying a pair of gloves and before coming into contact with a patient and before touching patient care equipment. N.J.A.C. 8:43A-24.8(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 review, interview, and policy review, it was determined that the facility failed to follow individualized dialysis prescriptions as prescribed by a medical provider for 3 of 7 sampled patients (Patient #3, #5, and #6). Findings include: A review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in April 2024, 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 informed.” 1. A review of Patient #3’s hemodialysis orders dated 03/22/2024, revealed the patient had a physician prescribed blood flow rate (BFR) of 300 milliliters per minute (mL/min). A review of Patient #3’s “Treatment Details Report,” dated 04/01/2024, revealed the “Intradialytic Vitals Stat Line” section indicated the patient’s BFR was documented at 250 mL/min from 12:27 PM until the treatment was terminated at 1:00 PM. A review of Patient #3’s “Treatment Details Report,” dated 04/03/2024, revealed the “Intradialytic Vitals Stat Line” section indicated the patient’s BFR was documented at 250 mL/min from 12:54 PM until the treatment was terminated at 1:25 PM. There was no documented objective rationale for the change to the prescribed BFR. 2. A review of Patient #5’s physician orders dated 03/12/2024 and a “Patient Summary Report” section named “Active Heparin Order,” dated 04/09/2024, revealed the patient had a prescribed hourly dose of 1000 units (U) of intravenous heparin to stop 60 minutes before the end of treatment. A review of Patient #5’s “Treatment Details Report” revealed a section called “Intradialytic Vitals Stat Line” that noted the following: - On 03/27/2024, the documentation indicated the heparin infusion pump was engaged during the entire treatment; - On 03/29/2024, the documentation indicated the heparin infusion pump continued to be engaged at 7:48 AM, 21 minutes before the treatment was terminated at 8:09 AM; - On 04/05/2024, the documentation indicated the heparin pump continued to be engaged at 7:44 AM, 29 minutes before the treatment was terminated at 8:13 AM; - On 04/08/2024, the documentation indicated the heparin infusion pump continued to be engaged from 8:19 AM through the termination of the treatment at 8:22 AM; - 04/10/2024, the documentation indicated the heparin infusion pump continued to be engaged at 7:45 AM, 30 minutes before the treatment was terminated at 8:15 AM; and - 04/15/2024, the documentation indicated the heparin infusion pump continued to be engaged at 7:52 AM, 30 minutes before the treatment was terminated at 8:22 AM. There was no documented objective rationale for the change to the prescribed heparin hourly dosage stop time. 3. A review of Patient #6’s “Patient Summary Report,” dated 03/26/2024, revealed a physician prescribed blood flow rate (BFR) of 300 milliliters per minute (mL/min) within an “Active Treatment Orders” section. A review of Patient #6’s “Treatment Details Report,” dated 03/30/2024 and 04/13/2024, revealed under “Intradialytic Vitals Stat Line” sections that the patient’s BFR was documented at 350 mL/min during both treatments. There was no documented objective rationale for the change to the prescribed BFR. During an interview on 04/17/2024 at 10:45 AM and after reviewing treatment sheets, the Facility Administrator and Clinical Nurse Manager (CNM) confirmed the patient treatment sheets for Patient #3 and Patient #6 lacked documentation regarding why changes occurred to the patients’ prescribed BFRs and confirmed Patient #5’s sheets lacked documentation regarding hourly heparin infusion dosage stop times. The Facility Administrator and CNM confirmed the staff were trained to follow physician orders and stated there “must be” a documented rationale when the physicians’ prescribed BFRs and/or medication orders were not achieved and/or followed. During an interview on 04/18/2024 at 3:15 PM, Patient Care Technician (PCT) #9 confirmed staff were trained to document a rationale for changes to the prescribed BFR. During an interview on 04/18/2024 at 3:45 PM, Registered Nurse (RN) #7 confirmed staff were trained to document a rationale for changes to the prescribed BFR and medications. During an interview on 04/19/2024 at 8:49 AM, the Medical Director confirmed staff were expected to document reasons for changes to the BFR and medication orders. N.J.A.C. 8:43A-24.4(a)”