Davita Las Cruces Renal at Home

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 28297 Based on interview, review of the facility’s “Dialysis Facility Report,” facility document review, and policy review the facility failed to identify the high mortality rate, failed to investigate the high mortality rate, and failed to implement performance improvement strategies to address the high mortality ratio. The failure to identify, investigate and implement strategies for high mortality ratio created missed opportunities for performance improvement to decrease deaths in the facility. Findings include: Review of the “Dialysis Facility Report,” for fiscal year 2024 revealed the following: “At this facility, the 2019-2022 Standard Mortality Rate (SMR) is 1.49, which is 49% more deaths than expected at this facility. Among all U.S. facilities, 94% of facilities had a four-year SMR lower than 1.49. This difference is statistically significant (p<0.05), so this higher mortality is unlikely to be due to random chance and probably represents a real difference from the expected mortality in the nation. The 2019-2022 SMR of observed to expected deaths is 0.97 and 0.97 for your State and Network, respectively. At this facility, the 2019-2021 first-year SMR of observed to expected deaths is 2.74, which is 174% more deaths than expected at this facility. Among all U.S. facilities, 98% of facilities had a first-year SMR lower than 2.74. This difference is statistically significant (p<0.05), so this higher mortality is unlikely to be due to random chance and probably represents a real difference from the expected mortality in the nation. The first-year SMR (2019-2021) of observed to expected deaths is 1.11 and 1.02 for your State and Network, respectively ...” Continued review of the “Dialysis Facility Report” under the section Mortality Summary for All Dialysis Patients (2019-22) & New Dialysis Patients (2019- 2021) revealed for 2022 57.1 % of patient reported withdrew from dialysis.” Review of the list of patient deaths, provided by the Facility Administrator, from September 2023 until August 2024 revealed the list included 12 patient deaths. Review of the “Facility Health Report (FHR),” (Computer program the facility uses for Quality Assessment and Performance Improvement) from September 2023 until August 2024, revealed deaths were included however there were no comments documented that indicated the facility did an investigation into any of the reported deaths. During an interview on 08/28/24 at 1:15 PM the Facility Administrator confirmed there were no comments, no investigation, and no action plan to mitigate patient deaths on the FHR. He/she stated most of the patient who were on the list of deaths had stopped dialysis prior to their death as their own personal choice. Review of the facility’s policy titled, “Continuous Quality Improvement Program,” revised April 2021, indicated, “. . .Facility Administrators (FAs) conduct periodic “Facility Heath Meetings (FHM) (also know as QAPI in the CMS Conditions for Coverage) with the CQI Committee to review issues and indicators regarding facility’s management and performance. FHM’s are conducted monthly ...The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following. . .Mortality- review of deaths ...Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained. . .””

“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: 28297 Based on interview, medical record review, and policy review, the facility failed to ensure that one of three home hemodialysis (HHD) patients (Patient (P)2) had a dialysis order to support the current treatment and included required criteria based on the facility policy. The failure to have an appropriate dialysis prescription that included requirements of the facility policy had the potential for adverse events that may go undetected and could affect one of three home hemodialysis patients. Findings include: Review of the medical record face sheet provided by the facility for P2 revealed the facility admitted the patient on 01/12/15 with diagnosis including end stage renal disease (ESRD). Review of the dialysis prescription provided by the facility revealed the current home hemodialysis prescription, dated 11/24/23, indicated, “Use the NXStage dialysis machine (a portable machine used to do hemodialysis in the home) four times a week for six hour each treatment. The dialysate bath was one potassium, three calcium, and 45 lactate.” P2 uses an arteriovenous graft (a plastic tube inserted under the skin that connects the vein to the artery). Under the section treated at night the answer was no and treated solo (meaning the patient can do dialysis without a care partner) was no. P2’s target weight was 133.0 kilograms. The maximum ultrafiltration rate was 13 milliliters/kilogram/hour. There is no indication from the dialysis prescription that P2 is on “Nocturnal” home hemodialysis treatments. Review of the 24 “HHD Nocturnal Flow Sheets,” provided by the facility from 06/16/24-08/14/24, for P2 revealed the patient started all treatments after 12 midnight and the treatments were not complete until anywhere from 6:30 AM to 8:45 AM. 20 of 24 flowsheets reviewed revealed the patient ran greater than the 6-hour prescription time. P2 only completed blood pressures at the beginning of the treatment, 15 minutes later and then at the end of the dialysis treatment. There was no doctors order that specified how often the patient was required to check their blood pressure during treatment as required. There was no indication the patient had a vascular access leak detection device or a NxStage Fluid Detection system during the 24 of 24 dialysis treatments as required for nocturnal home hemodialysis. Continued review of the dialysis flowsheets revealed the patients ending blood pressures were low for 10 of 24 dialysis flowsheets as follows: 06/16/24-post sitting blood pressure 88/49 with a standing of 73/50; 06/18/24 sitting blood pressure 87/50 with a standing of 76/40; 06/21/24 sitting blood pressure 97/55 and standing 68/47; 06/29/24 sitting 85/54 and standing 69/46; 07/02/24 sitting 114/62 and standing 83/49; 07/13/24 sitting 94/48 and standing 81/47; 07/15/24 sitting 109/59 and standing 87/56; 07/29/24 sitting 114/62 and standing 88/56; 08/03/24 sitting 109/63 and standing 81/54; 08/14/24 sitting 103/58 and standing 64/46. Review of the “Physician Encounter Notes (Medical Director),” dated 08/16/24 revealed the Physician documented to instruct the patient to do dialysis four days per week HHD and to only remove four liters of fluid. There is no documentation that the patient is on “Nocturnal Home Hemodialysis”. During an interview on 08/27/24 at 12:30 PM the Home Hemodialysis Nurse confirmed that P2 was on “Nocturnal Home Hemodialysis” and that blood pressures were only required at the beginning of the treatment, 15 minutes later and at the end of the treatment. He/she confirmed that the patient was non-compliant and only does the treatment three days a week and runs longer than ordered and removes more fluid than was ordered and that he/she had educated the patient on not following the dialysis prescription per the doctors’ encounter notes. He/she was not aware of the specific requirements per facility policy for patients to be on Nocturnal Home Hemodialysis. During an interview on 08/28/24 at 11:45 AM P2 confirmed he/she was on nocturnal home hemodialysis and completes all treatments at night while he/she sleeps. P2 confirmed the wife was trained and helps if he/she needed. P2 stated he/she was a difficult patient and did not do the dialysis prescriptions as ordered, and the facility staff had educated him/her about fluid removal and time. During a phone interview on 08/28/24 at 1:10 PM P2’s Physician (Medical Director) confirmed that P2 was on “Nocturnal Home Hemodialysis” and thought the facility was following the facility policies and procedure to complete the treatment. He/she was not aware of the specific requirement of a physician order for blood pressure monitoring, NxStage fluid detection system and vascular access leak detection. During an interview on 08/28/24 at 1:15 PM the Facility Administrator was aware there was a Home Hemodialysis patient on Nocturnal Home Hemodialysis however he/she was not aware of the specific requirements listed in the policy including a Physician order for blood pressure frequency, fluid detection monitoring and vascular access leak detection device. Review of the facility’s policy titled, “Home Nocturnal Hemodialysis using the NxStage System One, effective March 2016, indicated, “. . .The Physician prescription will include Initial loading dose, a patient specific rate for continuous infusion, the maximum amount of heparin to be infused, ...Vital sign frequency. When using the NxStage System one, the NxStage Fluid Detection system is required during nocturnal therapy to detect leaks from the cartridge or cycler,. . .a vascular access leak detection device will be utilized for nocturnal dialysis therapy. . .””