Davita Artesia Dialysis

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to appropriately perform hand hygiene during 3 of 8 observations of initiation and discontinuation of hemodialysis treatments. Findings included: The facility’s policy titled, “Infection Control for Dialysis Facilities” revised in 04/2023, revealed, “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.” The facility’s policy titled, “AV Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised in 10/2022, stated, “13. Do not palpate insertion site once area has been prepped. 13. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” The policy revealed, “16. Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation.” During an observation on 07/31/2024 at 9:17 AM, Certified Clinical Hemodialysis Technician (CCHT) #13 was at patient treatment station #6. CCHT #13 donned gloves then touched the dialysis machine. After touching the dialysis machine, CCHT #13 then opened a saline flush and flushed the patient’s arterial line. CCHT #13 failed to perform hand hygiene and change gloves prior to patient contact. During an interview on 07/31/2024 at 2:40 PM, CCHT #13 stated that hand hygiene and glove changes should be done prior to touching the patient. During an observation on 07/31/2024 at 10:31 AM, Patient Care Technician (PCT) #15 was at patient treatment station #12. At 10:37 AM, PCT #15 palpated a patient’s dialysis access site, then applied antiseptic and cannulated the access site. PCT #15 failed to change gloves and perform hand hygiene prior to cannulating the patient. During an interview on 07/31/2024 at 3:06 PM, the Clinical Coordinator stated that the expectation would be to change gloves and perform hand hygiene every time going between the patient and the dialysis machine. During an observation on 08/02/2024 at 8:31 AM, CCHT #12 was at patient treatment station #9. At 8:36 AM, CCHT #12 disinfected a patient’s dialysis access site, applied a tourniquet, palpated the access site, then cannulated the patient’s access site. CCHT #12 failed to perform hand hygiene and change gloves prior to cannulating the patient’s access site. During an interview on 08/02/2024 at 9:06 AM, CCHT #12 confirmed that their process when cannulating a patient is to palpate the dialysis access site, disinfect the skin, apply a tourniquet, palpate the access site again, and then cannulate the access site. During an interview on 08/02/2024 at 10:55 AM, the Medical Director confirmed that gloves should be changed, and hand hygiene performed after touching the dialysis machine and prior to touching the patient as well as prior to cannulation of the patient’s dialysis access site.”

“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: 50873 Based on interview, record review, and facility policy review, the facility failed to provide the necessary care and services to manage the patient’s volume status for 2 (Patient #2 and Patient #4) of 4 hemodialysis patients in the medical record review sample. Findings included: The facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in 04/2024, indicated, “2. The Nursing assessment will be performed and documented by a licensed nurse’ specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment included the following components:” “iii. Verification of prescription including machine parameters.” The policy 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. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR [Ultra filtration rate - the rate of fluid volume removal during dialysis treatment] and Max UFR.” Patient #2’s “Orders 06/30/2024 - 07/30/2024” revealed an order with a start date of 06/24/2024 for a maximum UFR of 13.0 milliliters (mL)/kilograms (kg)/hour (hr). Patient #2’s “Treatment Details Report,” dated 07/19/2024, revealed the patient’s treatment UFR was 14.1 mL/kg/hr. Patient #2’s “Treatment Details Report,” dated 07/22/2024, revealed the patient’s treatment UFR was 13.3 mL/kg/hr. During an interview on 07/30/2024 at 12:30 PM, the Facility Administrator (FA) confirmed that on 07/19/2024 and 07/22/2024 Patient #2’s UFR was greater than 13.0 mL/kg/hr. The FA stated that the facility expectation would be for the patient to be run per the treatment orders, unless there were ancillary orders present. The FA confirmed that there were no such ancillary orders for Patient #2 on 07/19/2024 and 07/22/2024. Patient #4’s “Orders 06/30/2024 - 07/30/2024” revealed an order with a start date of 07/04/2024 for a maximum UFR of 13.0 mL/kg/hr. Patient #4’s “Treatment Details Report,” dated 07/22/2024, revealed the patient’s treatment UFR was 13.1 mL/kg/hr. Patient #4’s “Treatment Details Report,” dated 07/24/2024, revealed the patient’s treatment UFR was 14.2 mL/kg/hr. During an interview on 07/30/2024 at 5:02 PM, the FA confirmed that on 07/22/2024 Patient #2 treatment UFR was 13.1 mL/kg/hr and on 07/24/2024 the patient’s treatment UFR was 14.2 mL/kg/hr. The FA stated the expectation would be that the treatment UFR did not exceed the maximum ordered UFR of 13.0 ml/kg/hr, unless there were an ancillary order. The FA confirmed that there were no provider orders to run the patient above the maximum UFR ordered. During an interview on 08/02/2024 at 10:55 AM, the Medical Director confirmed that the facility expectation would be for patient treatments to be run according to the prescription unless there were ancillary orders placed giving parameters for when it was ok to go outside of the dialysis prescription.”

“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: 50873 Based on interview, record review, and facility policy review, the facility failed to implement the adequacy plan for 2 (Patient #3 and Patient #4) of 4 hemodialysis patients in the review sample. Findings included: The facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in 04/2024, indicated, “2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components:” “iii. Verification of prescription including machine parameters.” The policy 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. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR [Ultra filtration rate - the rate of fluid volume removal during dialysis treatment] and Max UFR e. UF Profiling f. Blood flow rate [BFR] g. Dialysate flow rate [DFR].” The policy revealed, “10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” Patient #3’s “Treatment Details Report,” dated 07/15/2024, revealed a section titled “Dialysis Prescription” that included a transcription of an order for a BFR of 400 milliliters per minute (mL/min). The Treatment Details Report revealed that during treatment on 07/15/2024 the patient’s BFR was documented at 350 mL/min from 4:11 AM until 8:10 AM. During an interview on 07/30/2024 at 3:20 PM, the Facility Administrator (FA) confirmed that Patient #3’s BFR was not run per the patient’s provider orders. The FA stated that there was no documented rationale for deviating from the prescribed BFR. He stated that the expectation would be for the clinic staff to document why the BFR was not run per providers orders. Patient #4’s “Orders 06/30/2024 -07/30/2024” revealed an order with a start date of 07/04/2024 for a DFR of 600 mL/min. Patient #4’s “Treatment Details Report,” dated 07/19/2024, revealed the patient’s DFR was documented at 500 mL/min from 10:45 AM until 11:30 AM and 700 mL/min from 12:00 PM to 2:45 PM. Patient #4’s “Treatment Details Report,” dated 07/24/2024, revealed, the patient’s DFR was documented at 500 mL/min from 10:54 AM until 2:57 PM. During an interview on 07/30/2024 at 5:02 PM, the FA confirmed that Patient #4’s DFR was not run at the ordered DFR of 600 mL/min. The FA stated there was no documented rationale for deviating from the prescribed DFR. He stated that the expectation would be for the patient’s treatment to be run according to the dialysis prescription. During an interview on 08/02/2024 at 10:55 AM, the Medical Director confirmed that the expectation would be for the patient treatments to be run according to the dialysis prescription.”

“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: 50873 Based on interview, facility document review, and facility policy review, the facility failed to trend and analyze quality indicator information. This had the potential to affect all patients who received care at the facility. Findings included: The facility’s policy titled, “Continuous Quality Improvement Program,” revised in 04/2021, revealed, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following:” “Mortality - review of deaths.” The facility’s mortality charts for the timeframe from 07/2023 through 06/2024 revealed that the facility had a total of eight patient deaths. The charts showed that six of those deaths were attributed to cardiac causes and two were patients who had been receiving dialysis treatments for less than 90 days. During an interview on 08/01/2024 at 2:25 PM, the Facility Administrator (FA) stated that no trends in causes of mortality had been identified. He confirmed that the mortality charts showed that six out of eight causes of mortality were cardiac in nature. He stated no performance improvement strategies have been implemented to address the clinic’s patient mortality rate. The FA stated no focused review of aspects of care were conducted due to the lack of identified trends in patient deaths. The FA stated that during weekly interdisciplinary team (IDT) meetings, after a patient’s death there was a discussion of the patient’s recent hospitalizations, infections, and adequacy but those conversations were not documented. During an interview on 08/02/2024 at 10:55 AM, the Medical Director confirmed that it was not the practice at the clinic to do an analysis of patient deaths and stated that the clinic should begin that practice. During interview on 08/02/2024 at 12:45 PM, the Clinical Coordinator confirmed that there was no policy, procedure, or other facility documentation addressing how to perform a mortality review.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 50873 Based on observation and interview, the facility failed to safeguard patient records from unauthorized use. This had the potential to affect all patients who received care at the facility. Findings included: During an observation on 07/29/2024 at 11:42 AM an emergency binder with patient information was located on a shelf behind the nurses’ station. The nurses’ station was open to the clinic floor without doors to prevent access to the binders once on the treatment floor. During an interview on 07/29/2024 at 1:20 PM, the Clinical Coordinator (CC) confirmed that patient information was in a binder on a shelf in the nurses’ station and it was a concern that the information was store unsecured at the nurses’ station. He stated that usually clinical staff would be present in the treatment area during times when non-clinical persons would be in the clinic but admitted that at times the housekeeping staff might be in the clinic without clinical staff being present. A facility policy addressing the storage for patients’ health information was requested at the time of the interview but was not provided. During an observation on 08/02/2024 at 9:23 AM, with the CC, revealed that the emergency contact binder contained 34 patient records. The CC confirmed that no entries had been added or removed since the binder was observed at the nurses’ station on 07/29/2024. The CC stated that there were a couple of patient records above the facility census due to pending patients and visiting patient records that were included in the binder. During an interview on 08/02/2024 at 10:55 AM, the Medical Director confirmed that the expectation would be that patient information should be kept secure.”