Dialysis Clinic Inc. Hawthorne

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22676 Based on document review, interview, policy review, and review of manufacturer’s instructions, the facility failed to follow glucometer manufacturer’s instruction regarding ensuring the glucometers were in the recommended control range for one of one glucometer used in the facility. This had the potential to provide inaccurate glucose results that could result in mistreated blood glucose levels to all 70 patients receiving care at the facility. Findings include: Review of the “Embrace Pro blood glucose monitoring system manufactures instruction” dated 09/2020 indicated the glucose control should be between 86-116 and if the “test falls outside the range printed on the test strip vial, repeat the test ...” Review of “Blood Glucose Logs” provided by the Nurse Manager for glucometer (EE20IA02639 meter number) from 05/01/24 through 06/10/24 revealed: On 05/01/24 the glucose control was 119. On 05/02/24 the glucose control was 117. On 05/03/24 the glucose control was 118. On 05/04/24 the glucose control was 121. On 05/06/24 the glucose control was 130. On 05/07/24 the glucose control was 118. On 05/08/24 the glucose control was 128. On 05/09/24 the glucose control was 126. On 05/10/24 the glucose control was 131. On 05/11/24 the glucose control was 119. On 05/13/24 the glucose control was 132. On 05/14/24 the glucose control was 119. On 05/15/24 the glucose control was 121. On 05/16/24 the glucose control was 126. On 05/17/24 the glucose control was 123. On 05/2124 the glucose control was 128. On 05/22/24 the glucose control was 119. On 05/23/24 the glucose control was 131. On 05/24/24 the glucose control was 136. On 05/25/24 the glucose control was 132. On 05/27/24 the glucose control was 129. On 05/28/24 the glucose control was 126. On 05/29/24 the glucose control was 121. On 05/30/24 the glucose control was 123. On 05/31/24 the glucose control was 131. On 06/04/24 the glucose control was 121. On 06/06/24 the glucose control was 128. On 06/08/24 the glucose control was 120. There was no documented evidence the staff repeated the low control level calibration. During an interview on 06/10/24 at 2:30 PM, the Acting Nurse Manager confirmed that there was no documentation that staff repeated the calibration of the abnormal low control testing level. Review of the facility’s policy titled, “Embrace Pro Glucose Monitor” dated 11/14/23 indicated, “If test results does not fall into the range on the vial, repeat the test ...””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 22676 Based on record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for two of seven sampled in-center patients (Patient (P) 4, and P8). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the all 70 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P4’s electronic medical record (EMR) revealed a prescribed Blood Flow (BFR) rate of 350 milliliters per min (ml/min). The prescribed blood flow rate was included on each daily flow record. Review of three of six “Post Treatment” flowsheets from 05/27/24 through 06/10/24, in the EMR indicated the following: On 05/31/24, the BFR was documented at 300 ml/min from 8:11 AM through the end of treatment at 10:44 AM. On 06/07/24, the BFR was documented at 300 ml/min from 7:48 AM through the end of treatment at 10:47 AM. On 06/10/24, the BFR was documented at 300 ml/min from 7:40 AM through the end of treatment at 10:48 AM. There was no documented rationale for the change to the prescribed BFR. 2. Review of P8’s EMR revealed a prescribed BFR of 400 m/min. The prescribed rate was electronically applied to the top of the electronic record. Review of six of six “Post Treatment” flowsheets from 05/27/24 through 06/07/24, in the EMR indicated the following: On 05/27/24, the BFR was documented at 350 ml/min from 2:16 PM through the end of treatment at 3:46 PM. On 05/29/24, the BFR was documented at 300 ml/min from 1:03 PM through the end of treatment at 3:29 PM. On 05/31/24, the BFR was documented at 280 ml/min from 12:59 PM through the end of treatment at 2:59 PM. On 06/03/24, the BFR was documented at 300 ml/min from 12:59 PM through the end of treatment at 3:40 PM. On 06/05/24, the BFR was documented at 350 ml/min from 2:26 PM through the end of treatment at 3:31 PM. On 06/07/24, the BFR was documented at 320 ml/min from 1:02 PM through the end of treatment at 3:32 PM. There was no documented rationale for the change to the prescribed BFR During an interview on 06/11/24 at 2:30 PM, the Acting Nurse Manager confirmed the above findings and confirmed that staff did not follow the facility’s policy. Review of the facility’s policy titled, “ Problems The Charge Nurse Should Be Notified Of PRE, MID OR POST Dialysis” dated 01/18/24 revealed, “the inability to reach the prescribed BFR ...””