Davita Rose Rock Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 34696 Based on record review, interview, and policy review, the facility failed to provide emergency training to 52 of 58 in-center hemodialysis and nocturnal dialysis patients (Patients #1 to #22, #24, #26 to #50, #52, and #53) according to the policy. Findings included: A review of “The EMP (Facility Emergency Management Plan) (ICHD (In-center hemodialysis), Home)” indicated, “Authority and responsibility...The leadership...of the...dialysis facility (defined under this plan chronic in-center, peritoneal, and home hemodialysis) includes...Medical Director...FA (Facility Administrator)...Clinical Nurse Manager...The leadership team is committed to...adhere to policies, execute plans, and follow procedures developed to support the program...The facility shall comply with all federal, state, and local requirements...The FA ...is responsible for...implementation, adherence and training...Training and Education...The FA or designee is responsible to provide training of EMP...Patients...Annually...Facility specific emergency response procedures...Quarterly...Fire Safety Preparedness.” A review of the “Dialysis Emergency Procedure” checklist indicated, “Teammate to complete while instructing the patient...Evaluation of activities...Is patient able to comprehend the meaning of an emergency?...Is patient able to demonstrate clamping and disconnecting the hemodialysis lines? (Note...Many patient will not be able to complete this task)...Is patient willing to perform the clamp and disconnect emergency procedure?...Is patient able to exit treatment area without assistance?...Is patient able to tell you where the emergency exits and designated reassemble area are.” A review of the medical records for Patients #1 through #5, #19 indicated there was no documented evidence of the emergency preparedness training. During an interview on 11/20/2023 at 1:30 PM, the Facility Administrator (FA, Personnel #1) said there was no documented evidence of quarterly emergency preparedness education and/or training in the first, second, and third quarters of 2023 for pre-existing patients admitted to the facility. She said it was delegated it to the patient care technicians, but they forgot to do it.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 34696 Based on observation, interview, and record review, the facility was not maintained to ensure the safety of the patients, staff, and the public in one of five areas (lobby restroom). Findings included: The “Physical Environment” policy revision date 04/2018 indicated, “The building in which dialysis services are furnished will be constructed and maintained for all safety of the patients, the teammates, and the public... Teammates will be able to visualize patients at all times during hemodialysis treatments for patient safety...systems to ensure patient safety will be in place, such as a method for patients to call for help from restrooms.” On 11/20/2023, the following was observed: At 11:05 AM, during a tour of the facility with the Facility Administrator (FA, Personnel #1), it was observed that the cord used to call for help in the lobby restroom was wrapped around the handicap rail. The FA pulled the end of cord . The calling system would not engage. At th time of the findings, the FA said the cord should not have been wrapped around the rail. At 11:15 AM, Patient #1 was observed dialyzing in the isolation room at station #9. Patient #1’s face was covered with a hood. Patient #1 was not visible to the staff. At the time of the findings, the Charge Nurse (CN, Personnel #2) said Patient #1 refuses to uncover his face. The CN said there was no documented evidence of Patient #1’s refusal to uncover his face and/or education provided to Patient #1 to keep his face uncovered.”

“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: 34696 Based on observation and interview, the facility failed to implement and maintain a program to ensure that all equipment was maintained citing one of one area (hemodialysis treatment area). Findings included: On 11/20/2023 the following was observed: At 11:15 AM, it was observed in the hemodialysis treatment area that the tan vinyl covering on the treatment chairs at stations #1, #2, and #4 were stained black on the head and back rests. At the time of the findings, the Facility Administrator (FA, Personnel #1) said new parts had been ordered. The FA said the facility had protective coverings for the damaged chairs. The coverings were not observed on the chairs during the patient’s treatments.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34696 Based on record review and interview, the Interdisciplinary Team (IDT) failed to ensure one of five patients (Patients #1) had their high pre, intra, and post blood pressures (BP) assessed by an RN (Registered Nurse). Findings included: A review of the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy revision date 10/2023 indicated, “The Nursing assessment will be performed and documented by a licensed nurse, specifically an RN...This assessment included the following components...Review of patient reports, data collection...A physical assessment of the patient which includes...Evaluation of the volume status including edema...The prescription components are confirmed by a licensed nurse within one hour of treatment initiation along with the nursing assessment...Prescription components include but not necessarily limited to...target weight...blood flow rate (BFR)...The licensed nurse will use his or her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non -physician practitioner if applicable will be notified of any concerns that may preclude the initiation of dialysis...Intradialytic Data Collection / Assessment...If the dialysis prescription is not being met (including dialysis flow rate or change to or inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...abnormal findings or findings outside of any patient specific physician ordered parameters will reported to the licensed nurse immedidatly...The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status...All findings, interventions and patient response will be determined in the patent’s medical record...Additional documentation if applicable includes the following ...all medications including time administered, dose, route, and initials of person administering the medication...Indication and patient response to as needed (PRN) medication...Post Treatment Data Collection / Assessment...If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or mortification of physician (or NPP as applicable) if necessary prior to discharge of the patient from the facility...Abnormal findings...Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting Minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Blood pressure...Pre-dialysis...Systolic greater than 180 Millimeter of mercury (mmHg) or land 90 mmHg...Diastolic greater than or equal to 100 mmHg...Blood pressure- Intradialytic...Difference of 20 mmHg increase or decrease from patient’s last intradialytic treatment BP reading...If patient is not able to stand, document reason and sitting BP...Sitting BP for patient’s that cannot stand...Sitting systolic BP greater than 140 mmHg or less than 90 mmHg...sitting diastolic BP greater than 90 mmHg or less than 50 mmHg.” 1. Patient #1: The hemodialysis treatment record dated 10/26/2023 indicated the high pre-treatment sitting BP was 202/111. There was no documented evidence the RN was notified of the high BP prior to the start of the treatment. Patient #1’s high intradialytic systolic BPs ranged from 196 to 222. The high intradialytic diastolic BPs ranged from 113 to 177. Clonidine was administered. there was no documented evidence the RN completed a follow up assessment for the effectiveness of the Clonidine. There was no documented evidence the physician was notified of Patient #1’s high BPs. The hemodialysis treatment record dated 10/31/2023 indicated the high pre-treatment sitting BP was 212/139. There was no documented evidence the RN was notified of the high BP prior to the start of the treatment. Patient #1’s high intradialytic systolic BPs ranged from 184 to 201. The high intradialytic diastolic BPs ranged from 104 to 127. There was no documented evidence the physician was notified of Patient #1’s high BPs. The hemodialysis treatment record dated 11/14/2023 indicated the high pre-treatment sitting BP was 187/113. There was no documented evidence the RN was notified of the high BP prior to the start of the treatment. Patient #1’s high intradialytic systolic BPs ranged from 187 to 215. The high intradialytic diastolic BPs ranged from 104 to 207. There was no documented evidence the RN was notified to conduct an intradialytic assessment of Patient #1 high BPs. On 11/21/2023 at 10:30 AM, the Facility Administrator (FA, Personnel #1) said if a patient’s pre-treatment BP was 180/100, and the heart rate less than 120, then the patient’s treatment can be initiated. The FA said the Patient Care Technician should notify the RN prior to the initiation of the patient’s treatment so that an assessment maybe conducted. The FA said the RN should assess the effectiveness of PRN medications 30 minutes after administration.”