Davita Four Rivers Dialysis Center

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 31224 Based on interview and observation, it was determined that the water purification and storage system was not secured or restricted to prevent access by unauthorized users. Findings: Observation of the facility on 05/20/2025 beginning at 0935 revealed the door to access the water purification system had the same door lock code as the other interior doors of the facility. During interview with the FA and MCS on 05/20/2025 at approximately 1500, the above observation was confirmed.”

“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: 31224 Based on interview and the review of documentation, it was determined that the facility failed to ensure that all equipment was maintained and operated in accordance with the manufactures’ recommendations. Findings: Review of the facility’s “Oxygen Concentrator Filter Cleaning Log (as required by manufacturer)” revealed: * The designated cleaning frequency specified by manufacturer instructions was “weekly.” * For 2025, one weekly filter cleaning was documented on 01/02/2025 for 7 of 7 oxygen concentrators. No other weekly filter cleanings were documented. During interview on 05/20/2025 at 1415, the MCS confirmed the above findings.”

“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: 31224 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis treatment and monitoring for 4 of 4 ICHD patients (Patient #s 1-4). Findings: Patient #1 Review of Patient #1’s Treatment Details Reports dated 04/19/2025 through 05/17/2025 (13 treatments) revealed the patient’s VS, visualization and access checks were late during 8 of 13 treatments. Examples include, but are not limited to: * On 04/24/2025, the PCT documented a VS and access check at 0632. The next VS and access check was documented at 0741, 69 minutes later. After 0741, the next VS and access check was documented at 0943, 122 minutes. * On 05/06/2025, the PCT documented a VS and access check at 0812. The next VS and access check was documented at 0904, 51 minutes later. * Similar findings were noted on 04/19/2025, 04/26/2025, 04/29/2025, 05/01/2025, 05/03/2025, and 05/15/2025. Patient #2 Review of Patient #2’s Treatment Details Reports dated 04/21/2025 through 05/19/2025 (13 treatments) revealed the patient’s VS, visualization and access checks were late during 5 of 13 treatments. Examples include, but are not limited to: * On 04/28/2025, a PCT documented a VS and access check at 1310. The next VS and access check was documented at 1440, 80 minutes later. *Similar findings were noted on 04/21/2025, 04/30/2025, 05/09/2025 and 05/19/2025. Patient #3 Review of Patient #3’s Treatment Details Reports dated 04/21/2025 through 05/19/2025 (13 treatments) revealed the patient’s VS, visualization and access checks were late during 11 of 13 treatments. Examples include, but are not limited to: * On 04/25/2025, the PCT documented a VS and access check at 0935. The next VS and access check was documented at 1219, 164 minutes later. * On 05/09/2025, the PCT documented a VS and access check at 0908. The next VS and access check was documented at 1017, 69 minutes later. After 1017, the next VS and access check was documented at 1107, 49 minutes later. * Similar findings were noted on 04/21/2025, 04/28/2025, 04/30/2025, 05/02/2025, 05/05/2025, 05/07/2025, 05/14/2025, 05/16/2025, and 05/19/2025. Patient #4 Review of Patient #4’s Treatment Details Reports dated 04/19/2025 through 05/17/2025 (13 treatments) revealed the patient’s VS, visualization and access checks were late during 8 of 13 treatments. Examples include, but are not limited to: * On 04/24/2025, the PCT documented a VS and access check at 1224. The next VS and access check was documented at 1614, 230 minutes later. At 1614, the PCT documented that treatment was terminated. Staff failed to document VS and access checks throughout the entire treatment. * On 05/08/2025, the PCT documented a VS and access check at 0810. The next VS and access check was at 0919, 69 minutes later. At 1009, the PCT documented a VS and access check. The next VS and access check was documented at 1116, 67 minutes later. * Similar findings were noted on 04/22/2025, 04/25/2025, 04/28/2025, 05/10/2025, 05/15/2025 and 05/17/2025. Review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of April 2024, stipulated, * “Vital signs and treatment monitoring...are completed at least every thirty (30) minutes.” * “At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures iv. Fluid removal and/or replacement v. Vascular access visible and line connections intact. vi. Patient subjective statement(s) i.e. patient report on overall health, any complaints.” * “The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment.” During an interview on 05/21/2025 at 1040, the MCS confirmed the above findings.”