Davita Grants Pass II Dialysis

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47148 Based on observations and facility document review, it was determined that the facility failed to ensure that medications were prepared and stored correctly. Findings: Observation of a medication preparation area on 07/23/2024 at 0930 revealed the following: - A MDV of Heparin Sodium Injection 30,000 units per 30 mL was open without a label to indicate when it had been opened or who had opened the vial. - 14 syringes labeled with preprinted patient labels indicating “Heparin.” The labels on the syringes lacked the time and the preparer’s initials. - Several labeled syringes noted were for patients scheduled on this date; however the patients had not yet arrived at the facility for their treatment. Review of facility policy titled “Medication Policy,” dated October 2023, stipulated: * “Medication preparation should be performed only for the current shift of patients, i.e. do not prepare medications for more than one shift of patients.” * “If the medication is not immediately administered ... the medication must be labeled with the patient name, name of the medication, date, time prepared, dose and initials of teammate preparing the medication.” * “Label any open multi-dose vial that is not used immediately and store vial accordingly.” During an interview on 07/23/2024 at 1530, the FA and SMCS confirmed the above findings.”

“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 observation, it was determined that the water purification and storage system were not secured or restricted to prevent access by unauthorized users. Findings: Observation of the facility on 07/23/2024 beginning at 0850 revealed the water purification and storage system was located in a space within the supply room. The supply area had an entrance door off of a general access hallway and had a keyless entry lock which utilized a security door code. This door code was the same code for all other secured areas and could be entered by anyone with the door code, including those not trained in water monitoring and maintenance. During interview on 07/23/2024 at 0850, an AA reported the security door code was the same for all doors in the dialysis facility, including for the water purification and storage system room. During interview on 07/23/2024 at 1550, the FA confirmed the door code was the same and that unauthorized individuals could access this equipment.”

“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 monitoring or that the dialysis prescription was followed for 6 of 6 patients (Patients #s 1-6). Findings: 1. Review of patient treatment flowsheets reflected VS and safety checks were missed and/or abnormal findings were not reported to the RN. For example: * Review of Patient #2’s dialysis orders and treatment sheets dated 06/24/2024 through 07/22/2024 (13 hemodialysis treatments) reflected the following: - On 07/15/2024, the PCT documented a VS and access check at 1229. The next VS and access check was documented 94 minutes later at 1403. - On 07/22/2024, the PCT documented a VS and access check at 1339. The next VS and access check was documented 54 minutes later at 1433. - Similar findings were noted on 06/28/2024, 07/10/2024, and 07/12/2024. * Review of Patient #4’s treatment sheets dated 06/25/2024 through 07/20/2024 (13 hemodialysis treatments) reflected the following: - On 06/27/2024, the RN documented a VS and access check at 0840. A PCT documented the next VS and access check 44 minutes later at 0924. The next VS and access check was then documented 51 minutes later at 1015. - On 06/29/2024, the PCT documented a VS and access check at 1121. The RN documented the next VS and access check 57 minutes later at 1218. The RN documented a VS and access check at 1222, a PCT documented the next VS and access check 44 minutes later at 1306. A recheck was documented at 1307, however the next VS and access check was documented by a PCT 73 minutes later at 1420. - Similar findings were noted on 07/02/2024, 07/03/2024, 07/04/2024, 07/06/2024, 07/09/2024, 07/11/2024, 07/16/2024, 07/18/2024, and 07/20/2024. - On 07/11/2024 at 1238, three BP measurements were taken in short succession and read 118/97, 92/50, and 80/62 mm/Hg. At 1256, another PCT documented, “bp low pt offers no [complaints]; will monitor.” at 1302, two BP measurements were taken and read 76/51 and 101/46 mm/Hg after readjustment. At 1303, a PCT documented, “bp improving; uf paused to help support bp.” At 1332, two BP measurements were taken and read 65/46 and 87/41 mm/Hg, where the PCT documented, “ bp trending back down; pt alert.” The last BP measurement by the PCT was at 1400 and read 113/86 mm/Hg. At no point during this treatment did a PCT document notifying the RN of the low BP measurements, nor did the RN document they were aware. - Similar findings were noted on 07/16/2024 and 07/18/2024. 5. Review of Patient #5’s dialysis orders and treatment sheets dated 04/24/2024 through 07/15/2024 (13 hemodialysis treatments) reflected the following: - On 04/24/2024, the PCT documented a VS and access check at 0932. The next VS and access check was documented 73 minutes later at 1045. - On 07/12/2024, the PCT documented a VS and access check at 0948. The next VS and access check was documented 58 minutes later at 1046. - On 07/12/2024, the PCT documented a VS and access check at 1135. The next VS and access check was documented 55 minutes later at 1240. - On 07/12/2024, the PCT documented a VS and access check at 1240. The next VS and access check was documented 70 minutes later at 1350. - Similar findings were noted on 05/06/2024, 05/17/2024 and 05/24/2024. * Similar findings were noted for Patient #s 1, 3, and 6. 2. Review of patient treatment flowsheets reflected the BFR was adjusted without documentation to explain why the physician order was not followed, that the RN was notified of the change, or that the RN verified the dialysis prescription within 60 minutes of initiating treatment. For example: * Review of Patient #2’s dialysis orders and treatment sheets dated 06/24/2024 through 07/22/2024 (13 hemodialysis treatments) reflected the following: - On 06/28/2024, dialysis treatment was initiated at 1222. The RN did not verify the dialysis prescription until 1340, 78 minutes later. - On 07/05/2024, dialysis treatment was initiated at 1233. The RN did not verify the dialysis prescription until 1352, 79 minutes later. * Review of Patient #4’s treatment sheets dated 06/25/2024 through 07/20/2024 (13 hemodialysis treatments) reflected the following: - Physician orders for dialysis treatment indicated the BFR was 450 mL/min. - On 06/27/2024, the PCT reduced the BFR from 450 mL/min to 400 mL/min without supporting documentation. - On 07/02/2024, the PCT set the BFR at 400 mL/min at the start of treatment at 1026 without supporting documentation. The RN documented they verified the machine settings matched the prescription at 1044. The BFR remained at 400 mL/min for the duration of the treatment. - Similar findings were noted on 07/03/2024, 07/04/2024, 07/06/2024, 07/09/2024, and 07/11/2024. 3. Review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as last revised 04/2024, stipulated: - The nursing assessment would include, “Verification of prescription including machine parameters ... and complete the nursing assessment within one (1) hour of dialysis treatment initiation ...” - “Intradialytic treatment monitoring and data collection which my be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring for non-nocturnal treatments is completed at least every thirty (30) minutes” and includes vital signs, access checks and BFR. - “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.” - “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ... The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary ....”Abnormal findings include. “Systolic [BP] greater than 180 mm/Hg or less than 90 mm/Hg ... Diastolic [BP] greater than or equal to 100 mm/hg or less than 50 mm/Hg...” 4. During interview on 07/24/2024 at 1345, the SMCS and FA verified the above findings.”