Davita Deschutes River Dialysis

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 31224 Based on observation and interview, it was determined the facility failed to ensure all sinks were operational with warm water. Findings: During observations of the facility on 09/30/2024 starting at 1330, the sink located where patients entered the treatment floor was labeled “Patient Prep.” The faucet did not turn on when hands were placed in front of the sensor and the sink basin was observed to be dry. At the time of observation, the PCT verified that sink was used by patients to wash their dialysis access site prior to initiating treatment. The PCT also verified the sink was not operational. On 09/30/2024 at 1600, the FA and Biomed Tech verified the faucet was not working.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation for 6 of 28 (Patient #s 7-12) patients reviewed, it was determined the facility failed to have systems in place to ensure: 1. That patients were managed appropriately based on their testing results, according to CDC recommendations and facility policy. 2. That patients were routinely tested as required; and 3. The HBV serological status of all patients was known before admission. Findings: Review of the facility “Vaccinations and Surveillance Report,” printed on 09/30/2024 revealed: 1. Patient #7 was admitted to the facility on 05/06/2024 and tested as HBV Susceptible on 07/22/2024, 08/26/2024 and 09/23/2024. The Patient received a 40mcg dose of the Engerix-B vaccine on 10/25/2023 at the facility and on 11/27/2023 at an out-of-state facility. The facility failed to ensure the patient received all 4 required doses of the Hep B vaccine series. *Similar findings were identified for Patient #8. Review of the document, “Engerix-B Package Insert,” found at https://www.fda.gov/media/119403/download?attachment, stipulated the recommended dosage and adminstration schedule should be “Adults on hemodialysis: A series of 4 doses (2 mL each) as a single 2-mL dose or as two 1-mL doses on a 0-, 1-, 2-, 6-month schedule.” During interview with the FA on 10/04/2024 at 1430, they stated that Patient #7 had previously been a patient at the facility but left for the 6 months prior to the 05/04/2024 re-admit date. They confirmed the patient should have been offered the complete vaccine series upon readmittance to the facility. 2. Patient #12 was admitted to the facility on 06/01/2020. The facility failed to ensure that annual antibody testing, HBsAb, was drawn and resulted for 2021 and 2022. 3. Patient #9 was admitted to the facility on 04/04/2022. The patient’s HBcAb, total core antibody, was drawn 04/25/2022. The FA could not verify that the patient’s first treatment date was after the HBcAb was drawn and resulted. * Similar findings were identified for patient #s 10 and 11. Review of the facility policy, “Hepatitis B Surveillance, Vaccination, Infection control Measures and Isolation Guidance,” dated “April 2024” stipulated: - “HBV serological status (i.e., the results of Hepatitis B Surface antigen [HBsAg], Total Hepatitis B Core Antibody [total anti-HBc or HBcAb], and Hepatitis B Surface Antibody [anti-HBs or HBsAb] of all patients should be known before admission the the hemodialysis facility.” - “Vaccinate per manufacturers guidelines.” - “Routine Surveillance Testing” if the patient’s Antigen is negative, the Core is negative, the Antibody is greater than or equal to 10 then the patient’s status is considered “Immune due to vaccination” and “Surveillance Testing” should be an “Annual antibody” test. During interview with the FA on 10/04/2024 at 1430, the above findings were confirmed.”

“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: 37237 Based on observations, interviews and review of documentation, it was determined that the facility failed to ensure that medications were prepared and stored correctly. Findings: - Observation of the Home Program area on 09/30/2024 beginning at 1350 revealed an opened MDV of “Tuberculin Purified Protein Derivative (Mantoux) Tubersol,” (used for the detection of infection with Mycobacterium tuberculosis), available for use had “8/21/24 open” handwritten on the box. *Review of the manufacturer’s package insert stipulated “A vial of TUBERSOL which has been entered and in use for 30 days should be discarded.” * The FA confirmed the expired medication on 09/30/2024 at 1600. - Observation of the facility’s in-center medication refrigerator on 10/01/2024 at 1215 revealed 3 boxes of “Prevnar 13” (a pneumococcal vaccine) that expired on 09/30/2024. *The FA confirmed the medications had expired during the observation.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 37237 Based on observation and interview it was determined the facility failed to maintain a safe and functional treatment environment. Findings: Observation of the facility on 09/30/2024 beginning at 1305 revealed: - An opened bottle of “MesaLabs Conductivity Standard Solution 14.0 mS/cm” had “Date Opened 8/21/24” and “Discard Date 9/21/24” handwritten on the bottle. Instructions on the front label of the conductivity solution stipulated “Discard 30 days after opening.” - There was a large L-shaped crack in the wall close to the patient bathroom in the facility’s lobby. During interview with the FA on 9/30/2024 at 1600, the above findings were confirmed.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 37237 Based on observation and interview, it was determined the facility failed to prominently display notices that included the current State Agency mailing address and telephone complaint number. Findings: Observation of the facility lobby on 09/30/2024 beginning at 1305 revealed the “External Grievance Process” notice, posted in the lobby, contained inaccurate information for complaints and grievances reported to the state agency. The contact information posted listed the wrong State Agency, that included an incorrect email address and phone number. The FA confirmed the wrong SA contact information on 10/01/2024 at 1200.”

“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 medical records, and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and that VS monitoring was completed according to facility policy for 2 of 2 in-center hemodialysis patients reviewed (Patient #s 2 and 3). Findings: Patient #2 Review of Patient #2’s dialysis orders and treatment flowsheets dated 08/16/2024 through 09/27/2024 (12 hemodialysis treatments) revealed: - The BFR was changed without documentation to indicate why the physician orders were not followed in 10 of 12 treatments. - Staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes or every 15 minutes, when indicated during 10 of 12 treatments. Examples include, but were not limited to: The treatment flowsheet dated 09/27/2024 revealed the following: - The BFR was set to 400 mL/min by the PCT. Both the PCT and RN verified the prescription was 400 mL/min. Treatment was initiated at 1107 and the BFR was set at 400. At 1201, the BFR was recorded at 350. There was no documentation of the rationale for why the BFR was changed and the prescription not followed. - The patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented a VS check and visualization of the patient at 1132. The next check was documented at 1231, 59 minutes later. Similar findings were identified on 08/16/2024, 08/19/2024, 08/21/2024, 08/23/2024, 08/26/2024, 09/02/2024, 09/04/2024, 09/09/2024, 09/16/2024 and 09/20/2024. Patient #3 Review of Patient #3’s dialysis orders and treatment flowsheets dated 08/30/2024 through 09/27/2024 (13 hemodialysis treatments) revealed: - Physician orders included a running a 1K dialysate, a BFR of 450 mL/min, a maximum UFR of 13, and for the heparin infusion to be stopped 60 minutes prior to the end of treatment. - The BFR was changed without documentation to indicate why the physician orders were not followed in 5 of 13 treatments. - The maximum UFR was exceeded for 6 of 13 treatments. - The heparin infusion was not stopped 60 minutes before the end of treatment for 2 of 13 treatments. - Staff failed to complete VS checks and visualization of the patient’s access and face every 30 minutes or every 15 minutes, when indicated during 11 of 13 treatments. - The RN failed to verify the machine set up and orders and conduct the pre-treatment nursing assessment within 60 minutes of initiating treatment for 3 of 13 treatments. Examples include, but were not limited to: The treatment flowsheet dated 08/30/2024 revealed the following: - The BFR was set to 400 mL/min by the PCT. Both the PCT and RN verified the prescription was 450 mL/min. There was no documentation of the rationale for why the prescription was not followed.. - The patient’s vital signs were automatically documented by the dialysis system approximately every 30 minutes. However, staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes. A PCT documented a VS check and visualization of the patient at 0936. The next check was documented at 1030, 54 minutes later. - The PCT verified the prescription and initiated treatment at 0921. The RN verified the prescription and conducted the nurse assessment at 1151, 150 minutes later. The treatment flowsheet dated 09/23/2024 revealed: - The actual UFR was noted as 16.1. - Staff documentation of VS checks and visualization of the patient’s access and face failed to be completed every 30 minutes or every 15 minutes, as indicated. For example: * The PCT documented a check at 0939. The next check was documented by the PCT at 1057, 78 minutes later. * The PCT placed Patient #3 on q15 minute VS and checks at 1136 due to decreases in BP. The next check was done at 1223, 47 minutes later. The treatment flowsheet dated 09/25/2025 revealed: - The actual UFR was noted as 15.4. - The PCT documented a VS check and visualization of the patient at 0942. The next check was documented at 1040, 58 minutes later. - The PCT documented a VS check and visualization of the patient at 1103. The next check was documented at 1221, 78 minutes later. - The PCT documented treatment ended at 1242. The heparin infusion end time was documented as 1238, 4 minutes before the end of treatment. Similar findings were identified on 09/02/2024, 09/04/2024, 09/06/2024, 09/09/2024, 09/11/2024, 09/16/2024, 09/18/2024, 09/20/2024, and 09/27/2024. Review of the facility policy “1-03-08” titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as last revised “April 2024” stipulated “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment ... 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vital signs and treatment monitoring ... For non-nocturnal treatment is completed at least every thirty (30) minutes ... The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. 10. If the dialysis prescription is not being met (including flow rate or chance to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” During interview on 10/01/2024 at 1530, the FA confirmed the above findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 37237 Based on interview, review of clinical vaccine records, and review of documentation, it was determined the facility failed to implement facility policy that ensured pneumococcal vaccines were offered to qualifying patients for 3 of 28 patients (Patient #s 7, 8 and 13). Findings: Review of the facility’s “Vaccinations and Surveillance Report” printed on 09/16/2024 revealed pneumococcal vaccination status for 28 patients on the facility census revealed: * Patient #7 was admitted to the facility on 05/16/2024. The report listed the patient as, “The patient has no current Pneumococcal vaccinations documented.” * Patient #8 was admitted to the facility on 03/07/2022. The report listed only pneumococcal vaccines administered by other providers and failed to specify which vaccines had been given. * Patient 13 was admitted to the facility on 07/05/2023. The report listed only pneumococcal vaccines administered by other providers and failed to specify which vaccines had been given. Review of the facility policy titled “Pneumococcal Vaccination for Adult Hemodialysis Patients,” dated as last revised October 2023, included vaccination guidance based on which vaccine was administered (PCV13, PCV15, PCV20, or PPSV23). * For patients who had received only PPSV23, a dose of PCV20 or PCV15 could be administered at least one year after the most recent PPSV23 vaccine. * For no previous vaccine, a patient may receive PCV20 or PCV15 and PPSV23 at least one year later “(minimal interval is 8 weeks and can be considered in adults with an immunocompromising condition.)” The above results were confirmed on 10/01/2024 at approximately 1200 by the FA. Without knowing which pneumococcal vaccines had been previously administered, the patients’ vaccine status cannot be determined.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 31224 Based on interview and review of clinical records, it was determined the facility failed to ensure complete and accurate records were maintained for 1 of 2 in-center hemodialysis patients (Patient #3). Findings: Review of treatment flowsheets dated 08/30/2024-09/27/2024 revealed Patient 3 had physician orders for 1K dialysate during treatments occurring from 08/28/2024 through 09/06/2024 and 09/11/2024 to present. The treatment flowsheets indicated the 1K dialysate prescription was verified by the PCT and RN, however other orders, such as BFR, were also verified by the PCT and RN and were at times not followed. There was no other documentation to indicate whether Patient 3 received the 1K dialysate. During interviews on 10/01/2024 at 1620, the Biomed Tech reported the dialysis machines would run another dialysate without alarming. The MCS reported that the PCT and RN would be conducting a visual check for the 1K dialysate as it is drawn from a plastic jug and not from the main dialysate source from the wall. The MCS confirmed the documentation did not clearly show Patient #3 received the 1K dialysate as ordered. Refer to the findings cited at Tag V-503 under CFR §494.80(a)(2) Standard: Patient assessment that reflects physician orders were verified by the PCT and RN, but were not followed.”