Davita Yaquina Bay Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on interview, review of personnel files and review of documentation, it was determined the facility failed to ensure 6 of 17 (Staff #s 5, 7, 11, 12, 13 and 17) received required training on the facility’s emergency preparedness plan. Findings: The review of documentation included an audit worksheet of the facility staff training records which was completed by the FA on 04/10/2025. The worksheet revealed gaps in the required personnel documentation. Examples included, but were not limited to: - 3 of 17 staff (Staff #5 with a hire date of 02/17/2025, Staff #7 with a hire date of 03/08/2025 and Staff #13 with a hire date of 12/10/2024 lacked documentation of initial “EP Training” upon hire. - 3 of 17 staff (Staff #s 11, 12 and 13) lacked documentation of annual emergency preparedness training. During review of the facility policy titled, “Facility Emergency Management Plan” dated “April 2024” stipulated, “The FA, or designee, is responsible to provide training of EMP ... i. Annually ... Policy Facility Emergency Management Plan ... Facility specific emergency response procedures ... III ... Upon Hire ...” During an interview with the FA on 04/10/2025 at approximately 1100, the above findings were confirmed.”

“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 that the facility failed to ensure that the building was constructed and maintained to ensure the safety of the patients, staff and the public. Findings: Observation of the facility on 04/09/2025 beginning at 0845 revealed: - White precipitate was found accumulated on the connections inside many of the chase boxes. - An opened MDV of Heparin lacked a BUD label. It could not be determined when the vial had been opened. - The caulk around the patient handwashing sink was dirty, cracked and beginning to peel away from the sink surface. Above the sink, there was an area where the paint was chipped that exposed the wallboard underneath. These areas could not be cleaned effectively for infection control purposes. - The covers on eyewash station in the water room were hanging off and the nozzles were exposed to dirt and debris. During interview with the FA on 04/09/2025 at 1600, the above findings were confirmed.”

“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 3 of 3 patients (Patient #s 1, 2 and 3). Findings: 1. Review of Patient #1’s Treatment Details Reports dated 02/21/2025 through 03/21/2025 (13 treatments) revealed: - Physician orders were for BFR at 400 mL/min and DFR at 600 mL/min. - On 03/07/2025, the PCT initiated treatment at 0945 with the DFR set at 0 mL/min. At 1202, the DFR was increased to 600 mL/min. - On 03/10/2025, the PCT initiated treatment at 1000 with the DFR set at 500 mL/min, where it remained for the duration of treatment. - On 03/19/2025, the PCT initiated treatment at 1010 with the DFR set at 0 mL/min. At 1203, the DFR was increased to 500 mL/min. - On 03/21/2025, the PCT initiated treatment at 1003 with the BFR set at 350 mL/min, where it remained until 1135. The documentation indicated the RN verified the patient’s prescription matched what was being delivered during the dialysis treatment for the dates above. There was no documentation to show why the physician orders were not followed or that the RN was notified of the change. - Lapses of greater than 30 minutes were documented between patient VS, visualization and access checks for 7 of 13 treatments. For example, on 02/21/2025, a patient and VS check was documented by the PCT at 1006. The next check was documented at 1100, 54 minutes later. The PCT later documented another patient and VS check at 1108. The next check was documented at 12:08, 60 minutes later. - Similar findings were noted on 02/24/2025, 02/26/2025, 02/28/2025, 03/03/2025, 03/05/2025, and 03/19/2025. 2. Review of Patient #2’s Treatment Details Reports dated 03/10/2025 through 04/07/2025 (11 treatments) revealed: - Lapses of greater than 30 minutes were documented between patient VS, visualization and access checks for 9 of 11 treatments. For example, on 03/14/2025, a patient and VS check was documented by the PCT at 0906. The next check was documented at 1007, 61 minutes later. The PCT documented another patient and VS check 60 minutes later at 1106. The next check was documented at 12:03, 57 minutes later. - Similar findings were identified for treatment dates 03/10/2024, 03/17/2025, 03/21/2025, 03/24/2025, 03/26/2025, 03/31/2025, 04/02/2025 and 04/07/2025. 3. Review of Patient #3’s Treatment Details Reports dated 03/07/2025 through 04/07/2025 (13 treatments) revealed Patient #3 had systolic blood pressure readings greater than 180 mm/Hg. Examples include, but are not limited to: - On 03/14/2025 and 03/24/2025, Patient #3 was as having elevated blood pressure readings with systolic blood pressures measuring as high as 206 mmHg. There was no documentation to indicate the blood pressure was rechecked and/or the licensed nurse was notified. 4. Review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of April 2024, stipulated: - “Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law.” Prescription components listed included BFR and DFR. - “If the dialysis prescription is not being met (including dialysis flow rate or charge to/inability to obtain prescribed blood flow rate” the reason will be documented and the licensed nurse informed.” - “Abnormal findings ... will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy) ... Abnormal Findings ... Systolic greater than 180 mm/Hg...” During an interview on 04/10/2025 at 0910, the CC RN confirmed the above findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 31224 Based on interview, review of 2 of 3 patients’ plans of care (Patient #s 1 and 2) and review of documentation, it was determined that the facility failed to ensure that plans of care were signed by the IDT and the patient and/or the patient’s designee or that a reason for refusal was documented. Findings: Review of medical records of Patient #1 included a Plan of Care dated 03/28/2025 that lacked the signature of the MD, MSW, and the patient or patient’s designee. The record did note the patient was in the hospital and unavailable at the time. Review of medical records of Patient #2 included a Plan of Care dated as finalized on 03/03/2025. The facility failed to provide the signature sheet with the date and signature of the MD, MSW, RD and RN that participated. There was no documentation that the patient or patient designee was invited to the POC meeting or that they attended. Review of the facility policy, “Interdisciplinary Team (IDT) Patient Assessment and Plan Of Care,” dated as last revised in 10/2024, stipulated, “The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.” During interview on 04/10/2025 at 0910, the CC RN verified the above finding for Patent #1. During interview on 04/10/2025 at 1130 with the FA, they verified there was no signature sheet for Patient #2.”