Davita Linn Benton 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: 47148 Based on review of documentation and interview, it was determined the facility failed to demonstrate that its patient care staff maintains current CPR certification. Review of documentation included a Personnel Audit Tool-ESRD worksheet of the facility staff personnel records which was completed by the FA on 05/28/2025. The worksheet revealed 2 of 10 patient care staff (Staff #4 and #6) had current CPR certification. The worksheet revealed the following: * Staff #4, an RN, had “5/6/25” documented indicating their CPR certification was expired. * Staff #6, a PCT, had “4/8/25” documented indicating their CPR certification was expired. Review of the job descriptions for both PCT and RN specified that current CPR certification was required. During an interview with the FA and MCS on 05/28/2025 at 1300, the above findings were 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 review of documentation, it was determined that the facility failed to ensure equipment was maintained and operated in accordance with facility policies and manufacturer’s recommendations. Findings: Review of the “Procedure: 1-08-06C” log for glucometer quality control test results, from 01/01/2025 through 05/27/2025, revealed 17 instances when staff identified results were outside of the allowable parameters. Examples include, but are not limited to: * On 02/04/2025, the range for the high control was documented as 284-389, however the result was documented as “392” and circled to identify it was out of range. * On 02/28/2025, the range for the low control was documented as 90-120, however the result was documented as “127” and circled to identify it was out of range. * On 05/14/2025, the range for the low control was documented as 91-123, however the result was documented as “128” and circled to identify it was out of range. There was no documentation to indicate the control tests were run again or that the glucometer was removed from use to assess the cause of the malfunction. Review of facility policy titled, “EMBRACEPRO TM BLOOD GLUCOSE MONITOR: QUALITY CONTROL (QC),” dated 09/2020, stipulated, “If control results fall outside the acceptable range, the test must be repeated. If the monitor does not read control solution values accurately, it may not read patient blood glucose values accurately and is not safe to use. Following the manufacturer’s [directions for use], the meter must be assessed for the cause of the malfunction.” During interview with the CCRN and GFA on 05/27/2025 at 1505, the CCRN reported they would occasionally recheck the glucometer, but would sometimes continue to receive results that fell outside of the allowable parameters. They reported they did not remove the glucometer for further testing and confirmed the glucometer was still available for use with patients. The GFA 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: 47148 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 4 of 4 in-center hemodialysis patients reviewed (Patient #s 1-4). Findings: Patient #1 Review of Patient #1’s Treatment Details Reports dated 04/07/2025 through 05/23/2025 (11 treatments) revealed the following: - Physician orders for treatment medication included a prescription for “Heparin Pork ... Order stop time for hourly dose before end of treatment: 60 minutes.” * On 04/25/2025, the PCT documented the treatment was terminated at 1615. The heparin infusion was started at 1318 and ended at 1618 without supporting documentation. * On 04/28/2025, the PCT documented the treatment was terminated at 1532. The heparin infusion was started at 1258 and ended at 1542 without supporting documentation. * Similar findings noted on 04/07/2025, 04/16/2025, 05/19/2025, 05/21/2025 and 05/23/2025. Patient #2 Review of Patient #2’s Treatment Details Reports dated 04/15/2025 through 05/22/2025 (8 treatments) revealed the following: - Physician orders for dialysis treatment indicated the BFR was 450 mL/min. - On 05/08/2025, at 0540, the PCT set the BFR at 405 mL/min and initiated treatment. At 0738, the RN documented they verified the machine settings matched the prescription. The BFR remained at 405 throughout the duration of the treatment. - On 05/20/2025 at 0543, the RN set the BFR at 400 mL/min and initiated treatment. At 0546, the RN documented they verified the machine settings matched the prescription. The BFR remained at 400 throughout the duration of the treatment. *Similar findings noted on 04/17/2025, 05/06/2025 and 05/22/2025. - Physician orders included a target weight of 69 kg. The patient was over target weight for 8 of 8 treatments. * On 05/20/2025, the patient’s “Post Weight” was documented as 76.6 kg, 7.6 kg above the prescribed 69 kg “Target Weight.” * On 05/22/2025, the patient’s “Post Weight” was documented as 74.4 kg, 5.4 kg above the prescribed 69 kg “Target Weight.” * Similar findings noted on 04/15/2025, 04/17/2025, 04/22/2025, 05/06/2025, 05/08/2025 and 05/13/2025. - Physician orders included a UFR max of 13/mL/kg/hr. * On 05/08/2025, the UFR was 14.1 mL/kg/hr * On 05/13/2025, the UFR was 14.6 mL/kg/hr * Similar findings noted on 04/17/2025, and 05/22/2025 - VS monitoring and access checks were late on 6 of 8 treatments. * On 04/22/2025, the PCT documented a VS and access check at 0837. The next VS and access check was documented at 0956, 79 minutes later. * On 05/13/2025, the PCT documented a VS and access check at 0832. The next VS and access check was documented at 0937, 65 minutes later. * Similar findings noted on 04/15/2025, 04/17/2025, 05/06/2025, and 05/08/2025. - The nurse prescription verification and pre-assessment was conducted more than 60 minutes after the initiation of treatment for 1 of 8 treatments. * On 05/08/2025, the PCT initiated treatment at 0538. The RN documented they verified the prescription and conducted the pre-treatment assessment at 0738, 120 minutes later. Patient #3 Review of Patient #3’s Treatment Details Reports dated 04/25/2025 through 05/24/25 (10 treatments) revealed the following: - Physician orders for dialysis treatment indicated the DFR was 800 mL/min. * On 04/28/2025 at 0600, the PCT lowered the DFR to 600 mL/min, but there was no documentation to indicate why the DFR was changed. - VS monitoring and access checks were late during 3 of 10 treatments. * On 05/07/2025, the PCT documented a VS and access check at 0638. The next VS and access check was documented at 0744, 66 minutes later. * On 05/12/2025, the PCT documented a VS and access check at 0532. The next VS and access check was documented at 0626, 54 minutes later. At 0648, Patient #3 was placed on checks every 15 minutes. The LPN documented a VS and access check at 0740. The PCT documented the next VS and access check at 0816, 36 minutes later. * Similar findings were noted on 05/24/2025. Patient #4 Review of Patient #4’s Treatment Details Reports dated 04/23/2025 through 05/26/2025 (17 treatments) revealed the following: - The nurse prescription verification and pre-assessment was conducted more than 60 minutes after the initiation of treatment for 2 of 17 treatments. * On 04/28/2025, the PCT initiated treatment at 0612. The RN documented they verified the prescription and conducted the pre-treatment assessment at 0737, 85 minutes later. * On 05/24/2025, the PCT initiated treatment 0554. The RN documented they verified the prescription at 0602, 68 minutes later, and completed the pre-treatment assessment at 0604, 70 minutes later. - Physician orders for dialysis treatment included the BFR was 400 mL/min and DFR was 800 mL/min. * During 6 of 17 treatments, the BFR or DFR was adjusted without documentation to indicate why the BFR or DFR was changed. * On 04/23/2025 at 0631, the PCT lowered the BFR to 350 mL/min without documentation of the rationale. * On 04/28/2025 at 0613, the PCT set the DFR to 500. At 0737, the RN documented they verified the machine settings matched the prescription. At 0900, the RN documented the DFR was set to 600 mL/min, but did not indicate why the physician order was not followed. At 0700, the PCT documented they lowered the BFR to 375 mL/min without documentation of the rationale. * Similar findings were noted on 04/25/2025, 05/05/2025, 05/22/2025, and 05/26/2025. - VS monitoring and access checks were late during 11 of 17 treatments. * On 05/07/2025, the PCT documented a VS and access check at 0637. The next VS and access check was documented at 0741, 63 minutes later. The PCT documented a VS and access check at 0913. The next VS and access check was documented at 1010, 57 minutes later. * On 05/12/2025, the LPN documented a VS and access check at 0739. The RN documented the next VS and access check at 0857, 78 minutes later. * On 05/23/2025, the PCT documented a VS and access check at 0843. The next VS and access check was documented at 1009, 86 minutes later. * Similar findings were noted on 04/23/2025, 04/25/2025, 04/28/2025, 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, and 05/24/2025. Review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of April 2024, stipulated: - “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, UFR and Max UFR, target weight and heparinization (intradialytic infusion setting). - “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.” During an interview with the FA and MCS on 05/28/2025 at 1300, the above findings were confirmed.”