Davita Huntingdon Valley Dialysis

“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: 49974 Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control. Findings include: Review of Davita inc. Incenter Hemodialysis Policies and Procedures: Title: Medication Policy: “ Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications; Policy: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs monthly audit and inventory; 29. “All medications in the facility are checked monthly...All medications are checked monthly for expiration dates.” Observations conducted on the facility patient floor on May 20, 2025 at 11:42 am revealed the following: One (1) bottle of Calcitroil Capsule 0.25 mg with an expiration date of 3/2025. Medication was located in a medication drawer located on the patient floor. An interview conducted with the Facility Administrator on May 23, 2025 at approximately 11:30 AM confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49974 Based on review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and interviews with the facility administrator (FA) the facility failed to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings during HD, for seven (7) of seven (7) MR reviewed: MR#1, 2, 3, 4, 5, 6 and 7 Findings include: A review of the facility’s policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy: 1-03-08) on 5/22/25 at approximately 2:30PM stated “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes ... measurement of BP (blood pressure), Heart or pulse rate; Patient Weight” “The nursing assessment will be performed and documented by a licensed nurse. The assessment includes the following components: review of patient reports, data collection, response to treatment...Pre-Treatment Data Collection/Assessment: any abnormal findings during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis ...the licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner if applicable) will be notified of any concerns that may preclude the initiation of dialysis. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated....Intradialytic Data Collection/Assessment: the licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation .... Vital signs and treatment monitoring - for non-nocturnal treatments is completed at least every thirty (30) minutes ....Abnormal findings 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. The licensed nurse notifies the physician (or non physician practitioner if applicable) as needed of changes in patient status...Abnormal Findings - any weight loss from last post weight .... Blood Pressure Pre-Dialysis: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mmHg; Blood Pressure -Intradialytic: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mmHg; Blood Pressure Post Treatment: Standing systolic BP greater than 140 mmHg or less than 90 mmHg; Standing diastolic BP greater than 90 mmHg or less than 50 mmHg; Sitting BP for patient ’ s that cannot stand: Sitting systolic BP greater than 140 mmHg or less than 90 mmHg; Sitting diastolic BP greater than 90 mmHg or less than 50 mmHg; Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minutes or greater than 100 beats per minutes and/or an irregular heart beat.” A review of Medical Records (MR) was conducted on 5/22/2025 from approximately 9:15AM-2:30PM and revealed the following: MR #1, Admission Date: 7/1/2020. The hemodialysis flow sheet dated April 23, 2025 and 4/30/2025 did not contain documentation that post assessments were completed according to policy. MR #2, Admission Date. 5/24/2021 The hemodialysis flow sheet dated May 8, 2025 indicated that the patient was 2.9 kg over the estimated target weight. No documentation on file to address reason target weight not achieved. May 10, 2025 indicated a blood pressure reading of 180/100 at 12:33 pm, 183/102 at 13:01. The flow sheet did not indicate that the nurse was informed about the two episodes of hypertension and no post assessment was completed upon the conclusion of patient treatment according to policy. MR #3, Admission date 1/31/2025. The hemodialysis flow sheet dated May 5, 2025, May 7, 2025, May 9, 2025, May 14, 2025 and May 19, 2025 did not contain documentation that post assessments were completed according to policy. MR #4, Admission Date: 12/01/2019. The hemodialysis flow sheet dated May 7, 2025, May 12, 2025, May 14, 2025 and May 19, 2025 did not contain documentation that post assessments were completed according to policy. . MR #5, Admission Date 8/12/2024. The hemodialysis flow sheet dated May 5, 2025, May 9, 2025, May 14, 2026, May 16, 2025 and May 19, 2025 did not contain documention that post assessments were completed according to policy. MR #6, Admission Date 11/24/2021. The hemodialysis flow sheet dated for May 5, 2025, May 9, 2025, May 14, 2025, May 16, 2025 and May 19, 2025 did not contain documentation that post assessments were completed. The hemodialysis flow sheet dated for May 16, 2025 indicated that the patient treatment time was 3 hours, 1 minute instead of the prescribed treatment time of 3 hours, 30 minutes. No documentation on file to indicate reason for change in treatment duration according to policy. MR #7, Admission Date 11/17/2022. The hemodialysis flow sheet dated May 6, 2025 indicated a blood pressure reading of 185/112 - no notes to indicate that the nurse was notified. According to the electronic record for the same date at the same time indicated a blood pressure reading of 169/86. Facility Administrator could not explain the discrepancy in electronic documentation versus the printed flow sheet for the two different readings. Flow sheet dated for May 6, 2025 indicated a blood pressure reading at 6:34 am of 157/85, next reading was recorded at 8:04 am of 170/91. According to policy, blood pressure readings should be recorded every thirty (30) minutes. Flow sheet dated for May 15, 2025 did not indicate a post assessment was completed according to policy. An interview conducted with the Facility Administrator, Regional Operation Manager, Clinical Service Specialist, Clinical Coordinator and BioMedical Supervisor on May 23, 2025 starting at 11:30 AM confirmed the above findings.”