Davita Oaks Springs 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: 46886 Based on patient care area observations (OBS) and interviews with staff (EMP) the facility failed to comply with pharmaceutical manufacturer ’ s directions for vaccine use (DFU) during one (1) of three (3) OBS. (OBS3) Findings include: During an observation (OBS3) conducted on 9/11/24 at approximately 10:30 am of the patient care area, two vials of Engerix-B 20 mcg/mL vaccine Lot# 3H3RX with an expiration date of 7/12/24 were found within the patient medication refrigerator. The expired medications were presented to EMP2 (facility administrator) during OBS3 and then discarded. The finding was then reviewed during an exit interview on 9/13/24 at approximately 2:30 pm with EMP1 (Manager of Clinical Services), EMP2 (Facility Administrator), EMP3 (Regional Home Manager), EMP4 (Director of Clinical Services), EMP5 (Social Worker), EMP6 (Group Facility Administrator), EMP7 (Regional Operating Director), EMP8 (Group Operating Director), and EMP9 (Regional Operations Manager).”

“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: 46886 Based on a review of medical records (MR), policies, and interviews with staff (EMP) the facility failed to provide the necessary care and services to manage a patient ’ s volume status for one (1) of six (6) MRs reviewed. (MR1) Findings include: A review of facility policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment on 9/12/24 revealed: “ Purpose: To obtain and document baseline and ongoing information about the patient before, during and after dialysis treatment through data collection and nursing assessment. Post Treatment Data Collection/Assessment ...16. If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. ...Abnormal Findings ...Within each category, definitions may be adjusted by a patient specific order ...Blood Pressure Post Treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg ...Standing Diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ...If the patient is not able to stand, document reason and sitting BP ...Sitting BP for patient ’ s that cannot stand: Sitting systolic BP greater than 140m mm/Hg or less than 90 mm/Hg ...Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ... “ A review of medical records and dialysis treatment notes was conducted between 9/12/24 and 9/13/24 which revealed the following: MR1: Admit date 4/19/24. Treatment Details Reports for 8/10/2024 - 9/7/24 noted Treatment Parameter Orders of “ Post -Tx [treatment] may leave with - SBP [systolic blood pressure] below 150 mmHg. “ Treatment Details Report for 8/24/24 listed a Post-Treatment blood pressure of 201/114 mmHg. No documentation of physician notification for a Post Treatment SBP above 150 mmHg prior to patient discharge from facility was observed within the treatment notes. Treatment Details Report for 8/27/24 listed a Post-Treatment BP of 180/92 mmHg. No documentation of physician notification for a Post Treatment SBP above 150 mmHg prior to patient discharge from facility was observed within the treatment notes. Treatment Details Report for 9/7/24 listed a Post - Treatment BP of 246/145 mmHg. No documentation of physician notification for a Post Treatment SBP above 150 mmHg prior to patient discharge from facility was observed within the treatment notes. The treatment sheets for MR1 and policy were reviewed on 9/13/24 at approximately 10:00 am with EMP1 (Manager of Clinical Services) and EMP2 (Facility Administrator). It was determined that the nursing staff failed to follow policy and treatment parameters because they did not notify the physician of a SBP above 150 mmHg post dialysis treatment on 8/24, 8/27, and 9/7. The findings were then reviewed during an exit interview on 9/13/24 at approximately 2:30 pm with EMP1 (Manager of Clinical Services), EMP2 (Facility Administrator), EMP3 (Regional Home Manager), EMP4 (Director of Clinical Services), EMP5 (Social Worker), EMP6 (Group Facility Administrator), EMP7 (Regional Operating Director), EMP8 (Group Operating Director), and EMP9 (Regional Operations Manager).”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 46886 Based on facility observation (OBS), interviews with staff (EMP), and reviews of policies and facility logs, the medical director failed to ensure that all staff adhered to policies and procedures related to monitoring refrigeration temperatures for one (1) out of three (3) OBS. (OBS1) Findings include: During an observation (OBS1) of the patient care area on 9/9/24 at approximately 9:45 am a review of the facility ’ s refrigeration logs revealed that between April 1 to May 17, 2024 facility staff failed to appropriately complete documentation and provide interventions for a temperature reading above accepted limits. A log sheet for April 2024 failed to identify a Refrigerator ID and an acceptable temperature limit. In addition, the April 2024 log sheet documented a temperature of 72 degrees between 4/1 and 4/30, which was beyond both refrigeration and freezer limits, no action was taken. A log sheet for May 2024 listed the refrigerator ID as “ Lab “ and failed to identify an acceptable temperature limit. The May 2024 Lab refrigerator log documented a temperature of 72 degrees between 5/1 and 5/17, which was beyond both refrigeration and freezer limits. On 5/18 the Lab refrigerator log contained documentation of a temperature adjustment to 38 degrees. A review of facility policy Laboratory Specimens Requiring Refrigeration on 9/10/24 revealed: “ 2. The laboratory refrigerator is checked daily during normal operating hours for cleanliness and to verify the temperature remains between 36 degrees Fahrenheit and 46 degrees Fahrenheit. ...The temperature will be documented on the Laboratory Refrigerator Temperature Log ...5. Refrigerators that do not maintain temperatures in the acceptable, stated range will be repaired or replaced as soon as possible. Facility teammate must notify their Biomed technician .... “ On 9/10/24 at approximately 2:00 pm the temperature logs were reviewed with EMP2 (Facility Administrator) it was determined that the temperature logs were not completed correctly and actions for out of range temperatures were not documented. The findings were then reviewed during an exit interview on 9/13/24 at approximately 2:30 pm with EMP1 (Manager of Clinical Services), EMP2 (Facility Administrator), EMP3 (Regional Home Manager), EMP4 (Director of Clinical Services), EMP5 (Social Worker), EMP6 (Group Facility Administrator), EMP7 (Regional Operating Director), EMP8 (Group Operating Director), and EMP9 (Regional Operations Manager).”