Davita Lincoln Way Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 46886 Based on observations of clinic area (OBS) and employee interviews (EMP) the facility failed to provide and monitor a sanitary environment for one (1) out of three (3) clinic observations (OBS1). Findings include: During an observation (OBS1) performed on 1/29/24 between approximately 9:00 - 11:30 am the following expired medical devices and medications were discovered: Thirty (30) individual 250 mL bags of 0.9% Sodium Chloride injection Lot Y387545, expiration date August 2023. Seven (7) individual Clearguard HD antimicrobial end caps blood access device Lot 6368, expiration date 3-25-23. Four (4) individual RPC Item 7001-3902W, Lot 1800082, expiration date 8-31-2021. Twenty-seven (27) individual BD 22-gauge sterile Precision Glide Needle ref. 305155, unable to determine expiration date. Four (4) individual Curity Coviden Sponges, expiration date 6/2023. Seventeen (17) individual Curity Coviden Sponges, expiration date 11/1/2023. Fourteen (14) individual Criterion non-woven sponges, unable to discern expiration date. Thirteen (13) individual Cavilon No Sting Barrier Film, expiration date 1/2022. Sixteen (16) individual BD Safety-Lok 22-gauge 3mL syringes expiration date 7-31-23. Nine (9) individual BD Safety Lok 25-gauge 1 mL unable to discern manufacturer or expiration date. Two (2) bottles Fosrenol 1000 mg tablets expiration date 06/2023. The above findings were reviewed with EMP1 (Facility Administrator) during the onsite observation on 1/29/24 at approximately 11:30 am.”

“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: 46886 Based on observations of the treatment area (OBS), reviews of policies, and employee interviews (EMP) the facility failed to maintain a program that ensured dialysis machines and ancillary equipment were maintained and operated in accordance with manufacturer ’ s recommendations for two (2) of three (3) observation periods. (OBS1 and 2) Findings include: A review of agency policies on 1/29/24 at approximately 3:00 pm revealed: Citric Acid Policy ... “ Purpose: To provide guidelines for preparation and use of citric acid solution ...Policy: 2. A 2% citric acid solution must be used within seven (7) calendar days of preparation. 3. Follow dialysis delivery system ’ s manufacturer ’ s instructions for utilizing citric acid solution. 6. Citric acid concentrate is to be stored in a plastic container, labeled with preparer ’ s name, date, time and Hazardous Materials Information Sheet ...label ...7. All citric acid containers, uptake wands, and caps will be rinsed and disinfected every seven (7) days ... “ Medications Requiring Refrigeration ... “ To provide guidance for the storage and management of medications requiring refrigeration. ... 3. The refrigerator is checked during facility normal operating hours, by a licensed nurse teammate or designee. Checks will be documented on the Medication Refrigerator Management Log. ...a. Twice daily temperature checks located on the Digital Data Logger (DDL) display at the beginning and end of the day ...b. Daily checks will include: iv. DDL buffered probe placed near center of refrigerator ... “ During an observation (OBS1) performed on 1/29/24 between approximately 9:00 - 11:30 am the following was discovered: 1. Citric acid jugs labeled with dates of 1/4/24 and 1/11/24 were found stored in cupboards on the treatment floor. According to the labels, the citric acid was retained longer than the facility ’ s seven day policy. 2. A Medication refrigerator temperature monitor was found with the alarm off and a blank screen. An interview with EMP1 (Administrator) during OBS1 revealed that the temperature alarm was nonfunctioning and required a battery replacement. EMP1 was unsure of the LCD screen ’ s readings or the function of the alarm. EMP1 was made aware of the dates on the citric acid jugs. During an observation (OBS2) performed on 1/31/24 between approximately 9:30 am- 11:30 am the following was discovered: 1. A Citric Acid jug labeled 1/22/24 was found stored in a cupboard on the treatment floor. According to the label, the citric acid was retained longer than the facility ’ s seven day policy. 2. The Medication refrigerator monitor alarm remained off and a temperature reading was not visible on the DDL display. The findings were discussed with EMP1 (Administrator) during an exit interview on 2/2/24 at approximately 3:45pm.”

“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 facility policy/procedure, medical records (MR), and staff (EMP) interviews, the facility failed to assess and/or manage a patient ’ s blood pressure/volume status per facility policy for two (2) of six (6) MRs reviewed. (MRs 2 and 5) Findings include: Review of facility policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment on 1/29/24 revealed: “ INTRADIALYTIC DATA COLLECTION/ASSESSMENT ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ...ABNORMAL FINDINGS ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ’ s medical record. ...Blood Pressure-Intradialytic: Difference of 20 mmHg increase or decrease from patient ’ s last intradialytic treatment BP reading ... “ Review of MR1-4 and MR6 on 2/1/24 between approximately 10:00 am to 3:00 pm revealed the following: Review of MR2: Admission 8/18/23. Review of in-center Treatment Details Report between 1/15/24 - 1/31/24 Intradialytic monitoring revealed: 1/15/24: 7:34 entry by PCT4 BP 146/70. 8:04 entry by PCT5 BP 112/84 noted a greater than 20 point decrease from previous pressure, no documentation of RN notification per facility policy. 1/29/24: 7:34 timed entry by PCT4, Blood Pressure (BP) 146/74. 8:05 timed entry by PCT4, BP 117/68 noted a greater than 20 point increase from previous pressure, no documentation of RN notification per facility policy. A review of MR5 on 2/2/24 revealed the following: MR5: Admission: 6/9/21. Review of in-center Treatment Details Report between 1/15/24 - 1/31/24 Intradialytic monitoring revealed: 1/15/24: 9:32 am entry by PCT5 BP 150/83. 10:07 entry by PCT’s BP 93/81 noted a greater than 20 point decrease from previous pressure, no documentation of RN notification per facility policy. The findings were reviewed with EMP1 (Facility Administrator) during an exit interview on 2/2/24 at approximately 4:00 pm.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46886 Based on a review of facility policy/procedure, medical records (MR), and staff (EMP) interviews, the facility staff failed to assess and/or manage a patient ’ s prescribed dose of dialysis as per facility policy for three (3) of six (6) medical records reviewed. (MRs 1, 3, and 4) Findings include: Review of facility policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment on 1/29/24 revealed: “ INTRADIALYTIC DATA COLLECTION/ASSESSMENT ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ...ABNORMAL FINDINGS ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ’ s medical record. ...Pre/Intra/Post Patient reports/complaints ...of: Pain ... “ A review of MR1-4 and MR6 on 2/1/24 between approximately 10:00 am to 3:00 pm revealed the following: Review of MR1: Admission 1/3/23. Review of in-center Treatment Details Report from 1/16/24 to 1/30/24 Intradialytic monitoring revealed: 1/20/2024: Dialysis prescription read: Blood Flow Rate (BFR) 450 mL/min, verified by PCT1 (Patient Care Technician) at 9:51 am. 11:02 am entry by PCT1: BFR (Blood Filtration Rate) 450. 11:32 entry by PCT1 BFR 400. No documentation of RN notification or reason for BFR change per facility policy. Review of MR3: Admission 3/11/20. Review of in-center Treatment Details Report between 1/15/24 - 1/31/24 Intradialytic monitoring revealed: 1/15/24: 6:47 timed entry by PCT4 read, “ bf [blood flow rate] turned down to 400 due to pt [patient] saying [their] arm hurt ... “ No documentation per facility policy that RN was notified of abnormal patient findings of pain. Review of MR4: Admission 2/18/22. Review of in-center Treatment Details Report between 1/16/24 - 1/30/24 revealed: 1/23/24: Dialysis prescription read: Blood Flow Rate: 450 mL/min and was verified by PCT4 at 5:13. 6:02 timed entry by RN1 noted decrease of BFR from 450 to 400, no documentation of reason for BFR rate change as per facility policy. The findings were reviewed with EMP1 (Facility Administrator) during an exit interview on 2/2/24 at approximately 4:00 pm.”