Davita Northside Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 46886 Based on observations of the facility ’ s emergency response cart and employee interviews, the facility failed to monitor the supplies and medications designated for emergency use during one (1) of three (3) clinic observations. (OBS1) Findings include: During a clinic floor observation (OBS1) performed on 1/27/25 between 9:30 am to 1:00 pm the following expired medication was found in the emergency response cart: 2 vials of IV Benadryl lot #DBTU0121 with an expiration date of 12/2024. A review of the emergency cart ’ s daily checklist revealed that the expired medication checklist had not been completed between 7/2024 to 12/2024. The finding was reviewed with EMP1 (MCS) and EMP2 (FA) during an exit conference on 1/27/24 at approximately 2:00 pm.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 46886 Based on a review of policies and medical records (MR) and interviews with staff (EMP), the facility failed to complete an initial comprehensive assessment within 30 days of admission for one (1) of eight (8) MRs reviewed. (MR 6) Findings include: A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 1/30/25 revealed: “ ...A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment ...An initial Plan of Care, based on findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment ... “ A review of medical records on 1/29/25 between approximately 9:30 am - 11:00 am revealed: MR6: Peritoneal Dialysis (PD) patient admit date 11/16/21. MR contained a consent to treat signed on 11/16/21. EMP1 (MCS) was unable to obtain records for the initial RN assessment and the first dialysis treatment date and time. MR6 contained an IDT Patient POC Meeting Report noting the “ Date of First Dialysis: 12/13/2021 “ the POC Meeting was completed on 2/23/22, 72 days after the first dialysis date and 99 days after the consent to treat was signed. The facility failed to complete an IDT Patient Assessment and Plan of Care within 30 calendar days of MR6 ’ s admission date. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 pm.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 46886 Based on a review of policies and medical records (MR) and interviews with staff (EMP), the facility failed to complete a comprehensive reassessment within 90 days of admission for one (1) of eight (8) MRs reviewed. (MR6) Findings include: A review of facility policy Interdisciplinary Team (IDT) Patient Assessment and Plan of Care on 1/30/25 revealed: “ After completion of the 90 Day re-assessment, the Interdisciplinary Team will conduct an IDT meeting to make adjustments to the Plan of Care. This meeting and initiation of the updated Plan of Care must occur within 15 days of completion of the re-assessment ...90 Day Assessment Re-assessment initiated on Day 91, completed within 30 days ... “ A review of medical records on 1/29/25 between approximately 9:30 am - 11:00 am revealed: MR6: Peritoneal Dialysis (PD) patient admit date 11/16/21. MR6 contained a consent to treat signed on 11/16/21. EMP1 (MCS) was unable to obtain records for the first RN assessment and the first dialysis treatment date and time. MR6 contained an IDT Patient POC Meeting Report noting the “ Date of First Dialysis: 11/16/2021 “ the POC Meeting was completed on 4/27/22, 162 days after the noted first date of dialysis for MR6. The facility failed to follow policy and complete a comprehensive reassessment within 90 days of admission for MR6. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 pm.”

“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 reviews of medical records (MR), policies, and interviews with staff, the facility failed to monitor the patient per facility protocol for three (3) of five (5) in-center hemodialysis MRs reviewed. (MRs 3, 4, 5) Findings include: A review of Pre-Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment policy on 1/30/25 revealed: “ Intradialytic Data Collection/ Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT (Patient Care Technician) or licensed nurse includes: Vital signs and treatment monitoring ...non-nocturnal treatments are completed at least every thirty (30) minutes...At a minimum, obtain and document the following: Blood pressure, heart or pulse rate, blood and dialysate flows, arterial and venous pressures, fluid removal and/or replacement, vascular access visible and line connections intact, patient subjective statements i.e., patient report on overall health, any complaints ...Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately...Blood pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg Diastolic greater than or equal to 100 mm/hg or less than 50 mm/Hg...Heart or Pulse rate Pre/Intra/Post: less than 60 beats per minute or greater than 100 beats per minute ... “ A medical record (MR) review conducted on 1/30/25 between approximately 9:00 am to 12:00 pm revealed: MR3: Admit date: 10/6/10. MR3 contained a Treatment Details Report (TDR) sheet dated 1/13/25. Patient Care Technician #1 (PCT1) documented Systolic Blood Pressures (SBP) of 84 and 72 with an intervention but failed to document notification of the RN as per facility policy. MR4: Admit date: 6/25/24. MR4 contained Treatment Details Report (TDR) sheets dated 1/18/25 and 1/23/25 with Diastolic Blood Pressures (DBP) greater than 100 mm/Hg. TDR dated 1/18/25 PCT2 documented DBPs of 108, 100, and 112. TDR dated 1/23/25 PCT2 documented DBPs of 107-125 and an SBP of 200. 1/18/25 and 1/23/25 TDRs failed to contain documented RN notification of abnormal vital signs as per facility policy. TDRs dated 1/9/25 and 1/14/25 failed to document intradialytic vital signs at least every thirty minutes as per facility policy. MR5: Admit date: 11/11/24. MR5 contained a Treatment Details Report (TDR) sheet dated 1/13/25. PCT3 documented heart rates of 138, 142, 147, and 39 but failed to document notification of the RN as per facility policy. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 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 observations, reviews of medical records (MR), policies, and interviews with staff the facility failed to provide the patient ’ s ordered dialysis prescription treatment for four (4) of five (5) in-center hemodialysis MRs reviewed. (MRs 1, 2, 3, 5) Findings include: A review of Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment policy on 1/30/25 revealed: “ Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of flow rate which is verified and documented when the ordered rate it 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 include ...blood flow rate ...dialysate flow rate. Intradialytic (during dialysis) treatment monitoring which may be performed by the PCT or licensed nurse includes: ...at a minimum, obtain and document ...blood and dialysate flows ...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... “ A prescription observation conducted on 1/27/25 at approximately 11:45 am at dialysis station #10 revealed: IDT Patient Profile Worksheet prescription specified, “ ...Start date 1/13/2025 ...Dialysate Flow Rate 800 mL/min. A review of MR1 ’ s dialysis machine settings revealed a DFR of 600 ml/min, 200 mL/min less than the ordered DFR. A medical record (MR) review conducted on 1/30/25 between approximately 9:00 am to 12:00 pm revealed: MR1: Admit date 7/19/13. MR1 contained Treatment Details Report (TDR) sheets dated 12/27/24, 12/29/24, 1/3/25, 1/13/25, 1/22/25, and 1/24/25 with dialysis prescriptions listing a Dialysate Flow Rate (DFR) of 800 milliliters per minute. TDR sheets dated 12/27/24, 1/3/25, 1/13/25, and 1/22/25 documented a DFR of 700 ml/min, 100 ml/min less than the prescribed rate. TDR sheet dated 12/29/24 documented a DFR of 500 ml/min, 300 ml/min less than the prescribed rate. TDR sheet dated 1/24/25 documented a DFR adjusted to 600 ml/min, 200 ml/min less than the prescribed rate. Facility staff failed to provide MR1 ’ s prescribed DFR during a 1/27/25 station observation and during the 12/27/24, 12/29/24, 1/3/25, 1/13/25, 1/22/25, and 1/24/25 treatment dates and failed to provide a physician ’ s order for an adjusted DFR for all affected treatment dates as per facility policy. MR2: Admit date 8/5/24. MR2 contained a Treatment Details Report (TDR) sheet dated 1/22/25 with a prescribed Blood Flow Rate (BFR) of 450 ml/min. Facility staff documented a BFR of 400, 50 ml/min less than prescribed, and failed to document the reason for BFR adjustment as per policy. TDR sheet dated 1/24/25 listed a prescribed Dialysate Flow Rate (DFR) of 800 ml/min and noted a DFR of 500 ml/min, 300 ml/min less than the prescribed rate. Facility staff failed to provide MR2 ’ s ordered dialysis prescription on 1/22/25 and 1/24/25 and failed to follow facility policy requiring documentation of a reason for adjusting intradialytic BFRs or obtaining a physician orders for a changes to a DFR. MR3: Admit date 10/6/10. MR3 contained Treatment Details Report (TDR) sheets dated 1/13/25 and 1/15/25 with a prescribed Dialysate Flow Rate (DFR) of 800 ml/min. Facility staff documented DFRs of 700 ml/min, 100 ml/min less than the prescribed rate and failed to obtain a physician order for adjusting the DFR. MR5: Admit date 11/11/24. MR5 contained a Treatment Details Report (TDR) sheet dated 1/15/25 with a prescribed Blood Flow Rate (BFR) of 400 ml/min. Facility staff documented a BFR of 350 ml/min, 50 ml/min less than the prescribed rate. TDR dated 1/24/25 contained a prescribed treatment time of 210 minutes. Facility staff documented a total treatment time of 130 minutes, 80 minutes less than the prescribed treatment time. Facility staff failed to provide MR5 ’ s ordered dialysis prescription on 1/15/25 and 1/24/25 and to follow facility policy which required staff to document the reason a BFR could not be sustained per prescription or to document the reason a prescribed treatment duration could not be met. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 pm.”

“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 prescription observations (VER), employee interviews, and reviews of medical records (MR) the staff failed to follow facility policy for preparation and administration of parenteral medications for one (1) of five (5) prescription verification observations (VER). (VER4) Findings include: A review of Preparation and Administration of Parenteral Medications policy on 1/30/25 revealed: “ Label the syringe with the patient ’ s name, name of the prescribed medication, dose, date, time, and initials of licensed teammate preparing the dose. Preprinted labels may be used if available ... “ Prescription Verification Observation (VER) #4 conducted on 1/28/25 at approximately 10:00 am at station #3 revealed a heparin syringe with a hand-written label reading “ Hourly 1.2 “ attached to the dialysis circuit via the heparin administration line. The syringe label, prescription, and machine settings were reviewed with EMP3, RN clinical charge nurse and it was determined the medication label did not clearly list the heparin dosage. A review of MR10 ’ s 1/28/25 Treatment Details Report (TDR) on 1/29/25 revealed a prescription of “ Heparin 400 Units/Hr Infusion, Hourly Dose Infusion Rate: 0.4 ml/hr, Stop time for hourly dose before end of treatment: 60 minutes [4 hour total HD treatment, 3 hour heparin infusion] concentration 1:1000 Units/mL. “ Facility staff failed to follow policy and clearly label MR10 ’ s heparin infusion syringe with the prescribed dose. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 pm.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 46886 Based on a review of policies and medical records (MR) and interviews with staff (EMP) the facility failed to maintain complete, accurate, and accessible records for two (2) of eight (8) MRs reviewed. (MRs 6, 7) Findings include: A review of Medical Records Custodian and Maintenance policy revealed, “ ...The responsibilities of the Custodian of medical records include: Verifies that the medical records are complete, documented accurately, and maintained in accordance with accepted professional standards and practices ...Medical records will be made available under stipulation of confidentiality for inspection by authorized agents ...all manual flowsheets are to be filed and retained, in the event documentation is written, signed, and dated on an electronic printed out document it should be retained and filed in the medical record. All medical record entries and documents are properly dated and authenticated by the physician and or clinical teammate ... A review of medical records on 1/29/25 between approximately 9:30 am - 11:00 am revealed: MR6: Peritoneal Dialysis (PD) patient. Admit date 11/16/21. MR6 contained a 4/27/22 IDT Patient POC Meeting Report noting “ Date of First Dialysis: 11/16/2021 and a 2/23/22 IDT Patient POC Meeting Report noting “ Date of First Dialysis: 12/13/2021. “ EMP1 was unable to obtain a record of the initial nursing assessment or the first dialysis treatment to determine the actual first date of dialysis. MR7: Home Hemodialysis patient. Admit date 6/21/2010. EMP1 was unable to obtain documentation of an initial RN assessment, First Dialysis Treatment, 30-day IDT Assessment or 90-day IDT Assessment. During a 1/30/25 interview with EMP1 (MCS) and EMP2 Facility Administrator it was determined that the missing information was “ thinned from the chart “ and the documentation was not available for surveyor review. The facility failed to maintain complete, accurate, and accessible records for MRs 6 and 7. The finding was reviewed with EMP1 (MCS), EMP2 (FA), EMP3 (RN), EMP4 (LSW), EMP5 (ROD), and EMP6 (RDN) during an exit conference on 1/30/25 at approximately 2:15 pm.”