Davita Thorn Run Dialysis

“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: 38039 Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to assess and/or manage patient’s blood pressure for one (3) three of five (5) hemodialysis patients reviewed (MR1, MR4, and MR6). Findings include: Review of facility policy completed on 2/1/24 at approximately 3:00 p.m. revealed: TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, i For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ... Review of MR completed on 2/1/24 between approximately 10:00 a.m. and 12:00 p.m. revealed: MR1- Admission date 10/30/19. Treatment sheets reviewed dated between 1/6/24- 1/30/24. Treatment sheet dated 1/23/24 revealed patient was assessed at 12:03 p.m. Patient was not assessed again until 1:03 p.m. (60 minutes between assessments). MR4- Admission date 11/8/22. Treatment sheets reviewed dated between 12/31/23-1/26/24. Treatment sheet dated 1/10/24 revealed patient was assessed at 8:31 a.m. Patient was not assessed again until 9:31 a.m. (60 minutes between assessments). MR6- Admission date 4/2/21. Treatment sheets reviewed dated between 1/12/24-1/29/24. Treatment sheet dated 1/29/24 revealed patient was assessed at 10:33 a.m. Patient was not assessed again until 11:34 a.m. (61 minutes between assessments). Interview completed on 2/1/24 at approximately 3:10 p.m. with the facility administrator confirmed the above findings.”

“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: 38039 Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure blood flow rate (BFR) and/or dialysate flow rate (DFR) were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of five (5) MRs reviewed (MR4 and MR6). Findings include: Review of facility policy completed on 2/1/24 at approximately 3:00 p.m. revealed: TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, i. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ... Review of MR completed on 2/1/24 between approximately 10:00 a.m. and 12:00 p.m. revealed: MR4-Admission date 11/8/22. Review of treatment sheets dated between 12/31/23-1/26/24. Review of patient orders dated 12/29/22: blood flow rate (BFR) 350 and dialysate flow rate (DFR) 800. Treatment sheet dated- 1/12/24 DFR ran at 500 the entire treatment time. Review of treatment sheets dated between 12/31/23-1/26/24. Review of patient orders dated 1/12/24 blood flow rate (BFR) 350 and dialysate flow rate (DFR) 800. Treatment sheet dated- 1/12/24 DFR ran at 500 the entire treatment time. MR6- Admission date 4/2/21. Review of treatment sheets dated between 1/12/24-1/29/24. Review of patient orders dated 12/18/23: blood flow rate (BFR) 450, dialysate flow rate (DFR) 600. Treatment sheet dated-1/15/24 BFR ran at 400 the entire treatment time. Interview completed on 2/1/24 at approximately 3:10 p.m. with the Facility administrator confirmed the above findings.”