Davita Grant One 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: 40929 Based on employee (EMP) interviews, observations (OBS), review of facility policy and an interview with the facility administrator, the facility failed to ensure staff/employees follow its policy for medication preparation for one (1) of two (2) medication preparation observations (OBS#1). Findings include: A review of policy, 1-06-01A “Preparation and Administration of Parenteral Medications” on 1/29/25 at approximately 12:00 PM stated “7. If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol prep pad. A new alcohol prep pad is used prior to each time a vial is entered...” Observation of the treatment area was conducted on 1/27/25, from approximately 9:45 A.M. to 12:30 P.M. OBS#1 was conducted on 1/27/25 at approximately 11:38 AM. Medication preparation performed by PCT # 1. PCT #1 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial for two (2) times with a needles syringe. An interview with the facility administrator on 1/29/25, at approximately 2:00 P.M. 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: 40929 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 three (3) of seven (7) MR reviewed: MR#1, 3, & 5 Findings include: A review of the facility’s policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy: 1-03-08) on 1/29/25 at approximately 12:00PM 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;” “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 took place on 1/28/25 from approximately 9:45AM-3:00PM and revealed the following: MR #1. Start of Care at facility: 11/24/18. HD (hemodialysis) Treatment on 1/15/25 was initiated at 6:26 AM by the PCT (patient care technician) and revealed the following: at 6:34 AM the PCT documented a BP of 202/90. BP was checked again by the PCT at 7:05AM and found to be 206/94, 7:34 AM to be 205/97, 8:04 AM to be 233/99, 8:34 AM to be 205/91 and 9:04 AM to be 209/82 . There was no documentation of an RN intradialytic assessment. In addition, the PCT waited 30 minutes to re-check a BP of 233/99. In addition, Post-Treatment there was not a complete RN assessment documented (A complete RN post assessment includes all of the following: Vital Signs, Respiratory Assessment, Gastrointestinal, Access Assessment, Pain Assessment, Mental Status, Cardiovascular and Fluid, Mobility, and Integumentary Assessment). HD Treatment on 1/20/25 was initiated at 6:35AM by the PCT and revealed the following: at 6:35 AM BP was 203/91, at 7:04 AM was 211/93, at 7:36AM was 207/88. was no documentation of an RN intradialytic assessment. MR #3. Start of Care at facility: 11/22/24. HD Treatment on 1/13/25 was initiated at 11:35 AM by the PCT and revealed the following: at 1:14 PM BP was 205/108, at 1:04 PM was 204/106, and was rechecked again at 1:35 PM and was 169/85. There was no documentation of an RN intradialytic assessment. In addition, the PCT waited approximatley 30 minutes to re-check a BP of 204/106. In addition, Post-Treatment there was not a complete RN assessment documented (A complete RN post assessment includes all of the following: Vital Signs, Respiratory Assessment, Gastrointestinal, Access Assessment, Pain Assessment, Mental Status, Cardiovascular and Fluid, Mobility, and Integumentary Assessment). HD Treatment on 1/17/25 was initiated at 11:10 AM by the PCT and revealed the following: at 11:31 AM BP was 204/101, at 11:32 was 199/100, at 12:01 was 208/106 and was re-checked at 12:31 and was 180/87. There was no documentation of an RN intradialytic assessment. In addition, the PCT waited approximatley 30 minutes to re-check a BP of 208/106. MR #5. Start of Care at facility: 5/18/21. HD Treatment on 1/22/25 was initiated at 11:56 AM by the PCT and revealed the following: at 11:56 AM BP was 165/100, at 12:03 PM was 168/107, 12:33 PM was 159/117, 12:41 PM was 161/114, at 1:07 PM was 183/113 and at 1:33 PM was 143/99. There was no documentation of an RN intradialytic assessment or notification of abnormal BP. In addition, the PCT waited approximatley 30 minutes to re-check a BP of 183/113. In addition, Post-Treatment there was not a complete RN assessment documented (A complete RN post assessment includes all of the following: Vital Signs, Respiratory Assessment, Gastrointestinal, Access Assessment, Pain Assessment, Mental Status, Cardiovascular and Fluid, Mobility, and Integumentary Assessment). An interview conducted with Facility Administrator on 1/29/25 at approximatley 2:00PM confirmed the above findings.”