Davita City Line Dialysis

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 45377 Based on observations (OBS) of the in-center treatment (ICTX) area and interviews with the facility administrator and manager of clinical services, the facility failed to remove expired supplies and medications from the ICTX area for two (2) of two (2) observations (OBS): OBS #1 and OBS #2. Findings include: Facility Policy 1-05-10 Infection Control for Dialysis Facilities, reviewed on July 21, 2025 at approximately 3:00 PM reads in part, “ Supplies will be stored in a manner that maintains their integrity. “ The results of Monthly Infection Control (IC) Audits conducted by the facility, reviewed on July 22, 2025 at approximately 12:00 PM, found the following: IC Audits conducted 2/17/2025, 4/28/2025, 05/30/2025, and 06/24/2025 noted that “ all medications, medical treatment supplies, and lab supplies are not expired. “ Observations (OBS) of the in-center treatment area conducted July 21, 2025 from 9:00 AM to 12:30 PM, and July 22, 2025 from 7:30 AM to 8:30 AM revealed the following: OBS #1 Drawer #3, located in the nurses ’ workstation across from Patient Station 17 contained four (4) White Saniguard Catheter Caps, lot #2200044, expired 03/31/2025; ten (10) Blue Saniguard Catheter Caps, lot #2200057, expired 04/22/2025, and one (1) Blue Saniguard Catheter Cap, lot # 1900070, expired 05/07/2022. Drawer #1, located in the nurses ’ workstation across from Patient Station 8 contained five (5) White Saniguard Catheter Caps, lot #2200044, expired 03/31/2025, one (1) Blue Saniguard Catheter Cap, lot #2200057, expired 04/22/2025. Laboratory Area, top right cabinet contained one (1) Penn Medicine Transplant Institute Monthly Screening Kit, lot #4004121120, expired 10/31/2022. OBS#2 Medication Refrigerator located in the nurses ’ workstation across from Patient Station #2 contained one (1) box of ten (10) Influenza Fluzone High Dose Vaccines, lot# U8429AA, expired 06/2025. An interview conducted with the facility administrator and manager of clinical services on July 23, 2025 starting at 2:30 PM 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: 45377 Based on review of facility policy, hemodialysis (HD) treatment records, medical records (MR), and an interview with the facility administrator and manager of clinical services, the facility failed to ensure the HD blood flow rate (BFR) was administered per physician order for four (4) of seven (7) MR’s reviewed: MR#1, MR#2, MR#6, and MR#7 Findings include: Facility Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment reviewed on July 21, 2025 approximately 8:00 PM states, “Policy: 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment...The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation ....Prescription components include but are not necessarily limited to: f. Blood flow rate (BFR) flow rate (DFR)... If the dialysis prescription is not being met (including DFR or change to/inability to obtain prescribed BFR) the reason will be documented and the licensed nurse informed...” A review of medical records (MR) and hemodialysis treatment records was conducted on July 22, 2025 starting at 9:50 AM and again on July 23, 2025 starting at 7:30 AM. MR #1: Admission Date: 06/10/2025. The hemodialysis order called for a BFR = 400 mL/min. Treatment duration: 3 hours, 30 minutes. The HD Treatment Record for 07/08/2025 revealed: 6:14 AM: Treatment was initiated at the correct BFR 400mL/min 6:31 AM to 8:01 AM: BFR was decreased to 250 mL/min 8:31 AM: BFR was increased to 270 mL/min 9:01 to 10:01 AM: BFR was increased to 300 mL/min The HD Treatment Record for 07/19/2025 revealed: 7:07 AM BFR was initiated at the incorrect rate of 300 mL/min 8:01 AM BFR was decreased to 235 mL/min until the end of treatment. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates nor was there documentation of a reason as to why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR #2: Admission Date: 11/25/2024. The hemodialysis order called for a BFR of 400 mL/min. Treatment duration: 4 hours, 30 minutes. The HD Treatment Record for 07/09/2025 revealed: 05:59 AM Treatment was initiated at the correct BFR of 400 mL/min. 08:30 AM BFR was increased to 450 mL/min until the end of treatment. The HD Treatment Record for 07/14/2025 revealed: 06:13 AM. Treatment was initiated. BFR was initiated at the incorrect rate of 450 mL/min from 06:13 AM until 08:02 AM at which time it was decreased to the prescribed rate of 400 mL/min. for the remainder of the treatment. The HD Treatment Record for 07/18/2025 revealed: 06:02 AM. Treatment was initiated. BFR was initiated at the incorrect rate of 450 mL/min for the entire treatment. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates nor was there documentation of a reason as to why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR#6 Admission Date: 06/09/2022. The hemodialysis order called for a BFR 400 mL/min. Treatment duration: 4 hours. The HD Treatment Record for 07/10/2025 revealed: 07:02 AM Treatment initiated. BFR incorrectly initiated at 450 mL/min for the entire treatment. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates nor was there documentation of a reason as to why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR#7 Admission Date: 01/09/2020. The hemodialysis order called for a BFR 425 mL/min. Treatment duration: 4 hours. The HD Treatment Record for 07/08/2025 revealed: 06:46 AM Treatment initiated. BFR started at the correct rate of 425 mL/min. 07:02 AM BFR decreased to 400 mL/min and remained at that rate for the entire treatment duration. The HD Treatment Record for 07/10//2025 revealed: 06:53 AM Treatment initiated. BFR incorrectly initiated at 420 mL/min and remained at that rate for the entire treatment duration. The HD Treatment Record for 07/19/2025 revealed: 06:44 AM. Treatment initiated. BFR started at the correct rate of 425 mL/min 06:52 AM. BFR decreased to 410 mL/min until 8:02 AM 08:02 AM: BFR increased to the correct rate of 425 mL/min and remained at that rate for the entire treatment duration. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates nor was there documentation of a reason as to why the BFR was administered at a rate different from the prescribed amount for any of the above dates. An interview conducted with the facility administrator and manager of clinical services on July 23, 2025 starting at 2:30 PM confirmed the above findings.”

“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: 45377 Based on a review of medical records (MR), hemodialysis treatment records, facility policies, and an interview with the facility administrator and manager of clinical services, the facility failed to ensure that a nurse and/or physician was informed, per policy, of abnormal vital signs and patient complaints of chest pain for two (2) of seven (7) MR ’ s reviewed: MR#4 and MR#5. Findings include: Facility Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment reviewed on 07/21/2025 at approximately 8:00 PM states in part, “Abnormal findings or findings outside of any patient specific physician ordered parameters 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.....If an abnormal finding(s) 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....In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings.” Under the subtitle, “Abnormal Findings,”: “Blood pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg... Blood pressure Intra-Dialytic: Systolic greater than 180 mm/HG or less than 90 mm/HG, Diastolic greater than or equal to 100mm/HG or less than 50 mm/HG, .....Blood pressure Post Treatment: If the patient can stand: Standing systolic BP (blood pressure) 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...Patient complains of shortness of breath, difficulty breathing ...Pain, chest pain. “ Facility Policy 1-10-02 Chest Pain/Angina reviewed on 07/22/2025 at approximately 1:30 PM reads in part, Licensed nurse teammate assesses patient; Decrease blood flow rate to 150 mL/min; Decrease ultrafiltration rate; If hypotensive, restore the blood pressure per Hypotension procedure; Notify nephrologist for orders; Administer medications as ordered; Administer oxygen as ordered; If pain persists, discontinue treatment. Notify nephrologist and arrange transport of patient via EMS to emergency room; Document orders, event, action taken and patient response to treatment in the patient ’ s electronic health record.” A review of medical records (MR) and hemodialysis treatment records was conducted on July 22, 2025 starting at 9:50 AM and again on July 23, 2025 starting at 7:30 AM. MR#4 Admission Date 12/23/2018 contained hemodialysis (HD) treatment orders for a Blood Flow Rate (BFR) 500 ml (milliliters)/min (minute), Dialysis Flow Rate 800 mL/min, and a Maximum Ultrafiltration (UF) Rate 13/ml/kg/hr. Treatment time: 4 hours. The patient had an order for Nitrostat 0.4 milligrams, every 5 minutes as needed along with provider instructions which stated: “ do not exceed more than two (2) doses. Notify provider. “ The HD treatment record for 07/04/2025 revealed the following: 12:02 PM Treatment initiated by patient care technician (PCT). BFR 500, DFR 800 2:40 PM PCT Note: Patient reports chest pain. 2:41 PM PCT Note: BFR lowered 300; pt refused O2 (oxygen) at this time 3:03 PM PCT Note: Pt chest pains same; BP recheck (187/83), RN aware at chair side, will recheck BP. BFR 300, DFR 800 2:05 PM PCT Note: BP recheck 162/85, BFR 300, DFR 800 2:11 PM RN Note: Patient reports chest pain; oxygen was given at 2l (liters) by nasal cannula; Pt. refused clonidine. 2:12 PM RN Note: SO2 95% (oxygen saturation level obtained by pulse oximetry) 2:24 PM RN Note: Pt. refused nitro (nitrostat used for check pain) 2:32 PM PCT Note: Patient face, vascular access, and blood line connections visible; pt. resting, will monitor. BP 133/68. BFR 300, DFR 800. 4:02 PM PCT Note: Treatment terminated; Patient blood returned without complications. Normal saline rinseback given; BP low (99/57). Will recheck. Post Treatment BP: 137/58 (sitting); 130/69 (standing) Post Treatment HR: 75 BPM (sitting); 102 BPM (beats per minute) (standing) Nurses ’ Post Assessment Note states, “ HR 102, was rechecked using pulse oximeter. Pt c/o chest pain. RN instructed the pt to proceed to ER (emergency room). Education provided regarding s/s (signs & symptoms) of hyperkalemia (high potassium level), K=5.8 and potential complications. Pt. verbalized understanding. “ An interview conducted with the facility administrator (FA) and manager of clinical services (MCS) on July 23, 2025 at approximately 1:30 PM found that the FA and MCS confirmed that there were no additional clinical notes in the electronic medical record pertaining to the situation. The FA/MCS stated that most likely, the patient refused EMS services but confirmed that there was no documentation of the refusal. There was no documentation at 2:40 pm when the patient began to complain of chest pain that vital signs were checked, nor that the RN was notified. The BFR was decreased at 2:41 PM to 300 mL/min for the remainder of the treatment which is contrary to the Chest Pain/Angina Policy which states that the BFR should be lowered to 150 mL/min. The RN was at the patient ’ s chair side 23 minutes after the patient reported chest pain. Vital signs were not rechecked from 3:05 PM until 3:32 PM for a patient complaining of chest pain. There was no indication that EMS was called to transport the patient to the emergency department (or documentation of patient refusal), nor any indication that the physician was notified of the situation. The HD Treatment Record for 07/09/2025 revealed the following: 4:32 PM Treatment initiated. 5:03 PM PCT Note: Patient reports shortness of breath; nurse notified of patient complaints; 2L O2 given via nasal cannula. 5:30 PM PCT Note: BP (70/50) and HR (73) check. 5:32 PM PCT Note: BP 109/54 and HR (101) recheck. 6:00 PM RN Note: No voiced discomfort. 7:57 PM PCT Note: Treatment terminated. Nurses ’ Post Assessment Note states, “ asymptomatic, stable. “ There was no documentation that a respiratory rate was checked when the patient complained of shortness of breath, nor any time thereafter, nor any documentation specifically noting that the patient ’ s shortness of breath subsided at the time of discharge. MR#5 Admission Date 11/09/2021 contained HD treatment orders for a BFR 350 mL (milliliters)/min (minute), DFR 500 mL/min. Treatment time: 4 hours. The HD treatment record for 07/08/2025 revealed the following: 11:20 AM: Treatment initiated 12:31 PM:PCT Note: BP 184/105 1:01 PM: PCT Note: BP 185/104. RN aware 1:31 PM: PCT Note: BP 195/99 2:01 PM: PCT Note: BP 206/107 2:03 PM: PCT Note: BP 203/90 2:31 PM: PCT Note: BP 216/101 2:54 PM: RN Note: Patient blood pressure is elevated (179/100) 2:57 PM: RN Note: Improving. Cuff adjusted 3:02 PM: PCT Note: BP 178/91. 1:17 PM: PCT Note: BP 168/91. Treatment terminated There was a delay in the PCT notifying the RN of the continual elevation of the patient ’ s blood pressure. The HD Treatment Record for 07/10/2025 revealed the following: At the termination of the HD treatment (3:23 PM), the patient ’ s blood pressure was 199/105. The post assessment note by the RN states, “ BP elevated post-tx. Will notify MD. “ There was no documentation on the treatment record indicating that the physician was notified of the elevated blood pressure at the end of the HD treatment. An interview with the FA and MCS on July 23, 2025 at approximately 1:15 PM confirmed that there was no documentation in the electronic medical record of physician notification. An interview conducted with the facility administrator and manager of clinical services on July 23, 2025 starting at 2:30 PM confirmed the above findings.”