Davita Roosevelt Avenue 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: 39848 Based on review of facility policies and procedures, observations, and interview with Facility Administrator and facility clinical services manager, it was determined the facility failed to ensure a sanitary environment during three (3) of twelve (12) patient care observations. OBS #1-#3. Findings include: Review of End stage renal disease (ESRD) Core Survey field manual access of AV fistula or graft for initiation of dialysis on 2/24/25 at 3:52 PM revealed: “ Action: Insert cannulation needles; tape in place; initiate treatment; remove gloves, hand hygiene. “ Review of DaVita Incenter hemodialysis policies and procedures: Title: Infection control for dialysis facilities on 2/24/25 at 4:04 PM revealed: “ Purpose: to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment; Policy: “ The Centers for Disease control (CDC) recommendations for preventing transmissions of infections among chronic hemodialysis patients (dialysis precautions) will be followed when caring for all patients. Hand Hygiene: 1. All teammates, physicians, and non-physician (NPP) will perform hand hygiene b. prior to gloving and immediately after removal of gloves, d. after patient and dialysis delivery system contact, f. between patients even if the contact is casual; 7. Disposable gloves will be worn when caring for the patient or touching the patient ’ s equipment at the dialysis station ... a. gloves should be changed when: ii. When going from a “ dirty “ area or task to a “ clean “ area or task; iii. When moving from a contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient ’ s dialysis delivery system. “ Observation #1: 2/19/25 between 9:30 AM-9:35 AM: EMP #1 was observed discontinuing treatment for patient at station # 1 and did not perform glove change or hand hygiene after disconnecting patient ‘s blood lines and touching patient ’ s blanket to place in patient ’ s belongings bag. Observation #2: 2/21/25 between 9:30 AM-9:40 AM: EMP #2 was observed discontinuing treatment for patient at station # 5 and did not perform glove change or hand hygiene after touching patient ’ s blanket then handing the blanket to EMP # 3 then touched dialysis machine. Observation # 3: 2/21/25 between 9:30 AM-9:40 AM: EMP # 3 took patient ’ s blanket from EMP # 2 and was not wearing gloves, folded blanket and placed in patient ’ s belongings bag then proceeded to remove patient ’ s blanket from patient at station # 6 with no hand hygiene or gloves. An interview conducted with the facility administrator and facility clinical services manager on 2/21/25 at approximately 2:30 PM confirmed the above findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 39848 Based on review of policies/procedures, medical records (MR), and an interview with the facility administrator and facility clinical services manager; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for three (3) out of six (6) records reviewed (MR # 3, # 5- # 6). Findings include: Review of DaVita Incenter Hemodialysis policies and procedures title: Pre-intra-post treatment date collection, monitoring and nursing assessment on 2/21/25 at 1:05 PM revealed: Purpose: “ To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment ... “ ; Policy: 2. The nursing assessment will be performed and documented by a licensed nurse ...a. the assessment includes the following components: iii. Verification of prescription including machine parameters; v. review of documentation for accuracy, completion and patient data; 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; g. dialysate flow rate; Intradialytic data collection/assessment: 9. Intradialytic treatment monitoring and data collection ...includes: a. vital signs and treatment monitoring: iii. Non-nocturnal (daytime) treatments are completed at least every thirty (30) minutes; b. At a minimum, obtain and document the following: i. blood pressure; iii. Blood and dialysate flows.. “ ; 10. If the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed. “ Review of patient dialysis treatment flow sheets on 2/21/25 from 10:30 AM-2:00 PM revealed: Review of MR # 3 treatment flow sheets revealed the following: 1. Physician dialysis order dated 1/24/25 revealed: Blood flow rate (BFR): three hundred fifty (350). 2. Treatment flow sheet on 2/3/25 revealed Blood flow rate (BFR) during treatment noted to be four hundred (400) instead of the ordered BFR of three hundred fifty (350) and no documentation showing the reason for the different BFR or that the physician was notified. 3. Treatment flow sheet on 2/7/25 revealed BFR during treatment noted to be four hundred (400) instead of the ordered BFR of three hundred fifty (350) and no documentation showing the reason for the different BFR or that the physician was notified. Review of MR # 5 treatment flow sheets revealed the following: 1. Physician dialysis order dated 2/7/25 revealed: Blood flow rate (BFR): four hundred and fifty (450). 2. Treatment flow sheet on 2/10/25 revealed Blood flow rate (BFR) during treatment noted to be four hundred (400) and no documentation showing the reason for the different BFR or that the physician was notified. Review of MR # 6 treatment flow sheets revealed the following: 1. Physician dialysis order dated 12/24/24 revealed: Blood flow rate (BFR): four hundred (400). 2. Treatment flow sheet on 2/6/25 revealed Blood flow rate (BFR) during treatment noted to be between two hundred fifty (250) and three hundred fifty (350) during entire treatment and no documentation showing the reason for the different BFR or that the physician was notified. 3. Treatment flow sheet on 2/18/25 revealed Blood flow rate (BFR) during treatment noted to be between two hundred twenty (220) and three hundred twenty (320) during entire treatment and no documentation showing the reason for the different BFR or that the physician was notified. An interview conducted with the facility administrator and facility clinical services manager on 2/21/25 at approximately 2:30 PM confirmed the above findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 39848 Based on review of policies/procedures, medical records (MR), and an interview with the facility administrator; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for four (4) out of six (6) records reviewed (MR # 1, # 3- # 5). Findings include: Review of DaVita Incenter Hemodialysis policies and procedures title: Pre-intra-post treatment date collection, monitoring and nursing assessment on 9/25/24 at 4:05 PM revealed: Purpose: “ To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment ... “ ; Policy: 1. Patient data will be obtained and documented ....a. date collection includes but is not necessarily limited to: ii. Measurement of blood pressure (BP); 2. The nursing assessment will be performed and documented by a licensed nurse ...a. the assessment includes the following components: iii. Verification of prescription including machine parameters; v. review of documentation for accuracy, completion and patient data; 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; g. dialysate flow rate; Intradialytic data collection/assessment: 9. Intradialytic treatment monitoring and data collection ...includes: a. vital signs and treatment monitoring: iii. Non-nocturnal (daytime) treatments are completed at least every thirty (30) minutes; b. At a minimum, obtain and document the following: i. blood pressure; iii. Blood and dialysate flows “ ; 10. If the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed. “ Review of patient dialysis treatment flow sheets on 9/24/24 from 1:30 PM-2:30 PM revealed: Review of MR # 1 treatment flow sheets revealed the following: 1. Physician dialysis order dated 8/23/24 revealed: Blood flow rate (BFR): three hundred fifty (350). 2. Treatment flow sheet on 8/1/24 revealed Blood flow rate (BFR) during treatment noted to be between two to three hundred (200-300) instead of the ordered BFR of three hundred fifty (350) and no documentation showing the reason for the different BFR or that the physician was notified. Review of MR # 3 treatment flow sheets revealed the following: 1. Physician dialysis order dated 8/29/24 revealed: Blood flow rate (BFR): five hundred (500). 2. Treatment flow sheet on 9/6/24 revealed Blood flow rate (BFR) during treatment noted to be three hundred fifty (350) instead of the ordered BFR of five hundred (500) from start of treatment at 10:54 AM to 1:23 PM (two hours and twenty-nine minutes) when the BFR was adjusted to the ordered rate and no documentation showing the reason for the different BFR or that the physician was notified. Review of MR # 4 treatment flow sheets revealed the following: 1. Physician dialysis order dated 9/3/24 revealed: Blood flow rate (BFR): four hundred (400); Dialysate flow rate (DFR): eight hundred (800). 2. Treatment flow sheet on 8/31/24 revealed Blood flow rate (BFR) during treatment noted to be three hundred fifty (350) instead of the ordered BFR of four hundred (400) and Dialysate flow rate (DFR) was noted to be three hundred (300) instead of the ordered DFR of eight hundred (800) from 6:39 AM to 8:17 AM which is one hour and thirty-eight minutes (1 h 38 m) until DFR was adjusted. Review of MR # 5 treatment flow sheets revealed the following: 1. Physician dialysis order dated 8/12/24 revealed: Blood flow rate (BFR): four hundred (400); Dialysate flow rate (DFR): eight hundred (800). 2. Treatment flow sheet on 8/7/24 revealed Blood flow rate (BFR) during treatment noted to be three hundred fifty (350) instead of the ordered BFR of four hundred (400) from 5:05 PM through 6:35 PM (one hour and thirty minutes) when the BFR was adjusted to the ordered rate and no documentation showing the reason for the different BFR or that the physician was notified. 3. Treatment flow sheet on 8/12/24 revealed Blood flow rate (BFR) during treatment noted to be three hundred (300) instead of the ordered BFR of four hundred (400) and no documentation showing the reason for the different BFR or that the physician was notified. 4. Treatment flow sheet on 8/14/24 revealed Dialysate flow rate (DFR) during treatment noted to be five hundred (500) instead of the ordered DFR of eight hundred (800) and no documentation showing the reason for the different DFR or that the physician was notified. 5. Treatment flow sheet on 8/19/24 revealed Blood flow rate (BFR) during treatment noted to be two hundred to three hundred fifty (200-350) instead of the ordered BFR of four hundred (400) and no documentation showing the reason for the different BFR or that the physician was notified. 6. Treatment flow sheet from 9/11/24 revealed Blood flow rate (BFR) during treatment noted to be two hundred thirty (230) instead of the ordered BFR of four hundred (400) from 1:27 PM through 3:57 PM (three hours and fifty minutes) and no documentation showing the reason for the different BFR or that the physician was notified. An interview conducted with the facility administrator on 9/25/24 at approximately 8:50 AM confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 39848 Based on review of medical records (MR), policies and procedures and interviews with facility clinical manager and facility administrator, it was determined that the facility failed to adequately monitor blood pressures during treatment in one (1) of six (6) medical records (MR) reviewed (MR #4). Findings include: Review of DaVita Incenter Hemodialysis policies and procedures title: Pre-intra-post treatment date collection, monitoring and nursing assessment on 9/25/24 at 4:05 PM revealed: Purpose: “ To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment ... “ ; Policy: 1. Patient data will be obtained and documented ....a. date collection includes but is not necessarily limited to: ii. Measurement of blood pressure (BP); 2. The nursing assessment will be performed and documented by a licensed nurse ...a. the assessment includes the following components: iii. Verification of prescription including machine parameters; v. review of documentation for accuracy, completion and patient data; 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; g. dialysate flow rate; Intradialytic data collection/assessment: 9. Intradialytic treatment monitoring and data collection ...includes: a. vital signs and treatment monitoring: iii. Non-nocturnal (daytime) treatments are completed at least every thirty (30) minutes; b. At a minimum, obtain and document the following: i. blood pressure; iii. Blood and dialysate flows “ ; 10. If the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed. “ Review of patient dialysis treatment flow sheets on 9/24/24 from 1:30 PM-2:30 PM revealed: Review of MR # 4 treatment flow sheets revealed the following: 1. Treatment flow sheet on 8/31/24 revealed one (1) episode during this treatment of blood pressure not being taken between 7:05 AM to 8:17 AM which is one hour and twelve minutes (1 h 12 m) between blood pressure checks. Blood pressure 222/171 was taken at 7:05 AM and then taken again at 8:17 AM and was 196/94. An interview conducted with the facility administrator on 9/25/24 at approximately 8:50 AM confirmed the above findings.”