Davita Upper Darby Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 43085 Based on observations, review of agency policy and procedures, and interview with the facility administrator, it was determined that the facility staff did not practice proper hand hygiene during central venous catheter (CVC) exit site care and initiation of dialysis treatments, for one (1) of ten (10) observations. (Observation #2) Findings include: Reviewed facility ’ s policies and procedures on April 2, 2024 from 9:10AM until approximately 9:30AM. Procedure 1-04-02B titled “Central Venous Catheter (CVC) with ClearGuard HD Antimicrobial End Caps Procedure” states, “ ...1. Perform hygiene per procedure ...4. Remove old dressing and discard ....7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 8. ..using aseptic technique, clean exit site ...wait 60 seconds for air dry time...10. Remove gloves and discard, perform hand hygiene per procedure and re-glove ...12. Place sterile 2x2 gauze over the catheter exit site ...Seal edges of gauze with tape ...14. Remove gloves and discard, perform hand hygiene per procedure and re-glove ...16. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds ...17. Attach sterile 10ml syringes to the arterial and venous limbs ... “ Observation tour of treatment area was conducted on April 1, 2024 from approximately 9:30AM until approximately 1:15PM revealed: Observation #2: At approximately 11:04AM, PCT2 was observed performing central venous catheter (CVC) exit site care for a patient at station #4. PCT2 performed hand hygiene, donned clean gloves, and performed central venous catheter exit site care using proper technique. After PCT2 applied the sterile dressing to the CVC exit site, PCT2 did not remove gloves, perform hand hygiene or don clean gloves prior to initiation of dialysis treatment. PCT2 used the same gloved hands to close the catheter clamps, and disinfect CVC hubs. PCT2 then removed gloves, performed hand hygiene, donned new gloves and connected the sterile syringes to the hubs. An interview with the agency facility administrator, regional director, and clinical services director on April 4, 2024 at approximately 1:35PM confirmed the above the 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: 43085 Based on review of facility policy, medical records (MR), dialysis treatment documentation (flowsheets), and interview with the facility administrator, it was determined that the medical director failed to ensure that all policies and procedures relative to patient care and safety, were adhered to by all individuals who treat patients in the facility for three (3) of seven (7) in-center hemodialysis medical records reviewed (MR2, MR5, and MR7). Findings Included: Policy 1-03-08, titled “ Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment “ states, “ ...Pre-Treatment Data Collection/Assessment - 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered 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 ....6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis ...Intradialytic Data Collection/Assessment - ...11. 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 judgement based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient ’ s medical record ...Blood Pressure (BP) Pre-Dialysis: 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. 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 ...Blood Pressure Post-Treatment: ...Standing systolic BP 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 ... Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ...Pre/Intra/Post Patient Reports/Complaints and/or Teammate Observations of: Pain, chest pain ...Weakness or numbness ...Cramping ...Changes in level of consciousness, ability to communicate ... “ Reviewed medical records (MR) on April 2, 2024 from 11:55AM until approximately 2:50PM and April 3, 2024 from approximately 9:30AM until approximately 12:30PM. Reviewed dialysis treatment documentation (flowsheets) on April 2, 2023 from approximately 6:00PM until approximately 7:00PM and April 3, 2024 from approximately 9:00AM until approximately 9:30AM. MR2. Admission Date: 10/14/2022. DOB: 12/18/1958. Dialysis Treatment Order Date: 3/7/2024; Frequency: Three (3) days per week; Treatment Duration: 4 hours. Treatment Record for 3/25/2024: Pre-Treatment Blood Pressure (BP) sitting 182/97, documented by PCT. 9:28AM BP 175/98 “Patient access cannulated without difficulty; Normal saline prime given; Treatment started without complications; Patient reports SOB; Heart skipping beat this morning before treatment. RN notified” documented by PCT. 9:31AM Update “ BP elevated “ documented by PCT. 9:31AM BP 180/103 “ Patient awake; Alert; States no complaints at this time “ documented by PCT. 10:01AM BP 173/98 “ Patient awake; States no complaints at this time “ documented by RN. 10:31AM BP 178/105 “ Patient awake; Alert; States no complaints at this time; Patient BP trending high; Patient on phone “ documented by RN. 11:01AM BP 176/96 “ Patient awake; Alert; States no complaints at this time; Patient on phone “ documented by PCT. 11:31AM BP 171/99 “ Patient awake; Alert; State no complaints at this time; Patient BP trending high; RN notified “ documented by PCT. 12:01PM BP 174/102 “ Patient awake; Alert; States no complaints at this time; Patient talking on phone “ documented by PCT. 12:31PM BP 172/111 “ Patient awake; Alert; States no complaints at this time; Patient BP trending high “ documented by PCT. 12:33PM BP 172/103 “ Patient awake; Alert; States no complaints at this time “ documented by PCT. 1:01PM BP 176/98 “ Patient reports cramping in left leg; UF paused “ documented by PCT. 1:10PM Manual Entry “ Patient reports cramping worsening; 100ml NSS given “ documented by PCT. 1:28PM BP 175/98 “ Patient blood returned without complications; Treatment terminated; Patient reports cramp is gone “ documented by PCT. Post-Treatment sitting B/P 180/98, standing B/P 170/94, documented by PCT. No evidence documented that RN was notified during the last two (2) hours of treatment of BP readings out of facility parameters and that patient complained of cramping. No evidence documented that physician was notified. MR5. Admission Date: 8/30/2022. DOB: 4/9/1956. Dialysis Treatment Order Date: 11/15/2023; Frequency: Three (3) days per week; Treatment Duration: 4 hours and forty-five (.75) minutes. Treatment Record for 3/28/2024: Pre-Treatment Blood Pressure (BP) sitting 128/60, documented by PCT. 6:55AM BP 118/51 “Treatment started without complications” documented by PCT. 7:02AM BP 112/55 “ Patient awake; Alert; States no complaints at this time “ documented by PCT. 7:32AM BP 107/47 “ Patient awake; States no complaints at this time “ documented by PCT. 7:41AM BP 101/49 “ Patient states no complaints at this time; BP recheck; Patient monitored “ documented by PCT. 8:08AM BP 77/47 “ BP recheck; Patient alert and states no complaints “ documented by PCT. 8:09AM BP 90/42 “ Cuff adjusted; RN notified; Patient will remain monitored “ documented by PCT. 8:23AM BP 105/44 “ BP rechecked; Patient monitored “ documented by PCT. 8:32AM BP 86/35 “ Patient blood pressure low “ documented by PCT. (9:04AM Update “ UF turned off “ documented by PCT.) 8:51AM BP 96/83 “ Patient states no complaints at this time; BP recheck “ documented by PCT. 9:02AM BP 83/38 “ Patient blood pressure low; Patient monitored eyes closed; Patient resting “ documented by PCT. 9:32AM BP 50/40 “ Patient blood pressure low “ documented by PCT. 9:39AM BP 103/67 “ BP recheck; Patient monitored “ documented by PCT. 10:05AM BP 126/96 “ Patient monitored eyes closed; Patient resting “ documented by PCT. 10:32AM BP 81/31 “ Patient monitored eyes closed; Patient resting “ documented by PCT. 10:49AM BP 95/45 “ Treatment terminated “ documented by PCT. Post-Treatment sitting B/P 100/69, documented by PCT. No evidence documented that RN was notified during the last three (3) hours of treatment of BP readings out of facility parameters, and that physician was notified. MR7. Admission Date: 11/22/2022. DOB: 12/31/1959. Dialysis Treatment Order Date: 12/19/2023; Frequency: Three (3) days per week; Treatment Duration: 3 hours and thirty (30) minutes. Treatment Record for 3/29/2024: Pre-Treatment Blood Pressure (BP) sitting 162/88, documented by PCT. 11:00AM BP 177/76 “Treatment started without complications” documented by PCT. 11:02AM BP 154/82 “ Patient awake; Alert; States no complaints at this time “ documented by PCT. 11:32AM BP 183/84 “ Patient monitored; Watching TV no complications “ documented by PCT. 12:02PM BP 138/106 “ Patient monitored; Watching TV no complications “ documented by PCT. 12:33PM BP 191/89 “ Patient reports cramping; UF turned off “ documented by PCT. 13:02PM BP 180/155 “ Patient monitored; Watching TV no complications “ documented by PCT. 13:32PM BP 194/120 “ Patient monitored; Watching TV no complications “ documented by PCT. 14:02PM BP 163/76 “ Patient monitored; Watching TV no complications “ documented by PCT. 14:32PM BP 177/85 “ Patient monitored; Watching TV no complications “ documented by PCT. 14:34AM Updated “ Treatment terminated “ documented by PCT. Post-Treatment sitting B/P 169/87, documented by PCT. No evidence documented that RN was notified of BP readings out of facility parameters and that patient complained of cramping. No evidence documented that physician was notified. An interview with the agency facility administrator, regional director, and clinical services director on April 4, 2024 at approximately 1:35PM confirmed the above the findings.”