Davita Longs Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 41743 Based on review of the facility’s Emergency Preparedness Program (EPP) and interview, the dialysis facility failed to ensure staff demonstrated knowledge of emergency preparedness procedures. Findings include: Review of the facility EPP on 5/22/24 at 11:30 AM revealed no documented evidence of staff demonstrated knowledge of emergency procedures. During an interview on 5/22/24 at 12:50 PM, the Administrator confirmed the findings.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 41743 Based on observation, interview and review of facility policy and procedure, the dialysis facility failed to ensure that a system was in place to ensure that medications were secure at all times. Findings include: Observations on 5/21/2024 at 8:40 AM to 10:35 AM of the treatment room floor revealed (2) prefilled syringes labeled heparin and an open multidose vial of heparin lying on the medication area countertop with no staff in the immediate vicinity and medications unsupervised. During an interview on 5/22/2024 at 1:28 PM, the Clinical Manager stated, “Medications should be locked when staff is not present”. Facility policy, entitled “Medication Policy” revealed, “Medications are to be stored in locked areas if not under supervision”.”

“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: 41743 Based on record review, interview and review of facility policy and procedures, the dialysis facility failed to ensure the physician was notified of elevated blood pressures for 1 of 5 charts reviewed. (Patient #1). Findings include: Review of Patient #1’s record on 5/22/24 at 9:19 AM revealed Patient #1 was admitted to the dialysis facility on 3/20/24 with a diagnosis of End Stage Renal Disease. The Treatment Record dated 4/29/24 indicated Patient #1’s blood pressure was 201/108 after dialysis was completed and there was no documented evidence the physician was notified of the elevated blood pressure. The Treatment Record dated 5/08/24 indicated Patient #1’s blood pressure was 201/104 after dialysis was completed and there was no documented evidence the physician was notified of the elevated blood pressure. During an interview on 5/22/24 at 1:00 PM, the Clinical Manager (CM) stated, “The staff should have notified the MD (Medical Doctor).” Facility policy, entitled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT,” revealed, “ ...ABNORMAL FINDINGS ...Blood Pressure Post Treatment ...Standing systolic BP (blood pressure) greater than 140 mm/Hg ...Standing diastolic BP greater than 90 mm/Hg ...”.”