Davita Charles Towne 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: 41879 Based on observation, interview and review of facility policy and procedure, the dialysis facility staff failed to follow standard infection control practices for administration of medication by 1 of 3 Registered Nurses (RN) observed. (RN #3). The findings included: On 03/25/2024 at 12:41 PM observation of the treatment room area revealed RN #3 preparing medication. RN #3 obtained a vial of Heparin, removed the cap, and failed to wipe the septum of the Heparin vial prior to drawing up the medication in the syringe. On 03/25/2024 at 12:45 PM, the findings were verified with RN #3 . Facility policy, entitled “Preparation and Administration of Parenteral Medications (Non-EPO, Non-Parsibiv) With All Dialyzer Types,” reads, “If the medication is in an 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.””

“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: 36779 Based on observation, interview and review of facility policy and procedure, the dialysis facility staff failed to ensure 1 of 2 patients observed received the correct dialysate bath per physician orders. (Patient #9). The findings include: Facility policy, entitled “ Set-Up & (and) Priming a Single Use Dialyzer Utilizing Fresenius 2009 K, K2 and T Dialysis Delivery System with Streamline Bloodlines” reads, “Verify dialysis prescription: Ensure bicarbonate and prescribed dialysis are connected to dialysis machine...Finish testing dialysis machine per facility policy. Perform alarm and pressure tests. When all the tests pass the message ‘test complete’ will display. Check temperature, conductivity and pH of dialysate using independent meter...”. On 3/27/24 at 9:50 AM, PCT #1 was observed accessing Patient #9’s left upper arm arteriovenous graft (AVG). At 9:54 AM, Registered Nurse (RN) #2 was observed reviewing the settings on the dialysis machine. Observation revealed the dialysate bath line from the dialysis machine was connected to the wall unit labeled “2 K (potassium) 2.5 Ca (calcium).” At 10:03 AM, Patient # 9 was observed receiving dialysis treatment on 2 K 2 Ca bath. During an interview with RN #2 on 3/27/24 at 10:04 AM, review of the dialysis prescription revealed a prescription order for “3 K 2.5 Ca.” RN #2 stated Patient #9 was “on the jug because it’s 3 K and the wall is 2.5 K.” At 10:06 AM, RN #2 stated dialysis is “stopped” while PCT #1 “rechecks the conductivity.” During an interview with PCT #1 at 10:08 AM, he/she stated the machine “was supposed to be connected to the jug before starting” dialysis, so RN #2 told her/him to change it to the “jug” so she/he (PCT #1) “stopped” the dialysis to “recheck the conductivity” and place the patient on the correct dialysate bath. Review of Patient #9’s record on 3/27/24 at 2:30 PM revealed the dialysis prescription ordered 2/20/24 was for a 3 K-2.5 Ca dialysate bath. Review of the Treatment Details Report revealed, “ ...10:03 AM ...Treatment started ...10:05 AM ...recheck ...” of conductivity.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 36779 Based on record review, interview and review of facility policy and procedure, the dialysis facility failed to ensure the patients blood pressures were monitored in a timely manner for 4 of 8 patient records reviewed. (Patient # 1, #3, #6 and #7). The findings include: Review of Patient #1’s record on 3/26/24 at 10:47 AM revealed Patient #1 was admitted to the dialysis facility on 3/17/24 with a diagnosis of ESRD. The Treatment Details Report dated 3/22/24 indicated vital signs were taken at 15:26 PM and then at 16:35 PM (one hour and 9 minutes between vs checks). In an interview with RN #1 on 3/26/24 at 11:50 AM, she/he reviewed Patient #1’s record and confirmed there was more then one hour between vital signs on 3/22/24 and stated, “Vital signs are supposed to be done every 30 minutes”. Review of Patient #3’s record on 3/26/24 at 9:44 AM revealed Patient #3 was admitted to the dialysis facility on 7/30/21 with a diagnosis of ESRD. The Treatment Details Report dated 3/20/24 indicated vital signs were taken at 15:32 PM and then at 16:27 PM (57 minutes between vs checks). In an interview with RN #1 on 3/26/24 at 11:50 AM, she/he reviewed Patient #3’s record and confirmed there was more then 30 minutes between vital signs on 3/6/24. Review of Patient #6’s record on 3/26/24 at 1:20 PM revealed Patient #6 was admitted to the dialysis facility on 8/14/24 with a diagnosis of ESRD. The Treatment Details Report dated 3/6/24 indicated vital signs were taken at 7:36 AM and then at 8:32 AM (56 minutes between vital signs checks). In an interview with RN #1 on 3/26/24 at 11:50 AM, she/he reviewed Patient #6’s record and confirmed there was 56 minutes between vital signs on 3/6/24. Review of Patient #7’s record on 3/26/24 at 1:56 PM revealed Patient #7 was admitted to the dialysis facility on 7/21/23 with a diagnosis of ESRD. Review of the Treatment Details Report dated 3/4/24 indicated vital signs were taken at 12:10 PM and then at 2:21 PM (two hours and 11 minutes between vital signs checks). Treatment Details Report dated 3/11/24 indicated vital signs were taken at 11:31 AM and then at 12:31 PM (approximately one hour between vital signs). Treatment Details Report dated 3/15/24 revealed vital signs were taken at 1:30 PM and then at 2:27 PM (57 minutes between vital sign checks). In an interview with RN #1 on 3/27/24 at 11:50 AM, he/she reviewed Patient #7’s record and confirmed the findings. 41879”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 41879 Based on record review and interview, the dialysis facility failed to perform accurate documentation for 1 of 8 dialysis patient records reviewed. (Patient #4) The findings included: On 3/25/24 at 2:14 PM, Patient #4 was observed receiving dialysis treatment through a left upper arm arteriovenous graft (AVG). Review of Patient #4’s record on 3/26/24 at 10:37 AM revealed Patient #4 was admitted to the dialysis facility on 11/17/23 with a diagnosis of End Stage Renal Disease (ESRD). The “ACTIVE TREATMENT ORDERS,” indicated Patient #4 had a Right AVG. Review of the Treatment Details Reports dated 2/28/24, 3/1/24, 3/4/24, 3/6/24, 3/8/24, 3/11/24, 3/13/24, 3/18/24, 3/20/24 and 3/22/24 revealed, “ ...ACCESS ...Site ...Upper Arm (Right) ...” Review of an “OPERATIVE REPORT” dated 1/30/24 revealed, “ ...(Patient #4’s name) has been dialyzing very nicely via his/her left brachiocephalic AV (arteriovenous) fistula that was created on 10/12/2023 ...” During an interview on 3/27/24 at 2:00 PM, Registered Nurse (RN) #1 stated, “Patient #4’s dialysis access was in his/her “left upper arm.” RN #1 reviewed Patient #4’s record and confirmed the Patient Summary Report and the Treatment Details Reports for the month of March 2024 were all incorrectly documented with the wrong dialysis access site. RN #1 further stated, “It was changed from the right last year and the staff are supposed to evaluate the access site and document correctly”.”