Davita Lexington Dialysis (TN)

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 51246 Based on policy review, medical record review, observation, and interview, the facility failed to ensure dialysate prescriptions were followed as ordered by the physician for 3 of 9 (Patient’s #5, #6, and #7 ) sampled patients observed while receiving HD treatments on 1 of 2 (03/10/2025) observation days . The findings included: 1. Review of the facility policy titled, “Patient Orders for Patient Care” dated October 2024 revealed, “...To verify that orders are properly documented, transcribed, verified, and implemented in a timely manner for patient care in (Facility Name) facilities...” 2. Patient #5’s physician’s order dated 3/10/2025 documented the dialysis prescription which included a dialysate bath of 3K. Observation on 03/10/2025 at 11:40 AM on the treatment floor revealed Patient #5 was receiving HD treatment. The dialysis machine screen documented the patient was receiving a dialysate bath of 2 K at that time; however, the patient was receiving a dialysate bath from a gallon jug labeled 3 K. Patient #5 received the correct dialysate but the machine was incorrectly programmed to show Patient #5 was receiving a dialysate bath of 2 K. 3. Patient #6’s physician’s order dated 2/8/2025 documented the dialysis prescription which included bicarbonate at 39.0 mEq/L. Observation on 03/10/2025 at 11:50 AM on the treatment floor revealed Patient #6 was receiving HD treatment. The dialysis machine screen documented the patient was receiving a bicarbonate at 36 mEq/L. Patient #6 received the incorrect dose of bicarbonate for 55 minutes before the facility changed Patient #6’s bicarbonate to 39 mEq/ml as ordered by the physician. 4. Patient #7’s physician’s order dated 2/27/2025 documented the dialysis prescription which included a dialysate bath of 3 K. Observation on 03/10/2025 at 12:00 PM on the treatment floor revealed Patient #7 was receiving HD treatment. The dialysis machine screen documented the patient was receiving a dialysate bath of 3 K at that time; however the patient was receiving a dialysate bath from a gallon jug labeled 3 K. Patient #7 received the correct dialysate but the machine was incorrectly programmed to show Patient #7 was receiving a dialysate bath of 2 K. Refer to V-544”

“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: 51246 Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure physician’s orders for prescribed Dialysate were followed for 3 of 9 (Patient #5, #6, and #7) and 1 Random Patient (RP #1) observed hemodialysis patients. The findings included: 1. Review of facility policy, “Physician Orders for Patient Care” revised October 2024, revealed, “ ...To verify that orders are properly documented, transcribed, verified, and implemented in a timely manner for patient care in [Facility Name] facilities ...” 2. Medical record review for Patient #5 revealed an admission date of 10/27/2023 with diagnoses which included ESRD. Review of the physician’s orders dated 02/15/2025 revealed the following Dialysate Bath prescription: NIPRO, DIALYSATE LIQUID, 3 K, 2.5 Ca, Gallon. Observation on 03/10/2025 on the treatment floor at 11:40 AM revealed Patient #5 had a 3 k Dialysate bath running; however, the dialysis machine settings were set for a 2 k Dialysate bath. Patient #5 received hemodialysis for 40 minutes before the setting was corrected from a 2 k bath to a 3 k bath. During an interview on 03/10/2025 at 11:43 AM, PCT #1 stated, “That’s totally my fault” when asked by the GFA why Patient #5’s dialysate prescription was entered into the dialysis machine incorrectly. During an interview on 03/10/2025 at 11:44 AM, RN #1 was asked is she verified the dialysate prescription prior to initiation of treatment for Patient #5. RN #1 stated, “I thought I did, but maybe I didn’t” 3. Medical record review for Patient #6 revealed an admission date of 12/18/2023 with diagnoses which included Type 2 Diabetes Mellitus with CKD. Review of the physician’s orders dated 02/08/2025 revealed an order for Bicarbonate 39.0 mEq/L. Observation on 03/10/2025 on the treatment floor at 11:50 AM revealed Patient #6 had been running on Bicarbonate 36.0 mEq/L instead of 39.0 mEq/L for 55 minutes before the setting was corrected from 36.0 mEq/L to a 39.0 mEq/L. During an interview on 03/10/2025 at 11:57 AM, RN #1 stated, “I set up the machine and I verified the prescription for this patient [Patient #6].” 4. Medical record review for Patient #7 revealed an admission date of 12/19/2020 with diagnoses which include Type 2 DM with CKD. Review of the physician’s orders dated 02/08/2025 revealed the following Dialysate Bath prescription: NIPRO, DIALYSATE LIQUID, 3 K, 2.5 Ca, Gallon. Observation on 03/10/2025 at 12:00 PM revealed Patient #7 was receiving a hemodialysis treatment. Patient #7 had a 3 k Dialysate bath running; however, the dialysis machine settings were set for a 2 k Dialysate bath. Patient #7 received hemodialysis for 1 hour and 13 minutes before the setting was corrected from a 2 k bath to a 3 k bath as ordered by the physician. During an interview on 03/10/2025 at 12:05 PM, CCHT #1 stated, “I set up the machine. I am not sure if [RN #1] rechecked after [Patient #7’s] treatment initiated.” During an interview on 03/10/2025 at 12:15 PM, the GFA confirmed staff members should verify and ensure that the dialysis prescriptions in the machines match the MD orders. 5. Medical record review for Random Patient #1 revealed an admission date of 01/29/2025 with diagnoses which include ESRD. Observation on 03/10/2025 on the treatment floor at 11:20 AM revealed Random Patient #2’s name on the dialysis machine screen where Random Patient #1 was receiving hemodialysis. During an interview on 03/10/2025 at 11:20 AM, the GFA stated that she had not been made aware of the issue with the former patient’s name not clearing out before the next patient began treatment. During an interview on 03/10/2025 at 11:20 AM, PCT #1 stated that the previous patient’s information should clear out of the dialysis machine when it [dialysis machine] is disinfected; however, she had noticed that the names had not cleared out on several occasions. PCT #1 stated she had not reported the issue to anyone. During an interview on 03/10/2025 at 2:00 PM, CCHT #1 stated that he had noticed the name not being changed on dialysis machines at several [Facility Name] facilities but had never reported the issue. He stated, “From now on I will turn in a ticket” to ensure someone has been notified of the issue.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51246 Based on facility policy review, observation, and interview, the facility failed to ensure appropriate measures were taken by 2 of 2 (CCHT #1 and PCT #1) staff members to reduce the risk of infection during cannulation of an AVF and/or AVG prior to initiation of hemodialysis. The findings included: 1. Review of the facility policy, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised October 2022 revealed, “ ... Perform inspection, auscultation and palpation on entire length of access. Determine presence of bruit and thrill... While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to the table above). [TABLE: Skin Antiseptic: Povidone Iodine - Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site. - Effective Contact Time: 30 seconds - Air Drying Time: 2 minutes] ...All skin antiseptics work to kill bacteria on the skin and require specific air-dry times... For patients who have a documented allergy to povidone iodine or [Brand Name] necessitating alcohol alone, apply alcohol using a circular rubbing motion, center out for 60 seconds and allow to dry for 15 seconds prior to cannulation ...Alcohol can be very drying to the skin and less effective than other skin antiseptics. Teammate will need to use a minimum of 4 prep pads per site for at least 60 seconds total contact time to adequately prep cannulation site ...” 2. Medical record review for Patient #5 revealed an admission date of 10/27/2023 with diagnoses which included ESRD. Patient #5’s medical record documented an allergy to Povidone Iodine/Betadine. Observation on 03/10/2025 at 10:49 AM on the treatment floor revealed PCT #1 initiating hemodialysis on Patient # 5 via an AVF/AVG. PCT #1 failed to listen and feel of the access site before cannulation. PCT #1 failed to clean the access site per facility policy by failing to allow the Povidone Iodine/Betadine to dry per facility policy by only allowing one-minute dry time instead of two minutes per facility policy. 3. Medical record review for Patient #7 revealed an admission date of 12/19/2020 with diagnoses that included Type 2 Diabetes Mellitus and CKD. Patient #7’s medical record documented an allergy to Povidone Iodine/Betadine. Observation on 03/10/2025 at 10:09 AM on the treatment floor revealed CCHT #1 initiating hemodialysis on Patient #7 via an AVF/AVG. CCHT #1 failed to feel the access site before cannulation. CCHT #1 failed to clean the access site per facility policy for patients with a documented allergy to Povidone Iodine/Betadine. CCHT #1 scrubbed insertion site #1 with an alcohol pad for 25 seconds and then with a second alcohol pad for 15 seconds and then allowed the site to dry for 10 seconds before cannulation. CCHT #1 scrubbed the insertion site #2 with an alcohol pad for 17 seconds and then with a second alcohol pad for 19 seconds and then allowed the site to dry for 10 seconds before cannulation. CCHT #1 failed to use at least 4 alcohol prep pads per site per facility policy; failed to allow the alcohol to make effective contact time of 60 seconds; and failed to ensure the sites dried for 15 seconds before cannulation. During an interview on 03/12/2025 at 9:52 AM, the GFA confirmed staff were expected to follow the facility policy for initiation of dialysis with an AVG/AVF. She stated staff should look at the site and then auscultate and palpate the access site to determine if a thrill and bruit is present. She confirmed that Povidone Iodine/Betadine should have a 30 second contact time and a dry time of 2 minutes. If alcohol is used instead of Betadine a 60 second contact time with alcohol should be allowed per each site along with a 15 second dry time per each site before cannulation is attempted.”