Davita Capelville Dialysis Center

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to ensure the IDT implemented and completed a POC for 1 of 5 (Patient #1) sampled patients reviewed. The findings included: 1. Review of the facility’s “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” policy (revised 10/2024) revealed, “...The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care...” 2. Medical record review for Patient #1 revealed an admission date of 9/18/2024 with diagnoses which included ESRD and HTN. There was no documentation of a completed POC for Patient #1. In an interview on 2/25/2025 at 9:15 AM, the facility’s FA verified there was no completed POC for Patient #1.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to ensure patients leaving treatment greater than 1 kg over target weight was addressed by the RN for 1 of 2 (Patient #5) sampled patients leaving treatment greater than 1 kg over target weight. The findings included: 1. Review of the facility’s “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” policy (revised April 2024) revealed, “...POST TREATMENT DATA COLLECTION/ASSESSMENT...If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge...ABNORMAL FINDINGS...Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time...Fluid Status...Post-Treatment: If patient is above or below 1 kg from the target weight...” 2. Medical record review for Patient #5 revealed an admisison date of 10/4/2024 with diagnoses which included Chronic Kidney Disease and DM. Patient #5’s target weight was documented as 94.5 kg. Review of the 1/20/2025 Treatment Details Report revealed Patient #5’s post-treatment weight was 99.2 kg. This was 4.7 kg over the target weight. There was no documentation the RN addressed the post-treatment weight. Review of the 2/12/2025 Treatment Details Report revealed Patient #5’s post-treatment weight was 99.8 kg. This was 5.3 kg over the target weight. There was no documentation the RN addressed the post-treatment weight. Review of the 2/14/2025 Treatment Details Report revealed Patient #5’s post-treatment weight was 99.1 kg. This was 4.6 kg over the target weight. There was no documentation the RN addressed the post-treatment weight. In an interview on 2/26/2025 at 9:30 AM, the facility’s FA verified the post-treatment weights greater than 1 kg over the target weight should have been addressed by the RN.”

“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: 46831 Based on policy review, medical record review and interview, the facility failed to ensure physician’s orders for prescribed BFR and/or DFR were followed for 4 of 5 (Patient #1, #2, #4 and #5) sampled patients. The facility also failed to notify the physician of changes to the ordered dialysis prescription. The findings included: 1.Review of the “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” policy revised April 2024, revealed “...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” 2. Medical record review for Patient #1 revealed an admission date of 9/18/2024 with diagnoses which included ESRD and HTN. Review of physician’s orders dated 2/21/2025 revealed a BFR of 350 and DFR of 600. Review of the 1/20/2025 Treatment Details Report revealed the BFR was 400 from 11:42 until 3:03 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 1/24/2025 Treatment Details Report revealed the DFR was 500 from 10:18 AM until 2:24 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. Review of the 2/5/2025 Treatment Details Report revealed the BFR was 400 from 10:28 AM until 2:41 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 2/10/2025 Treatment Details Report revealed the DFR was 800 from 10:42 AM until 2:43 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. Review of the 2/17/2025 Treatment Details Report revealed the DFR was 800 from 12:30 PM until 2:39 PM. There was no documentation why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. 3. Medical record review for Patient #2 revealed an admission date of 2/14/2024 with diagnoses which included Hypertension/Large Vessel Disease, Hypertensive Chronic Kidney Disease, and ESRD. Review of physician’s orders dated 2/12/2025 revealed a BFR of 400 and a DFR of 500. Review of the 1/13/2025 Treatment Details Report revealed the BFR was 350 from 12:32 PM to 2:50 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 1/20/2025 Treatment Details Report revealed the BFR was 350 from 12:01 PM to 3:32 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 1/24/2025 Treatment Details Report revealed the BFR was 350 from 6:16 AM to 10:00 AM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 4. Medical record review for Patient #4 revealed an admission date of 2/1/2012 with diagnoses which included Glomerulonephritis (a kidney disease that damages the glomeruli, the tiny filters in the kidneys that remove excess water and waste from the blood), Membranoproliferative Glomerulonephritis (MPGN - a rare kidney diseas that damages the glomeruli, or filters, through an abnormal immune response.) Type 1, and ESRD. Review of physician’s orders dated 9/28/2024 revealed a BFR of 350 and a DFR of 600. Review of the 1/13/2025 Treatment Details Report revealed the BFR was 400 from 11:11 AM to 2:43 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 1/20/2025 Treatment Details Report revealed the BFR was 400 from 11:16 AM to 12:01 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 1/27/2025 Treatment Details Report revealed the BFR was 400 from 11:37 AM to 12:29 PM and 300 from 12:45 PM to 3:30 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 2/7/2025 Treatment Details Report revealed the BFR was 400 from 11:04 AM to 2:42 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. 5. Medical record review for Patient #5 revealed an admisison date of 10/4/2024 with diagnoses which included Chronic Kidney Disease and DM. Review of physician’s orders dated 12/19/2024 revealed a BFR of 400 and DFR of 600. Review of the 1/17/2025 Treatment Details Report revealed the BFR was 350 from 1:06 PM until 3:01 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the 2/17/2025 Treatment Details Report revealed the BFR was 200 from 10:12 AM until 1:31 PM. There was no documentation why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. In an interview on 2/26/2025 at 9:30 AM, the FA verified the BFR and DFR should be followed per physician’s orders. The FA also verified staff should document why orders were not followed, and notify physician.”