Davita Las Palmas Dialysis Center

“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: 22676 Based on observation, interview, and facility policy review, the facility failed to ensure that staff providing care to patients did not wear artificial nails and keep nails trimmed. This deficient practice had the potential to result in increased infections to all 44 patients receiving care at this incenter hemodialysis unit. Findings include: Observation on the treatment floor on 11/15/24 at 9:00 AM Licensed Vocation Nurse (LVN) 8 was observed wearing 1/2-inch-long artificial nails. LVN 8 was observed starting dialysis for a patient (P)3 with a Central Venous Catheter (CVC). An interview with the LVN8 on 11/15/24 at 1:30 PM, he/she confirmed that his/her nails were artificial and ½ inch long. An interview with the Administrator 11/15 at 2:00 at 2:00 PM he/she confirmed that staff are not supposed to wear artificial nails. Review of facility policy titled, “Infection Control for Dialysis Facilities” dated 04/23, stated “It is the requirement for al DaVita teammates whose primary location if working in a facility to have only natural nails and finger length should not extend more than ¼ inch. Traditional nail polish that is not chipped may be worn.””

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 22676 Based on interview, document review, and policy review, the facility failed to ensure the Phoenix meter calibration for 3 out of 3 meters was verified for one out of 30 days reviewed. This had the potential to cause harm to all 44 in-center hemodialysis patients receiving care at the facility by failure to ensure the meters were calibrated prior to verifying the dialysis machines conductivity prior to each patient’s dialysis treatment. Findings include: Review of the “Phoenix Meter Daily Calibration Logs,” from 09/01/24 through 9/30/24, revealed the facility failed to check for the calibration on 09/06/24 for all three phoenix meters (P23029, P11587 and P32459.) In an interview with Biomedical Technician 5 on 11/13/24 at 12:30 PM, he/she confirmed the above findings. Review of facility’s policy titled, “Measuring Conductivity, Temperature and/or pH using the phoenix conductivity Meter” indicated, “Level 1 calibration is completed by a trained teammate, if daily verification readings are inaccurate per manufactures recommendation ...””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22676 Based on review of glucometer logs, interviews, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results for all 44 patients receiving care at the facility. Findings included: Review of electronic “Blood Glucose Logs” for two out of three months reviewed, from 09/01/24 through 11/13/24 revealed the following: Review of the meter for the treatment unit labeled “Meter WW19LAO1362” for October 2024: On 10/16/24, the recorded acceptable low control range was 91-123, the recorded low control was 176. On 10/21/24, the recorded acceptable low control range was 91-123, the recorded low control was 125. On 11/11/24 the recorded acceptable low control range was 91-123, the recorded low control was 124. On 11/13/24 the recorded acceptable low control range was 91-123, the recorded low control was 124. During an interview on 11/13/24 at 3:00 PM, the Facility Administrator confirmed the findings and agreed the staff did not repeat the low-level as required by the manufacturer’s instruction. Review of the facility’s policy titled, “Blood Glucose Monitoring Device,” dated 11/06/23, revealed, under “Policy Training” section revealed, “Calibration and control testing shall be performed each operating day ...” Review of the “Embrace Pro Blood Glucose Monitoring Quality Control, (QC)” indicated, “QC procedures are performed and documented every day the monitor is used ...The results should fall within the range. If control solution results are out of range, repeat the test.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 18750 Based on medical record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for three of 20, sampled in-center dialysis patients (Patient (P1, P15, and P16). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 44 patients receiving in-center dialysis treatments at this facility. Findings include: Review of facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment.” States, “The prescription components are confirmed by a licensed nurse with in one hour of the treatment initiation. Prescription components include but are not necessarily limited to dialysate flow rate.” Review of facility policy titled, “Incenter Hemodialysis Policies and Procedures,” revised April 2024 revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring, and reviewing the patient’s response to the treatment and status prior to discharge. Policy. . . 3. Patient identity, participation and machine settings are verified by teammate prior to initiation of treatment with exception of blood flow rate which is verified and documented when ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by the state law. Prescription components include but are not necessarily limited to:.. e UF [ultrafiltration] profiling f. Blood flow rate. . . 1. A review of P1’s electronic medical record (EMR) revealed a prescribed Dialysis Flow Rate (DFR) of 400 milliliters per minute (ml/min). A review of two of six “Post Treatment” flowsheets from 10/30/24 through 11/11/24 in the EMR indicated the following: a. On 10/30/24, the DFR was documented at 800 ml/min from 6:30 AM until 9:54 AM. b. On 11/01/24, the DFR was documented at 800 ml/min from 8:00 AM until 9:00 AM. There was no documentation for the change to the prescribed DFR. During an interview on 11/14/24 at 2:00 PM, the Administrator confirmed the above findings and confirmed that the staff did not follow the physician’s order for dialysis treatment. 2. Review of P15’s medical record provided by the facility, revealed an “ESRD Facility Incident Report Form,” dated 02/02/24, located under the “Patient Information” section with and admission date of 11/13/13 with diagnoses of hypertension, aortic stenosis, and atrial fibrillation. Review of P15’s Treatment Detail Report, dated 01/29/24, revealed preassessment vitals in which the blood pressure (BP) reading was 89/49 millimeters of mercury (mm/Hg) which indicated a low BP. The physician was notified and gave orders to initiate treatment with ultrafiltration (UF) off. The treatment was initiated at 10:35 AM, with a BP of 78/56 mm/Hg. At 10:42 AM There is documentation by the Licensed Vocational Nurse (LVN) that the UF is on. At 11:00 AM, the BP is 66/47 mm/Hg and a UF reading of 930. At 11:04 AM documentation notes, “UF remains off.” At 11:15 AM, the LVN has documented, “uf on. . .” BP is 96/52 mm/hg and UF reads 930. At 11:30 AM, BP is 82/52 mm/Hg and UF has been turned off. During an interview on 11/15/24 at 11:30 AM, the Administrator was asked about the treatment and why the UF was being turned on and off. The Administrator stated, “I do not understand why the UF is being turned on and off. The patient’s BP is low, and the physician ordered the treatment to run without the UF.” Interview on 11/15/24 at 12:44 PM, Registered Nurse (RN)6 stated, “Often the patient came in with fluid overload and it was hard to get the fluid off because of the low blood pressure. The physician ordered to run treatment without ultra-filtration. That was the order. It should have remained off.” Interview on 11/15/24 at 1:16 PM, Licensed Vocational Nurse (LVN)8 was asked about running the treatment with the ultrafiltration on when the physician ordered to run without. She stated, “If the physician ordered the UF off then it should remain off. The patient would tell us to turn it on so the fluid could be gotten off, but her blood pressure ran too low to have the UF on.” 3. Review of P16’s medical record provided by the facility, revealed an “ESRD Facility Incident Report Form” dated 03/04/24. Located under the “Patient Information” section with and admission date of 08/28/20 with diagnoses of hypertension, diabetes mellitus, and congestive heart failure. Review of the physician orders, dated 02/27/24, the order was BFR at 350 milliliters per minute (mL/min). Review of the Treatment Detail Report, dated 03/01/24, revealed a BFR of 400 mL/min. During an interview on 11/15/24 at 11:30 AM, the Administrator was asked about the difference in the BFR rate. She stated, “I do not have any idea why run at 400 rather than 350. There should be documentation.” During an interview on 11/15/24 at 12:44 PM, RN6 recalled the patient had cardiac issues. He was asked about the BFR rate being different than what was ordered he said, “there should be documentation why the change.” During an interview on 11/15/24 at 1:16 PM, LVN8 was asked about the BFR not being what the physician ordered. LVN8 stated, “BFR should be run at the ordered rate, unless an issue and then you document.””