Davita Champions Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 Based on interview and record review, the facility failed to ensure patients’ physicians (Nephrologist) conduct visits every two weeks on patients, while patients are receiving hemodialysis treatment in the facility in 1 of 8 (Patient ID #1) records reviewed for timely physician’s visits as required by the Texas State Regulations. Findings: Patient ID #1 Review of patient ID #1 records documented he was admitted to the facility on 08/13/2024. Review of records document that patient was seen by a Nurse Practitioner, staff ID #J on 08/15/2024 and 09/05/ 2024. There was no documentation the patient was seen by a physician as required . On 10/10/2022 at 14:00 PM in the conference the surveyor reviewed the documentation of physician visits with the Facility Administrator, staff ID #A. Administrator confirmed there was no documentation of every 2-week physician visit. No additional information was received prior to exit of survey.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 30124 Based on record review and interview the facility’s direct care staff failed to administer patient’s hemodialysis treatment based on the physician’s order in the patient plan of care for 1 of 8 sampled patients (Patient #1). Review of the facility’s current policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08, last revision April 2024. 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 during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the 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 state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model. b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated. i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting) INTRADIALYTIC DATA COLLECTION/ASSESSMENT 10. 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. Findings: Review of patient ID #1 clinical records revealed the following: Hemodialysis orders for treatment dated 08/13/2024 as follows: 3.5 hours, Dialysate 2.0 potassium, 2.5 calcium, 138 mEq/L , sodium, 37 mEq/L Bicarbonate. Blood flow rate 350 mL/min, dialysate flow rate 500 mL/min. Patient #1 Records Reviewed Review of the patient’s treatment sheets revealed documentation that on the following dates the patient’s blood flow was not maintained at the prescribed rate of 350 mls/ minute without documented justification as why. 08/15/2024: Patient’s hemodialysis treatment initiated at 14:12 PM by the registered nurse at a blood flow rated of 350 mls/min. At 17:00 PM the patient care technician assigned to the patient reduced the blood flow rate to 300 mls/min and remained at that rated until treatment was terminated by the registered nurse at 17:46 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 08/17/2024: Patient’s hemodialysis treatment initiated at 14:08 PM by the registered nurse at a blood flow rated of 350 mls/min. At 14:30 PM the patient care technician assigned to the patient reduced the blood flow rate to 310 mls/min until 15:31 PM where the patient care technician increased the blood flow rate to 350 mls/min. At 16:30 the patient care technician reduced the blood flow rate to 300 mls/min and remained at that rated until treatment was terminated by the registered nurse at 17:54 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 08/22/2024: Patient’s hemodialysis treatment initiated at 14:34 PM by the registered nurse at a blood flow rated of 260 mls/min. At 15:01 PM the patient care technician assigned to the patient increased the blood flow rate to 350 mls/min until 16:01 PM where the patient care technician decreased the blood flow to 300 mls/min. The blood flow rated remained at 300ml/min until treatment was terminated by the registered nurse at 18:01 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 08/24/2024: Patient’s hemodialysis treatment initiated at 14:00 PM by the registered nurse at a blood flow rated of 350 mls/min. At 16:30 PM the patient care technician assigned to the patient reduced the blood flow rate to 285 mls/min. At 17:00 PM the patient care technician reduced the blood flow rate to 225 and remained at that rated until treatment was terminated by the registered nurse at 17:36 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 08/29/2024: Patient’s hemodialysis treatment initiated at 14:24 PM by the registered nurse at a blood flow rated of 300 mls/min. At 15:00 PM the patient care technician assigned to the patient reduced the blood flow rate to 275 mls/min and remained at that rated until treatment was terminated by the registered nurse at 18:18 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 08/31/2024: Patient’s hemodialysis treatment initiated at 17:04 PM by the registered nurse at a blood flow rated of 350 mls/min. At 18:50 PM the patient care technician assigned to the patient reduced the blood flow rate to 300 mls/min and remained at that rated until treatment was terminated by the registered nurse at 19:38 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 09/05/2024: Patient’s hemodialysis treatment initiated at 09:58 AM by the registered nurse at a blood flow rated of 200 mls/min. At 10:30 AM the patient care technician assigned to the patient increased the blood flow rate to 350 mls/min and remained at that rated until 12:00 PM when the patient care technician reduced the rate to 185 ml/min. At 12:30 PM a patient care technician increased the rate to 300 mls/min. At 13:00 PM a licensed vocational nurse reduced the blood flow to 260 mls/min and at 13:07 PM she increased it to 290 mls/min. At 13:30 PM the licensed vocation nurse increased blood flow rate to 300 mls/min treatment was terminated by the licensed vocational nurse at 14:01 PM, blood was documented at 325 mls/min. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 09/07/2024: Patient’s hemodialysis treatment initiated at 09:58 AM by the registered nurse at a blood flow rated of 200 mls/min. At 12:00 PM the patient care technician assigned to the patient reduced the blood flow rate to 185 mls/min. At 12:30 PM patient care technician increased the blood flow rate to 300 mls/min. At 13:00 PM licensed vocational nurse decreased blood flow to 260 mls/min and at 13:07 PM increased blood flow to 290 mls/min. At 13:30 PM the licensed vocational nurse increased the blood flow to 300 mls/min and remained at that rated until treatment was terminated by the registered nurse at 14:01 PM. With a blood flow rate of 325 mls/min. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. 09/10/2024: Patient’s hemodialysis treatment initiated at 14:37 PM by the licensed vocational nurse at a blood flow rated of 350 mls/min. At 15:00 PM the licensed vocational nurse reduced the blood flow rate to 300 mls/min and at 15:30 PM reduced the blood flow to 295 mls/min. At 16:30 the licensed vocational nurse increased the blood flow to 350 mls/min and remained at that rated until treatment was terminated by the licensed vocational nurse at 18:21 PM. Review of the record (treatment sheet) revealed no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate of 350 mls/min. Interview on 10/10/2024 at 15:00 PM with staff ID #B revealed the arterial pressure may have been high, but the reason was not documented.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on record review and interview, the facility’s Medical Director failed to ensure the registered nurse completed an initial assessment on a new patient to the facility prior to initiation of hemodialysis treatment in 1 of 8 sampled patients (patient ID #1). Policy Reviewed: The facility’s current policy Title:” Initial Patient Nursing Assessment for New Patients”; Policy: 103-07, Last Revision April 2024. Policy: 1. An registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility. Record Review for Patient ID #1 Review of the initial patient nursing assessment dated on day of admission 08/13/2024 documents time completed of the assessment at 17:23 PM. Hemodialysis treatment was initiated at 13:24 PM which was prior to the completion of the initial nursing assessment. Interview on 10/10/2024 with Manager of Clinical Services, staff ID #B confirmed the initial nursing assessment should have been completed prior to initiation of treatment.”

“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: 10802 Based on observation, interview and record review, facility failed to ensure direct care staff and patient remove gloves and wash/ sanitize hands after removing contaminated gloves in 3 of 6 staff observed and 1 sampled patient. Registered Nurse (G), Patient Care Technician (B), Licensed Vocational Nurse (F) and Patient #9 Findings Review of Facility’s current Policy and Procedure on Infection Control for Dialysis facilities Policy: 1-05-01- revised April 2023 directed staff as follows: “ Patients and care givers will be encouraged to: (2) (a) Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. (b) Perform hand hygiene after treatment before leaving treatment area. (3) Use of alcohol- based hand rub may be substituted for handwashing. “ Hand Hygiene: All teammates, physicians and Non-physicians (NPP) will perform hand hygiene (a) Upon entering and exiting the patient treatment area (b) Prior to gloving and immediately after removal of gloves (c) After contamination with blood or other infectious material (d) After patient and dialysis delivery contact (e) After interacting with wall boxes (i.e., plugging / unplugging acid/bicarb, lines form dialysis machine, changing acid types, when exchanging a dialysis machine) (f) between patients even if the contact is casual. (g) Before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. Station 12; Registered Nurse (G) Patient #8 On 02/5/2024 at 10:55 a.m. Registered Nurse (G) was observed at station #12 . The Registered Nurse was providing care to Patient #8. Registered Nurse (G) donned a pair of clean gloves, examined patient #8’s legs pre- hemodialysis treatment, reset the hemodialysis machine of the patient, removed one hand of her contaminated gloves and entered information in the chairside computer which is shared by two patients. The Registered Nurse did not remove her contaminated gloves and wash/ sanitize her contaminated hands after examining the patient pre- treatment and resetting the patient’s hemodialysis machine. ( The patient’s hemodialysis treatment ) had already started. Patient #2 Registered Nurse (G) On 02/ 05/2024 at 11:45 a.m. Registered Nurse (G) was observed at station #16. The Registered Nurse was providing central venous catheter care to Patient #2 who has a right double lumen central venous catheter in place which is utilized for his hemodialysis treatment. The Registered Nurse was providing central venous catheter care in preparation for initiation of hemodialysis treatment on the patient. Observation revealed Registered Nurse (G) wearing a pair of clean gloves examined the patient’s legs pre- treatment. After examination of the patient’s legs, Registered Nurse (G) removed her contaminated gloves. After removing her contaminated gloves Registered Nurse (G) did not wash/ sanitize her hands. Registered Nurse (G) picked up clean gloves from a box of gloves stored on the computer station which is shared by two patients. Registered Nurse (G) removed the soiled dressing from the patient’s central venous catheter insertion site and limbs and then using the contaminated gloves used to remove the contaminated dressing from the patient’s central venous catheter insertion site and limbs she rearranged the clean supplies stored on a chux on the chairside for the patient’s central venous catheter care. After rearranging the supplies Registered Nurse (G) removed her contaminated gloves, picked up clean gloves from a box of gloves stored on the computer station. The registered Nurse did not wash or sanitize her contaminated hands. Registered Nurse (G) walked over to the clean supply drawer located in the center of the hallway and retrieved 4X4 gauze dressings with her contaminated hands. The registered Nurse then removed her gown and left the unit. Subsequent observation at 11:55 a.m. revealed Registered Nurse (G) returned to the chairside of Patient #2 to connect the external blood line to the patient’s central venous catheter. Registered Nurse (G) donned a pair of clean gloves connected the patient’s external blood lines to his central venous catheter. After initiation of the patient’s hemodialysis treatment, Registered Nurse (G) removed one hand of her contaminated gloves, held it in her left hand and then entered information in the chairside computer shared by two patients. Facility’s Medical Clinical Support personnel was present and observed the break in infection control technique. After entering information in the computer shared by two patients Registered Nurse (G) placed the contaminated glove he was holding in her left hand on the computer station. Interview on 02/05/2024 at 12:10 p.m., The Surveyor informed Registered Nurse (G) of the break in infection control technique while providing central venous catheter care to Patient #2. Registered Nurse (G) states” I take full responsibility of it. Generally, when I come in my things are usually all set up.” Patient Care Technician (B) On 02/05/2024 at 11:50 a.m. Patient Care Technician (B) was observed at station #15. The Patient Care Technician was preparing to cannulate Patient #7’s vascular access located on his right arm. The Patient Care Technician wearing a pair of gloves, cleaned the patient’s vascular access site, removed his contaminated gloves, walked over to the clean supply drawer and removed 4X4 dressing from the drawer. The Patient Care Technician (did not wash/ sanitize his hands after removing the contaminated gloves prior to going into the clean supply drawer. Patient #9 On 02/05/2024 at 11:10 a.m. revealed Patient #9 returned to the station due to bleeding from his vascular access site post hemodialysis treatment. Licensed Vocational Nurse (F) reinforced the patient’s dressings to his vascular access site and the patient held his vascular access site with his gloved hands. After holding his vascular access site Licensed Vocational Nurse (F) ) removed his contaminated gloves, gave it to Licensed Vocational Nurse (F) and the patient walked to the scale and reset the scale with his hands after removing his contaminated gloves. The Surveyor immediately notified Licensed Vocational Nurse (F) that he did not encourage the patient to wash/ sanitize his hands after removing the contaminated gloves used to hold his bleeding access site. Licensed Vocational Nurse ( F) states “ should I clean the scale?””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review facility’s direct care staff failed to clean/ sanitize, prime buckets, Hansen connectors, blue clamps, laminate stored on intravenous pole, water hoses, water box, chase, and television console during terminal cleaning of hemodialysis units. In 3 of 6 staff observed terminally cleaning hemodialysis units post hemodialysis treatment of patients. Patient Care Technician (B), Licensed Vocational Nurse (F) And Licensed Vocational Nurse (H) Findings: Review of the facility’s current policy and procedure on Infection control for Dialysis Facilities: Policy # 1-05-01 revised April 2023 directs staff as follows: “At the end of each treatment, the dialysis station will be cleaned and disinfected. (a) Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs and frequently contacted by healthcare personnel (e.g., control panel; top front and sides of dialysis machine, touchscreens, countertops.) The Wall box, drain and water supply lines are considered part of the dialysis delivery system. Pressurized washers, spray bottles, or sprayers for cleaning purpose will not be used on wall boxes or adjoining area. Teammates will monitor and address wall box residue / built up and patency issues. Priming containers are to be emptied prior to disinfection. Drain line and water supply line should not be placed with end in prime containers or in a position where they can drip into or contaminate the prime bucket. 14 Non disposable items are to be disinfected after each patient use, prior to removal from treatment area/ station and if contaminated between uses. If items cannot be cleaned and disinfected it will be dedicated for use on a single patient. (a)Stethoscope will be disinfected with alcohol prep and 1:100 (one to one hundred) bleach solution and if they are visible contaminated with blood or body fluid should be disinfected with 1:10 (one to ten) bleach solution. (b)Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution.” Patient Care Technician (B) (Station 14) On 02/5/ 2024 at 10:45 a.m. Patient Care Technician (B) was observed terminally cleaning station # 14 hemodialysis machine # Nipro Surdial DX 14-22EC00338 Observation revealed during terminally cleaning of the unit Patient Care Technician (B) did not clean/ sanitize the Hansen connectors, prime bucket, blue clamps and laminate on the intravenous pole, chase, water box and television console. The patient care technician brought clean dialyzer and external blood line and placed them in the chair in preparation for an on coming patient. Patient Care Technician (B) (Station 15) On 02/5/2024 at 10:56 a.m. Patient Care Technician (B) was observed terminally cleaning station #15, hemodialysis machine Nipro Surdial DX # 20-22EW 0344. Observation revealed during terminally cleaning of the unit Patient Care Technician (B) did not clean/ sanitize the Hansen connector, prime bucket, blue clamps, and laminate stored on the intravenous pole, chase, water box and television console. On 02/05/2024 at 10:58 a.m. Patient Care Technician (B) was observed stringing the external blood lines and dialyzers and priming them in preparation for an oncoming patient. On 02/5/2024 at 10:58 a.m. Patient Care Technician (B) checked the conductivity and PH of the dialysate solution in preparation for initiating hemodialysis treatment on a coming patient. On 02/05/2024 at 11:01 a.m. Patient Care Technician (B) accompanied Patient #2 to the scale to be weighed in preparation for initiation of hemodialysis treatment. The Surveyor requested the patient wait in the lobby. Interview on 02/05/2024 at 11:03 a.m., The Surveyor informed Patient Care Technician (B) that during terminal cleaning of stations 14 and 15 he did not clean and sanitize the Hansen connectors, prime bucket, blue clamps and laminate hanging on the intravenous pole, chase, water box and television console. Patient Care Technician (B) states “You mean the water box also.” Licensed Vocational Nurse ( F) ( station 8) On 02/5/2024 at 11:25 a.m. Licensed Vocational Nurse (F) was observed terminally cleaning station # 8, hemodialysis machine Nipro Surdial DX # 8-22EW0346. Observation revealed during terminally cleaning of the unit Licensed Vocational Nurse (F) did not clean/ sanitize the Hansen connectors, prime bucket, chase, water box and television console. On 02/05/2024 at 11:30 a.m. Licensed Vocational Nurse (F) was observed stringing the external blood lines and dialyzers and priming them in preparation for an oncoming patient’s hemodialysis treatment. On 02/5/2024 at 11:36 p.m., the Surveyor informed Licensed Vocational Nurse (F) that he did not clean/ sanitize the Hansen connectors, prime bucket, chase, water box and television console. Licensed Vocational nurse (F) states “ I have to break it down?” Licensed Vocational Nurse (H ) (Station 15) On 02/06/2024 at 9:30 a.m. Licensed Vocational Nurse (H) was observed terminally cleaning station (15) post hemodialysis treatment of a patient. Observation revealed the Licensed Vocational Nurse did not clean/ sanitize the chase, water box and television console during terminal cleaning of the unit. On 02/06/2024 at 9:38 a.m. Licensed Vocational Nurse (H) was observed setting up clean external blood lines and dialyzers in preparation for an oncoming patient’s hemodialysis treatment. The Surveyor immediately notified her that she did not clean/ sanitize the chase, water box and television console during terminal cleaning of the unit. Licensed Vocational Nurse (H) states “ see how clean it is” pointing to the water box. She then states, “I was going to clean the TV after setting up this,” referencing setting up the external blood lines and dialyzers on the hemodialysis machine.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview, the facility’s governing body failed to provide a clean environment. Findings: Observation on 02/06/2024 at 9:10 a.m. of the facility’s stock room revealed an air conditioning vent in the ceiling of the room. The vent was matted with accumulation of black material. Observation on 02/06/2024 at 9:40 a.m. of the facility’s treatment unit, stations 1 - 8 revealed four air conditioning vents with accumulation of brown/ and black material. The Surveyor notified the Facility’s Clinical Coordinator of the particles on the vents. The Clinical Coordinator states” I will get it cleaned.” Review of the facility’s policy and procedure on Physical environment Policy # 8-04-01 revised April 2018 directs staff as follows: “The dialysis facility will be designed, constructed, equipped and maintained to provide dialysis patients, teammates and the public a safe , functional and comfortable treatment environment.””

“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: 10802 Based on observation, and interview , Facility failed to ensure expired supplies are not stored and in use in the facility. Findings: Observation on 02/06/2024 at 8:53 a.m. of the facility’ stock room revealed 4 packets ( total 400 ) BD vacutainer green top blood tubing ( Lot number 3016654) on the shelf in the stock room with expiration date 1/31/2024. Observation on 02/06/2024 at 9:15 am of the facility’s treatment unit revealed a tri station with Standard buffer solution 7.00 which expired on 10/4/2023 and a bottle of RPC 14.0 MS/ CM conductivity solution 14.00 MS/ CM which expired on 1/19/2024. The Surveyor immediately notified Patient Care Technician (I) who was responsible for water of the expired solutions. He states” I am sorry.””

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s registered nurses failed to ensure patients’ hemodialysis prescriptions ordered by the physicians are implemented during hemodialysis treatment in 2 of 12 current sampled patients and 5 closed records. Patient #s 6, 10 Findings Patient #6 On 02/5/2024 at 07:17 a.m. Patient #6 was observed at station #12. The Patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the Patient’s clinical record revealed a physician’s order dated 12/4/2023 for Nipro 15 Elisio 15 H dialyzer. The Surveyor immediately notified Registered Nurse ( G) that the patient was not utilizing the dialyzer prescribed by the physician. Registered Nurse ( G) said “ the order is not changed.” Patient #10 On 02/5/2024 at 7:30 a.m. Patient #10 was observed in the isolation room of the facility, the patient was receiving hemodialysis treatment, at a blood flow rate of 450 mls/ minute and dialysate flow rate of 800 mls/ minute via left upper arm vascular access. The patient was utilizing dialysate solution of 3 mEq potassium and 2.5 calcium. Review of the patient’s clinical record located in the chairside computer revealed an order dated 7/19/2023 for dialysate solution of 3 mEq potassium and 2.25 mEq calcium. The Surveyor immediately notified Licensed Vocational Nurse (F) that the patient was not utilizing the correct dialysate prescription ordered by the physician of 2 K 2.25 calcium. Licensed Vocational Nurse (F) States “ We do not have 3 K 2.25 calcium dialysate solution. I will tell the charge nurse.” Review of the Patient’s treatment sheets dated 2/2/2024, 1/31/2024, 1/26/2024, 1/24/2024, 1/22/2024 1/19/2024, 1/17/2024, 1/15/2024, 1/12/2024 revealed documentation which indicated that the patient utilized 3 mEq potassium and 2.25 calcium, although the facility does not stock the dialysate solution.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the Facility’s registered nurse failed to conduct intradialytic assessments on patients who experienced a change in condition in 2 of 12 current sampled patients and 5 closed records. Patient #6, and 16 Findings Review of Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN ’ s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual ’ s performance and activity. 5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN ’ s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. Review of the facility’s current policy and procedure on pre- intra and post assessment; Policy # 1-03-08 directs staff as follows: “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record.” Patient #6 On 02/5/2024 at 07:17 a.m. Patient #6 was observed at station #12. The Patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s clinical record, located in the chairside computer, revealed a physician’s order for a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s treatment sheet dated 1/29/2024 revealed the following findings. Pre- treatment assessment completed by the registered nurse at 5:31 a.m. with documented blood pressure of 106/43, heart rate of 69 beats per minute and sitting blood pressure of 102/54 and heart rate of 69 beats per minute. The record revealed the patient’s hemodialysis treatment was initiated by the Patient Care Technician assigned to the patient at 5:44 a.m., with documented blood pressure of 103/55. 06:03 a.m.; patient’s documented blood pressure 86/37, heart rate of 64 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:05 a.m.; patient’s documented blood pressure 103/51, heart rate of 64 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:31 a.m.; patient’s documented blood pressure 118/35, heart rate of 71 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:34 a.m.; patient’s documented blood pressure 121/42, heart rate of 72 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. The patient care technician assigned to the patient documented “ bp rechecked; dbp low: uf rate decreased reported to nurse.” 06:39 a.m.; patient’s documented blood pressure 100/54, heart rate of 74 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. The patient care technician assigned to the patient documented “ bp rechecked ; cuff readjusted; bp improved. uf rate decreased reported to nurse.” 07:01 a.m.; patient’s documented blood pressure 58/41, heart rate of 75 beats per minute, blood flow rate of 430 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:02 a.m.; patient’s documented blood pressure 109/35, heart rate of 76 beats per minute, blood flow rate of 430 mls/ minute and dialysate flow rate of 500 mls/ minute 7:08 a.m.; The Patient Care Technician assigned to the patient documented “ bfr reset to 380 due to AP alarm.” 07:31 a.m.; patient’s documented blood pressure 105/26, heart rate of 77 beats per minute, blood flow rate of 380 mls/ minute and dialysate flow rate of 500 mls/ minute 07:33 a.m.; patient’s documented blood pressure 108/43, heart rate of 77 beats per minute, blood flow rate of 380 mls/ minute and dialysate flow rate of 500 mls/ minute 08:06 a.m.; patient’s documented blood pressure 126/47, heart rate of 73 beats per minute, blood flow rate of 380 mls/ minute and dialysate flow rate of 500 mls/ minute 08:25 a.m. patient’s documented blood flow rate of 400 mls/. 08:30 a.m.; patient’s documented blood pressure 129/52, heart rate of 70 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute 09:01 a.m.; patient’s documented blood pressure 113/27, heart rate of 72 beats per minute, blood flow rate of 0 mls/ minute and dialysate flow rate of 500 mls/ minute 09:03 a.m.; patient’s documented blood pressure 98/51 heart rate of 70 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute 09:16 a.m.; patient’s documented blood pressure 112/51 heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute Patient’s hemodialysis treatment discontinued by the Patient Care Technician. Review of the patient’s clinical record revealed no documented intradialytic assessment by the registered nurse assigned to the patient although the patient’s blood pressure was labile ( going up and down) . The patient care technician changed the ultra-filtration rate, decreased the patient’s blood flow rate with no documented assessment by the registered nurse assigned to the patient. Patient’s treatment sheet dated 1/19/2024. Pre- treatment assessment completed by the registered nurse at 5:31 a.m. with documented blood pressure of 11/55, heart rate, of 93 beats per minute and sitting blood pressure of 98/47 and heart rate of 72 beats per minute. The record revealed the patient’s hemodialysis treatment was initiated by the patient care technician assigned to the patient at 5:47 a.m. with documented blood pressure of 94/39 and heart rate of 71 beats per minute. 05:48 a.m. patient’s documented blood pressure 104/54, heart rate of 64 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:02 a.m.; patient’s documented blood pressure 103/48, heart rate of 63 beats per minute, blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:31 a.m.; patient’s documented blood pressure 88/30, heart rate of 69 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:36 a.m.; patient’s documented blood pressure 79/24, heart rate of 69 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 06:43 a.m.; patient’s documented blood pressure 117/57, heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:01 a.m. ; patient’s documented blood pressure 94/20, heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:05 a.m.; patient’s documented blood pressure 163/53, heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:31 a.m.; patient’s documented blood pressure 105/36, heart rate of 75 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:38 a.m.; the patient Care Technician documented “bfr reduced to 400 d/t > 250 arterial pressure.” 07:42 a.m.; patient’s documented blood pressure 115/53, heart rate of 69 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:46 a.m.; patient’s documented blood pressure 111/68, heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 08:01 a.m.; patient’s documented blood pressure 95/32, heart rate of 65 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 08:07 a.m.; patient’s documented blood pressure 102/57, heart rate of 72 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 08:16 a.m.; patient’s documented blood pressure 136/50, heart rate of 72 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 08:32 a.m.; patient’s documented blood pressure 109/25, heart rate of 67 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 08:33 a.m.; patient’s documented blood pressure 94/53, heart rate of 70 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. 09:01 a.m.; patient’s documented blood pressure 133/62, heart rate of 66 beats per minute, blood flow rate of 375 mls/ minute and dialysate flow rate of 500 mls/ minute. 09:16 a.m. patient’s documented blood pressure 113/57 heart rate of 68 beats per minute, blood flow rate of 400 mls/ minute and dialysate flow rate of 500 mls/ minute. Patient’s hemodialysis treatment terminated. Review of the Patient’s clinical record revealed no intradialytic assessment by the registered nurse. On 02/07/2024 at 1:10 p.m. the Surveyor reviewed the patient’s treatment sheet with the Facility’s Charge Nurse who validated that intradialytic assessment should have been done on the patient Patient #16 On 02/05/2024 at 8:02 a.m. Patient #16 was observed on the treatment unit of the facility at station # 5. The patient was receiving hemodialysis treatment, at a blood flow rate of 400 mls/ minute and dialysate flow rate of 800 mls/ minute. Review of the patient’s clinical record, located in the chairside computer, revealed a physician’s order for a blood flow rate of 450 mls/ minute and dialysate flow rate of 800 mls/ minute. Review of the patient’s treatment sheet dated 02/02/2024 revealed documentation which indicated the following: The record revealed the patient’s hemodialysis treatment was initiated at 05:50 a.m. by the Licensed Vocational Nurse at a blood flow rate of 450 mls/ minute and dialysate flow rate of 800 mls per minute via a central venous catheter. Documentation indicated that at 06:30 a.m. the Licensed Vocational Nurse decreased the patient’s blood flow rate to 400 mls/ minute. The patient’s blood flow rate remained at 400 mls /minute until the patient’s hemodialysis treatment was discontinued by the Licensed Vocational Nurse at 09:06 a.m. There was no justification documented why the patient’s blood flow rate was decreased to 400 mls/ minute. There was no documented intradialytic assessment by the registered nurse.”