Davita College Park 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 observation, interview and record review: the facility failed to ensure patient’s nephrologist round and assess patient’s every two weeks in 5 of 8 sampled patients: Patient #s 2, 6, 8, 11 and 12. Findings: Patient ID #2 On 11/20/2024 at 11:20 AM, Patient #2 was observed at Station #17, machine #19 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min via a left upper arm arteria venous fistula vascular access. Patient receives dialysis 3 x week for 3.5 hours. Review of the patient’s clinical record revealed physician progress note dated 10/02/2024 and 10/30/2024. Further record review revealed physician progress note dated 08/23/2024 and 09/20/2024. There is no documented physician progress note every two weeks as required by state regulations. Patient ID #6 On 11/21/2024 at 11:30 AM, Patient #6 was observed at Station #8, machine #20 receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 600 mL/min via a central venous catheter vascular access. Patient receives dialysis 3 x week for 3.0 hours. Review of the patient’s clinical record revealed physician progress note dated 09/26/2024 and 10/26/2024. Further record review revealed physician progress note dated 08/21/2024 and 09/17/2024. There is no documented physician progress note every two weeks as required by state regulations. Patient #8 On 11/20/2024 at 12:30 PM, Patient #8 was observed at Station #23, machine #4 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 700 mL/min via a left upper arm arteria venous graft vascular access. Patient receives dialysis 3 x week for 3.0 hours. Review of the patient’s clinical record revealed physician progress note dated 09/13/2024 and 10/11/2024. Further record review revealed physician progress note dated 10/11/2024 and 10/30/2024. There is no documented physician progress note every two weeks as required by state regulations. Patient #11 On 11/20/2024 at 12:15 PM, Patient #11 was observed at Station #3, machine #13 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 600 mL/min via a left upper arm arteria venous fistula vascular access. Patient receives dialysis 3 x week for 3.0 hours. Review of the patient’s clinical record revealed physician progress note dated 10/21/2024 and 11/18/2024. There is no documented physician progress note every two weeks as required by state regulations. Patient ID #12 On 11/20/2024 at 12:00 PM, Patient #2 was observed at Station #15, machine #10 receiving hemodialysis treatment at a blood flow rate of 250 mL/min and dialysate flow rate of 800 mL/min via a left forearm arteria venous fistula vascular access. Patient receives dialysis 3 x week for 3.5 hours. Review of the patient’s clinical record revealed physician progress note dated 10/02/2024 and 11/18/2024. Further record review revealed physician progress note dated 08/30/2024 and 09/16/2024. There is no documented physician progress note every two weeks as required by state regulations. Interview on 11/21/2024 at 2:30 PM with the Clinical Services Manager, staff ID #G confirmed the above findings.”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s interdisciplinary team failed to develop and implement interdisciplinary comprehensive care plans on patients who experienced change in condition in 3 of 8 sampled patients; Patient #4, 5 and 13 (B) the facility’s registered nurses failed to ensure patients’ hemodialysis treatments were administered based on the patient’s physician orders in 2 of 8 sampled patients. Patient #s 1 and 2 (C) Based on observation, interview and record review the facility failed to implement its physician’s Bylaws to ensure patients’ nephrologist conduct two weekly visits on patients in 2 of 8 sampled patients; Patient #2 and 11 Findings: Cross reference V 541, V 546 V 560”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s quality assessment performance committee failed to develop a robust comprehensive quality assessment improvement program, which identifies deficient areas of care and services of dialysis patients, conduct root cause analysis and develop and implement plans to address all aspect of care and services of patients who receive hemodialysis treatment. Findings: Patient #13 Review of Patient #13’s clinical record, (hospital discharge record) dated 11/03/2023 revealed the following documentation: “Physical deconditioning, status post fall, shoulder fracture left, end stage renal disease, frequent falls, humerus Fracture.” Review of the Facility’s most current Quality assessment Performance meeting for November / completed in December 2023 revealed the patient’s fall was not addressed. Review of the facility’s quality assessment performance improvement plan/ data for September 23, October 23 and November 2023 revealed documentation which indicated patients with hemoglobin under 9 mg/ dl had an upward trend, i.e., September = 7, October =11, December =14. Review of the facility’s quality assessment performance improvement plan for September 23, October 23, and November 2023 revealed no documentation that the facility’s QAPI analyses the data, conducts a root cause to determine the reason for the upward trend and develop and implement a plan to address the upward trend. Mortality Review of the facility’s quality assessment performance improvement plan/ data for September 23, October 23 and November 2023 revealed documentation which indicated the following: September 2023; The facility had 2 patients’ mortality. October 2023; The facility had 1 patient’s mortality. November 2023; The facility had 1 patient’s mortality. Facility’s documented gross mortality 26. During review of the meeting minutes and data with the Facility’s Administrator, it could not be determined who were the patients and cause of mortality. There was no root cause analysis of the patients’ mortality and a plan develop and implement to address patient’s mortality. Central venous catheter Review of the facility’s quality assessment performance improvement plan/ data for November 2023 revealed documentation which indicated the following: Patients with central venous catheter over 90 days= 32.6 % Review of record for November 2023 revealed no documentation that the facility’s QAPI analyses the data, conducts a root cause to determine the reason for the facility’s outcome of 32.6% of patient having central venous catheter over 90 days and develop and implement a plan to address patients with central venous catheter over 90 days. Physicians Visit of In - center Hemodialysis Patients Review of patient’s clinical record revealed documentation which indicated that certain physicians were not seeing their patients as required. Review of the quality assessment performance plan meeting minutes revealed documentation which indicated this issue was identified in 9/26/2023 with completion date of 10/16/2023. The plan included sending certified letter to the identified physician and the medical director to communicate with physician on rounding visits. Review of the quality assessment performance meeting minute revealed no further revaluation of the plan. Review of a sample of patients’ clinical record revealed documentation which indicated one sampled patient’s most current visit documented by the patient’s Nephrologist was dated July 2023 and August 2023. Interview during review of the meeting minutes with the Facility’s Regional Operations Director, revealed he said one of the two physicians included in the deficient practice was sent for peer review, however this action is not included in the quality assessment performance plan.”

“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’s direct care staff failed to encourage patients to wash/ sanitize hands after holding their vascular access sites and removing contaminated gloves in 4 of 5 random patients observed; Random patients #s 6, 7, 8, 9. (B) Facility’s direct care staff failed to wash / sanitize hands after removing contaminated gloves in 3 of 4 staff observed. Patient Care Technician (D), (B), ( E). 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: (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.” Random Patient #6 On 12/27/2023 at 8:55 a.m. Random Patient 6 was observed on the treatment unit at station #1. The patient was wearing a glove to her right hand and holding her vascular access site on her left hand with the glove. On 12/27/2023 at 9:00 a.m. Patient Care Technician (D) reinforced the dressing to the patient’s left upper arm vascular access site post hemodialysis treatment. After Patient Care Technician (D) reinforced the dressing to the patient’s vascular access site, the patient wearing the contaminated glove, picked up her pocketbook, her pillow and other personal items and walked to the scale accompanied by Patient Care Technician (D). When reaching the scale, the patient placed her personal items down, removed the glove and gave it to Patient Care Technician (D) who discarded it. The patient reprogrammed the scale used by the general patient population with her unwashed hands, weighed, picked up her personal items and left the unit without washing or sanitizing her hands after removing the contaminated glove. Patient Care Technician (D) did not encourage patient #6 to wash/ sanitize her hands after removing the contaminated glove used to hold her vascular access site post hemodialysis treatment. Random Patient #7 On 12/27/2023 at 9:27 a.m. Random Patient #7 was observed at station #6 on the treatment unit. The patient was holding his vascular access site on his left arm with his right gloved hand. Patient Care Technician (B) reinforced the dressing to the patient’s right arm and Registered Nurse (A) removed the contaminated glove from the patient’s right hand. Patient #7 picked up his personal items, walked to the scale accompanied by Patient Care Technician (B). The patient reset the scale with his unwashed hand used to hold his vascular access site, weighed, picked up his personal items and left the unit without washing / sanitizing his hands after holding his vascular access site post hemodialysis treatment. Patient Care Technician (B) did not encourage patient #7 to wash/ sanitize his hands after removing the contaminated glove use to hold his vascular access site post hemodialysis treatment. Random Patient #8 On 12/27/2023 at 9:50 a.m. Random Patient #8 was observed on the treatment unit at station # 4. The patient was wearing a glove to his right hand and holding his vascular access site on his left hand with the glove. On 12/27/2023 at 9:58 a.m. Patient Care Technician (D) reinforced the dressing to the patient’s left arm vascular access site post hemodialysis treatment. After the reinforcing the dressing to the patient’s vascular access site, the patient removed the contaminated glove, picked up his walking cane and bag and walked to the station accompanied by Patient Care Technician (D). The patient weighed and left the unit without washing or sanitizing his hands used to hold his vascular access site post hemodialysis treatment. Patient Care Technician (D) did not encourage patient #8 to wash/ sanitize his hands after removing the contaminated glove use to hold his vascular access site post hemodialysis treatment. Random Patient #9 On 12/27/2023 at 9:52 a.m. Random Patient 9 was observed on the treatment unit at station # 3. The patient was wearing a glove to his right hand and holding his vascular access site on his left hand with the glove. On 12/27/2023 at 9:58 a.m. Patient Care Technician (D) reinforced the dressing to the patient’s left arm vascular access site post hemodialysis treatment. After reinforcing the dressing to the patient’s vascular access site, the patient removed the contaminated glove, picked up his bag and walked to the scale accompanied by Patient Care Technician (D). The patient weighed and left the unit without washing or sanitizing his hands used to hold his vascular access site post hemodialysis treatment. Patient Care Technician (D) did not encourage patient #9 to wash/ sanitize his hands after removing the contaminated glove use to hold his vascular access site post hemodialysis treatment. During an interview with Patient Care Technician D on 12/27/2023 at 10:00 a.m The Surveyor informed Patient Care Technician D that the patients he terminated hemodialysis treatment on were allowed to leave the clinic without washing/ sanitizing hands. Patient Care Technician (D) states “ Sometimes we tell them.” Patient Care Technician (D) On 12/27/2023 at 6:19 a.m. Patient Care Technician (D) was observed at station #19. Patient #3’s hemodialysis machine alarmed, and the patient care technician picked up a glove from the clean box of glove in the station, reset the hemodialysis machine with the glove while holding it, he did not don the glove. Patient Care Technician (D) discarded the glove, walked to the rack which held gowns, removed his gown, hung it on the rack and left the unit with his unwashed/ sanitized hands. The Surveyor immediately notified Patient Care Technician (D) that he did not wash, sanitize his hands after resetting the patient’s hemodialysis machine and removing his contaminated gown. Patient Care Technician (D) states “Yes Mam.” Patient Care Technician (B) On 12/27/2023 at 08:40 a.m. Patient Care Technician (B) was observed on the treatment floor of the facility. The patient care technician was terminally cleaning hemodialysis station #7; hemodialysis machine #7 post hemodialysis treatment of a patient. During terminally cleaning of the hemodialysis unit, the cleaning towel fell to the floor. Patient Care technician (B) retrieved the towel from the floor, removed his contaminated gloves, walked over to the clean cabinet, opened a packet of clean towels, and picked up clean gloves from the box of gloves stored in station #7. Patient Care Technician (B) did not wash/ sanitize his hands after removing the contaminated gloves Patient Care Technician (E) On 12/29/2023 at 6:25 a.m. Patient Care Technician (E) was observed at station #11. The patient care technician was cannulating Random Patient #12’s vascular access site. After cannulating the patient’s vascular access site, the patient care technician removed her contaminated gloves, picked up clean gloves from the box of gloves located in the station. Patient Care Technician (E) did not wash/ sanitize her hands after removing her contaminated gloves prior to picking up gloves from the clean box of gloves. The Facility’s interim Clinical Coordinator was present during the observation. The Surveyor immediately notified Patient Care Technician (E) of the break in infection control technique of her not washing /sanitizing hands after cannulating the patient’s vascular access. Patient Care Technician (E) states “ sorry.””

“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 observations, staff interview and review of the facility’s policies and procedures, the facility’s direct care staff failed to clean/disinfect Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, television console, water hoses, water box and chase during terminal cleaning of hemodialysis dialysis units in 2 of 3 staff observed during terminal cleaning of contaminated hemodialysis stations: Patient Care Technician B, Patient Care Technician (D) 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.” Station 7 Hemodialysis machine #7 On 12/27/2023 at 08:40 a.m. Patient Care Technician (B) was observed on the treatment floor of the facility. The patient care technician was terminally cleaning hemodialysis station #7; hemodialysis machine #7. The hemodialysis station was previously used by a patient for hemodialysis treatment. During terminal cleaning of the contaminated hemodialysis station, Patient Care Technician (B) did not clean/ disinfect the Hansen connectors, stethoscope, television console, water hoses, water box and chase. The patient care technician wiped over the Hansen connectors holder in which they were encased. Station#1 Hemodialysis #2 On 12/27/2023 at 09:40 a.m. Patient Care Technician (D) was observed on the treatment floor of the facility. The patient care technician was terminally cleaning hemodialysis station #1; hemodialysis machine #2. The hemodialysis station was previously used by a patient for hemodialysis treatment. During terminal cleaning of the contaminated hemodialysis station, Patient Care Technician (D) did not clean/ disinfect the Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, intravenous pole, water hoses, water box and chase. On 12/27/2023 at 10:10 a.m. Registered Nurse (A) was observed setting up clean blood lines and dialyzer in preparation for an oncoming patient. The Surveyor notified Patient Care Technician (D) that he did not clean/ disinfect Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, intravenous pole, water hoses, water box and chase. Patient Care Technician states “ok.” Station 6 Hemodialysis # 11 On 12/27/2023 at 10:05 a.m. Patient Care Technician (B) was observed on the treatment floor of the facility. The patient care technician was terminally cleaning hemodialysis station #6; hemodialysis machine #11. The hemodialysis station was previously used by a patient for hemodialysis treatment. During terminal cleaning of the contaminated hemodialysis station, Patient Care Technician (B) did not clean/ disinfect the Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, intravenous pole, television console, water hoses, water box and chase. The patient care technician wiped over the Hansen connectors holder that they were encased in. The Patient Care technician wiped only the front of the hemodialysis machine and over the encased Hansen connectors, and the chair in the station. Station 5 Hemodialysis machine #25 On 12/27/2023 at 10:15 a.m. Patient Care Technician (B) was observed on the treatment floor of the facility. The patient care technician was terminally cleaning hemodialysis station #5; hemodialysis machine #25. The hemodialysis station was previously used by a patient for hemodialysis treatment. During terminal cleaning of the contaminated hemodialysis station, Patient Care Technician (B) did not clean/ disinfect the Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, intravenous pole, television console, water hoses, water box and chase. The patient care technician wiped over the Hansen connectors holder that they were encased in. The Patient Care technician wiped only the front of the hemodialysis machine and over the encased Hansen connectors, and the chair in the station. On 12/27/2023 at 10:17 a.m. Patient Care Technician (B) was observed setting up clean blood lines and dialyzer and priming the dialyzer in preparation for an on coming patient. The Surveyor notified him that he did not clean/ sanitize disinfect the Hansen connectors, stethoscope, emergency supply stored on the intravenous pole of the hemodialysis machine, intravenous pole, television console, water hoses, water box and chase. Patient Care Technician states “thank you.””

“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, interview and record review, the facility’s direct care staff failed to follow manufacturer’s recommendation for use changing filters of oxygen concentrators in use by patients in the facility in 3 of 4 oxygen concentrators in use in the facility. Findings: Review of the Manufacture’s Direction for use DeVilbiss 525 DS series 5-liter series, revealed the following manufacture’s direction for use: “Preventative Maintenance Summary Patient Daily Clean the humidifier bottle (if used). Weekly Clean air filter on back of unit. Clean exterior of cabinet, other clean and replace cannula/mask and tubing as instructed by manufacture.” “Between Patient Maintenance 1. Discard oxygen tubing, cannula & humidifier bottle. 2. Wash or replace the cabinet air filter. 3. Wash the concentrator cabinet. 4.Check oxygen concentration. If the unit falls within specification, the extended life intake bacteria filter does not need to be replaced between patient.” Observation on 12/ 29/2023 at 7:10 a.m. of station # 9 revealed Devilbiss 5 L (reference # 525DS B2 0706008205 in use by patient #1 Observation of the facility’s nurses station revealed the following oxygen”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s interdisciplinary team failed to develop and implement interdisciplinary comprehensive care plans on patients who experienced change in condition in 3 of 8 sampled patients; Patient #4, 5 and 13 Findings: Review of the facility’s Policy and Procedure on Interdisciplinary Team (IDT) Patient assessment and Plan of Care Policy # 5-15-02 Directs staff as follows: “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 expected care.” “Plan of Care The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the plan of care will be consistent with current evidence - based professionally - accepted clinical practice standards.” Patient #4 On 12/27/2023 at 7:20 a.m., Patient #4 was observed on the treatment floor of the facility at station #20. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysis flow rate of 700 mls/ minute via a right upper arm fistula. The patient was receiving intravenous Heparin via the pump at 500 units hourly and 3000 units bolus. Interview with Patient #4 during the observation revealed he said he was away from the facility for two weeks visiting another state when he fell and lacerated his kidney, had a hematoma to his kidney and was admitted to the hospital for four days. The patient said he had numerous falls in 2022 because he was anemic. Review of a hospitalization record dated 10/31/2023 revealed the following documentation:” Acute blood loss anemia. Anemia secondary to ESRD on dialysis. Renal hematoma, left renal mass, HTN, HLD hyperlipidemia, DM type 2, hypothyroidism, gout, history of recent fall, anemia, ESRD, near syncope.” Follow up with urology service 2- 4 weeks.” Review of a nephrologist’s progress notes in the hard chart of the patient’s clinical record revealed the following documentation by the patient’s nephrologist dated 11/15/2023 “Seen and examined. C/O urine brown x 3 days. No gross hematuria. No issues with HD. Dark urine may be residual blood. Will get U/A and cult. Anemia low HB.” Review of the patient’s laboratory findings revealed the following values: 10/09/2023 -Hemoglobin 11.3 gms/ dl 11/13/2023 -Hemoglobin 8.0 gms/ dl 12/11/2023 -Hemoglobin 9.7 gms/ dl Review of the patient’s Interdisciplinary comprehensive care plan dated 10/04/ 2023 provided by Medical Clinical Support Personnel revealed the care plan did not reflect the patient’s recent fall/ potential for falling and diagnosis of near syncope, and hematoma of the kidney. Interview with Facility’s Charge nurse on 12/27/2023 revealed she said she was not aware of the documentation in the patient’s clinical record by the patient’s Nephrologist which indicated the following “dated 11/15/2023” Seen and examined. C/O urine brown x 3 days. No gross hematuria. No issues with HD. Dark urine may be residual blood. Will get U/A and cult. Anemia low HB.” There was no order documented by the physician and no documentation of communication with the interdisciplinary team. Interview on 12/27/2023 with the Facility’s Regional Operations Director revealed he said when the patient’s nephrologist rounds on patients, nurses are not aware of his findings because he does not round with nurses or other disciplines. Patient #5 Review of Patient #5’s clinical record revealed he sustained a fall on 4/14/2023 in the facility post hemodialysis treatment. The patient was transferred to the hospital and was hospitalized from 4/14/2023 - 4/18/2023. Review of the patient’s clinical record revealed documentation which indicated the patient was on numerous medications which contributes to the potential of the patient’s falling. Review of the patient most current assessment health maintenance / safety assessment by the registered nurse revealed documentation in the assessment Ambulatory status “not yet documented.” Review of the patients most current interdisciplinary plan of care signed by the interdisciplinary team 8/29/2023 - 10/17/2023 revealed no comprehensive care plan to address the patient’s fall and risk of patient falling. Patient #13 Interview on 12/29/2023 at 1:10 p.m., with the Facility’s Regional Operation Director revealed he said Patient #13 fell twice at home and sustained fracture. Review of Patient #13’s clinical record, (hospital discharge record) dated 11/03/2023 revealed the following documentation: “Physical deconditioning, status post fall, shoulder fracture left, end stage renal disease, frequent falls, humerus Fracture.” Interview on 12/29/2023 at 1:25 p.m. with the Facility’s Administrator revealed she said the patient is currently residing in a rehabilitation but comes to the facility for hemodialysis treatment. Review of a reassess and interdisciplinary comprehensive assessment/ care plan dated 11/20/2023 provided by the Facility’s Administrator, documented the following: “Rehabilitation; Meet and maintain desired level of vocational activity.” The Interdisciplinary care plan did not address the patient’s multiple falls and the potential for falling. On 12/29/2023 The Surveyor reviewed the patient’s interdisciplinary assessment/ care plan with the Facility’s Regional Operations Director and The Facility’s Administrator who confirmed that the patient’s plan of care did not reflect the patient’s multiple falls and hospitalization.”

“POC-MANAGE MINERAL METABOLISM CFR(s): 494.90(a)(3) Provide the necessary care to manage mineral metabolism and prevent or treat renal bone disease. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview, the facility’s registered nurses failed to ensure patients’ hemodialysis treatments were administered based on the patient’s physician orders in 2 of 8 sampled patients. Patient #s 1 and 2 Findings: Patient #1 On 12/27/2023 at 7:12 a.m. Patient #1 was observed at station # 9, hemodialysis machine #22. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 700 mls/ minute via a left upper arm arteriovenous fistula. The patient was utilizing dialysate concentrate of 2 potassium and 2.5 calcium. Review of the physician’s order located in the chairside computer revealed a physician’s order dated 12/11/2023 for 3 potassium and 2.5 calcium. Review of the patient’s clinical record revealed documentation which indicated the patient’s hemodialysis treatment started at 5:31 a.m. The Surveyor immediately notified Registered Nurse (A) that the patient was not utilizing the prescription of 3 potassium and 2.5 calcium prescribed by the physician. Registered Nurse (A) states “sorry about that.” She said another nurse on the unit verified the prescription. Interview on 12/27/2023 at 7:15 a.m. with Registered Nurse (C) revealed she said she had identified that the patient was using the wrong dialysate concentrate approximately 30 minute prior to the Surveyor’s observation but she was busy with another patient. Review of the Patient’s treatment sheet dated 12/27/2023 at 07:27 a.m.: revealed the following entry:” Patient blood pressure low. Patient awake; alert and states no complaints at this time. Patient was started at 2 K bath. Potassium bath changed to #K as prescribed.” This was documented after the Surveyor’s observation. Review of Patient #1’s treatment sheet dated 12/ 04/2023 revealed documentation which indicated the Patient’s was maintained at 300 mls/minute by the patient care technician from 8:31 a.m. to 9:43 a.m. Documentation by the patient care technician assigned to the patient indicated the patient was tolerating his hemodialysis treatment. There was no justification documented by the registered nurse why the patient’s blood flow rate was not maintained at the prescribed rate. Patient #2 On 12/27/2023 at 8:15 a.m. Patient # 2 was observed in station 17. The patient was utilizing hemodialysis machine #23. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysate flow rate of 800 mls per minute via an arteriovenous graft. Review of the patient’s clinical record located in the chairside computer revealed a physician’s order dated 12/27/2023 for blood flow rate of 350 mls/ minute and dialysate flow rate of 800 mls per minute. Review of the patient’s treatment sheet dated 12/27/2023 revealed the patient’s blood flow rate was maintained at 400 mls/ minute by the patient care technician from 6:32 a.m. - 10:30 a.m. The record revealed the patient’s prescription was verified by the registered nurse at 06:53 a.m. There was no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate . On 12/27/2023 the Surveyor notified the Medical Clinical Support personnel of her findings. She confirmed that there was no justification documented why the patient’s blood flow rate was not maintained at the prescribed rate.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review the facility failed to implement its physician’s Bylaws to ensure patients’ nephrologist conduct two weekly visits on patients in 2 of 8 sampled patients; Patient #2 and 11 Findings: Review of the facility’s medical staff bylaws: approved May 2021 directs staff as follows: Rounding and Documentation Requirements: “Ensure patients are rounded on in compliance with DaVita, ESRD Network state and federal requirements.” Patient #2 On 12/27/2023 at 8:15 a.m. Patient # 2 was observed in station 17. The patient was utilizing hemodialysis machine #23. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysate flow rate of 800 mls per minute via an arteriovenous graft. Review of the patient’s clinical record (Patient Summary of Information) revealed the patient was admitted to the facility on 6/26/2023 from an out of state facility with diagnosis of hypertension large vessel disease, hypertensive chronic kidney disease unspecified on in - center hemodialysis three times weekly. Review of the patient’s clinical record revealed a history and physical completed by the patient’s nephrologist on 7/12/2023, a comprehensive encounter completed on 9/6/ 2023 by the nephrologist. Limited visit by the nurse practitioner dated 9/12/2023, a comprehensive encounter completed on 10/18/2023 and a comprehensive encounter signed by the nephrologist 11/17/2023 and finalized by the physician on 11/25/2023. The patient was not seen by the nephrologist every two weeks as required by the state’s regulation. On 12/27/2023 at 2:00 p.m. the Surveyor reviewed the patient’s clinical record with the Medical Clinical Support personnel. She confirmed that the patient’s nephrologist did not document rounding on the patient every two weeks. Patient #11 Review of Patient #11’s clinical record patient summary of information revealed the patient was admitted to the facility on 1/14/2017 with diagnosis of hypertension and end stage renal disease on in- center hemodialysis three times weekly. Review of the patient’s hospitalization record revealed he was admitted to the hospital 07/28/2023, to 08/01/2023: Diagnosis: upper gastrointestinal bleed, acute blood loss anemia, ESRD on dialysis, hypertension, and morbid obesity. Hospital Course “This is a, David K with hemodynamic 63 - year old morbid obese male with history of ESRD, HD MWF, hypertension, admitted to hospital on 7/28/2023 with GI bleeding and symptomatic anemia. Hospital course patient got GI and renal consult. He got EGD which showed erosive gastritis and gastric ulcer. He also got blood transfusion. On 7/31/2023, patient’s, patient’s condition is stable He will discharge home. Follow with GI and renal consultation. Review of the patient’s clinical record revealed the most current documented visit by the patient’s nephrologist was dated 7/12/2023 and a history and physical dated 8/2023. There was no further documentation of a physician’s visit to the patient since 8/2023. On 12/29/2023 at 11:45 a.m. the Surveyor requested further documentation of the physician’s visit. Interview with the Medial Clinical Support revealed she said the only documentation of physician’s visit was dated 7/12/2023 and a history and physical dated 8/23.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s quality assessment performance committee failed to develop a robust comprehensive quality assessment improvement program, which identifies deficient areas of care and services of dialysis patients, conduct root cause analysis and develop and implement plans to address all aspect of care and services of patients who receive hemodialysis treatment. Findings: Patient #13 Review of Patient #13’s clinical record, (hospital discharge record) dated 11/03/2023 revealed the following documentation: “Physical deconditioning, status post fall, shoulder fracture left, end stage renal disease, frequent falls, humerus Fracture.” Review of the Facility’s most current Quality assessment Performance meeting for November / completed in December 2023 revealed the patient’s fall was not addressed. Review of the facility’s quality assessment performance improvement plan/ data for September 23, October 23 and November 2023 revealed documentation which indicated patients with hemoglobin under 9 mg/ dl had an upward trend, i.e., September = 7, October =11, December =14. Review of the facility’s quality assessment performance improvement plan for September 23, October 23, and November 2023 revealed no documentation that the facility’s QAPI analyses the data, conducts a root cause to determine the reason for the upward trend and develop and implement a plan to address the upward trend. Mortality Review of the facility’s quality assessment performance improvement plan/ data for September 23, October 23 and November 2023 revealed documentation which indicated the following: September 2023; The facility had 2 patients’ mortality. October 2023; The facility had 1 patient’s mortality. November 2023; The facility had 1 patient’s mortality. Facility’s documented gross mortality 26. During review of the meeting minutes and data with the Facility’s Administrator, it could not be determined who were the patients and cause of mortality. There was no root cause analysis of the patients’ mortality and a plan develop and implement to address patient’s mortality. Central venous catheter Review of the facility’s quality assessment performance improvement plan/ data for November 2023 revealed documentation which indicated the following: Patients with central venous catheter over 90 days= 32.6 % Review of record for November 2023 revealed no documentation that the facility’s QAPI analyses the data, conducts a root cause to determine the reason for the facility’s outcome of 32.6% of patient having central venous catheter over 90 days and develop and implement a plan to address patients with central venous catheter over 90 days. Physicians Visit of In - center Hemodialysis Patients Review of patient’s clinical record revealed documentation which indicated that certain physicians were not seeing their patients as required. Review of the quality assessment performance plan meeting minutes revealed documentation which indicated this issue was identified in 9/26/2023 with completion date of 10/16/2023. The plan included sending certified letter to the identified physician and the medical director to communicate with physician on rounding visits. Review of the quality assessment performance meeting minute revealed no further revaluation of the plan. Review of a sample of patients’ clinical record revealed documentation which indicated one sampled patient’s most current visit documented by the patient’s Nephrologist was dated July 2023 and August 2023. Interview during review of the meeting minutes with the Facility’s Regional Operations Director, revealed he said one of the two physicians included in the deficient practice was sent for peer review, however this action is not included in the quality assessment performance plan.”

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s governing body failed to ensure direct care staff providing care and services to facility’s hemodialysis patients receive orientation and training prior to assigned direct care of hemodialysis patients in 1 of 1 staff which floated to the facility. Patient Care Technician (E) Findings: On 12/27/2023 at 8:00 a.m. Patient Care Technician (E) was observed on the treatment floor of the facility. The patient care technician was cannulating patients’ vascular accesses, initiating, monitoring, and terminating hemodialysis treatment on patients and preparing hemodialysis machines for hemodialysis treatment of patients. The Surveyor requested of Patient Care Technician (E) to open the panel of the patient’s hemodialysis machine so that she could validate the patient’s prescription. Interview with Patient Care Technician (E) during the request revealed she states “I generally work at another facility; this is my first time at this facility. I have never worked with these machine because the facility I work at have a different type of machine. I am having a difficult time with these hemodialysis machines.” The Surveyor asked Patient Care Technician (E) if she had training and orientation to the facility since it is her first time at the facility. Patient Care Technician (E) said she had no training on the hemodialysis machines and that she had no orientation to the unit. Review of the assignment sheet for 12/27/2023 revealed Patient Care Technician (E) was assigned to provide care to four hemodialysis patients in Pod 3. During an interview with the Facility’s Administrator on 12/27/2023 at 2:30 p.m., the Surveyor asked the Facility’s Administrator when she was made aware that Patient Care Technician (E) was assigned to the unit and why she was not provided training and orientation to the unit. The Facility’s Administrator responded, “Last night.” She did not give a reason why the Patient Care Technician was not provided with training and orientation prior to assignment of care and services in the facility.” Review of a personnel and training file provided by the Facility’s Administrator revealed documents included in the file was a Medical Director’s delegation for cannulation, medication and saline administration, signed by the patient care technician 12/27/2023, emergency equipment checklist, blood glucose testing PCT procedural skills verification checklist which had Patient Care Technician’s (E’s) name and training start date. There was no initial or verification of competency and A Myron L Conductivity meter (D-1) skills checklist signed by patient Care Technician. Patient Care Technician (E) On 12/29/2023 at 6:25 a.m. Patient Care Technician (E) was observed at station #11. The patient care technician was cannulating random patient #12’s vascular access site. After cannulating the patient’s vascular access site, the patient care technician removed her contaminated gloves, picked up clean gloves from the box of gloves located in the station. Patient Care Technician (E) did not wash/ sanitize her hands after removing her contaminated gloves prior to picking up gloves from the clean box of gloves. The interim Clinical coordinator was present during the observation.”