Davita Ace Dialysis

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 30124 Based on observation, interview, and record review the facility staff failed to monitor patients’ vascular accesses to ensure patient safety by failing to ensure dialysis access were visible throughout the dialysis treatment for 1 of 10 stations (stations #9), during patients’ dialysis treatment. Allowing patients to cover access sites and line connections with blankets provides an opportunity for accidental needle dislodgement or disconnection to go undetected. This practice placed patients of the facility at risk for potential needle dislodgement and/or disconnection which could result in exsanguination and harm. Policy Reviewed of the facility’s current policy Title: Pre-Intra-post Treatment Data Collection, Monitoring and Nursing assessment; Policy: 1-01-08; Revision date 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. Intradialytic Date Collection/Assessment: 9. C. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. Findings included: During a tour of the facility on 7/02/2024 along with staff #B the following was observed: Patient ID #5 at station #9 was observed to be receiving his dialysis treatment. Patient was observed receiving dialysis treatment with a blood flow of 350 ml/minute through a right chest central venous catheter. Patient #5 had her vascular access covered with blankets and not visible during their dialysis treatment. This finding was confirmed in an interview with the staff member #B on 07/02/2024. Staff was observed immediately uncovering the patient’s access and educating the patient to leaving their dialysis access uncovered and visible during dialysis.”

“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 that employees followed the facility’s current policy and procedure in that pre-nursing assessment were not completed within the first hour of initiation of hemodialysis treatment for 3 of 8 selected patient records reviewed. (Patient ID# 1, 2, 6). Policy Reviewed: Review on 07/02/2024 of the facility’s current policy along with clinical services staff ID #B titled: “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08; 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. Policy: 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). 3. The prescription components are confirmed by a licensed nurse with one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Record Review: Review on 07/02/2024 of patient records along with staff ID #B identified the following: Patient ID #1 hemodialysis treatment record: 06/20/2024 hemodialysis treatment initiated at 06:28 AM Pre-assessment completed at 08:27 AM. 06/29/2024 hemodialysis treatment initiated at 05:57 AM Pre-assessment completed at 07:14A PM. Patient ID #2 hemodialysis treatment record: 06/13/2024 hemodialysis treatment initiated at 10:15 AM Pre-assessment completed at 11:22 AM. 06/20/2024 hemodialysis treatment initiated at 11:19 AM Pre-assessment completed at 13:04 PM. 06/27/2024 hemodialysis treatment initiated at 10:50 AM Pre-assessment completed at 12:12 PM. Patient #6 hemodialysis treatment record: 06/18/2024 hemodialysis treatment initiated at 11:07 AM Pre-assessment completed at 13:44 PM. Interview on 07/02/2024 at with staff ID #B confirmed the initial nursing assessments were not completed within the first hour of dialysis for the above findings.”