Davita Dialysis Care of Weatherford

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 30377 Based on review of medical records, policy and procedures, and staff interview, the facility staff failed to ensure that patient vital signs that fell outside of the facility’s set parameters were reported to the Registered Nurse and/or physician for further assessment and intervention in 1 (Patient #1) of 7 patient medical records reviewed. The facility staff failed to follow the ‘Notification Parameters for Weatherford Revised Date 03/24/2025.” Findings include: Review of hemodialysis flow sheets on 02/03/2026 in the facility conference room revealed the following: Patient #1 Flow Sheet dated 01/02/2026 Dialysis Prescription Treatment Time: 3.5 hours Pre Treatment Vitals: Time: 03:36 PM Blood Pressure: 80/58 Heart Rate: 112 Post Treatment Vitals: Time: 06:52 PM Blood Pressure: 108/62 Heart Rate: 116 There was no documentation provided at time of review that the registered nurse was notified prior to the dialysis technician initiating the dialysis treatment that the patient’s blood pressure and heart rate fell outside of facility’s acceptable parameters. Flow Sheet dated 01/12/2026 Dialysis Prescription Treatment Time: 3.5 hours Pre Treatment Vitals: Time: 04:01 PM Blood Pressure: 152/88 Heart Rate: 116 Post Treatment Vitals: Time: 07:42 PM Blood Pressure: 116/64 Heart Rate: 107 There was no documentation provided at time of review that the registered nurse was notified prior to the dialysis technician initiating the dialysis treatment that the patient’s heart rate fell outside of facility’s acceptable parameters. A review of the facility policy, “Notification Parameters For WEATHERFORD REVISED DATE 03/24/2025.” stated that the following parameters were provided for the direct patient care staff to give guidance when a registered nurse needed to evaluate the patient status. Pre Treatment: Systolic Blood Pressure greater than 180 Diastolic Blood Pressure greater than 100 Systolic Blood Pressure less than 100 Diastolic Blood Pressure less than 50 DO NOT START TREATMENT UNTIL APPROVED BY THE CHARGE NURSE Heart Rate greater than 100 Heart Rate less than 50 An interview conducted on 02/03/2026 at 12:30 PM with Staff Member #5, following her own review of the findings, revealed she was unaware of the discrepancies found in the flow sheets.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 30377 Based on review of hemodialysis flow sheets and staff interview the nursing staff failed to evaluate the appropriateness of the dialysis prescription by failing to complete a post dialysis assessment. Based on review of medical records and staff interview the facility’s nursing staff failed to address elevated potassium lab values and adjust dialysate formula per the physician order in a timely manner. Based on review of Quality Assessment and Improvement Performance (QAPI) meeting minutes and staff interview the medical director failed to ensure that all required members attending the monthly QAPI meetings. The medical director failed to ensure that the facility analyze, make recommendation, and develop action plans including root cause analysis to minimize events that occurred in the facility and take appropriate action to reduce future events. These deficient practices identified have the potential to cause harm to all patients at the facility. Refer to tags V 0504, V0505, and V0712”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 30377 Based on observation and staff interview the facility staff failed to ensure a clean and sanitary environment was monitored and maintained in the in-center treatment area. This deficient practice had the likelihood to result in the transmission of infectious agents within the facility and between patients, staff members, and members of the public. During a tour of the facility’s clinical areas with Staff # 1 on 03/10/25 at 1:00 PM and again on 3/12/25 at 5:02 PM the surveyor observed the following infection control issues: In-Center Treatment Area: Opened glove boxes stored on small shelves directly behind the dialysis station. Manual blood pressure stand base, IV pole base, and crash cart lower drawer with excessive dust build up. Used gowns stored on hooks that allowed the gown to touch the floor. Multiple dialysis machines with light yellow / brown stains at the base of the machine Multiple blood pressure cuffs attached to the dialysis machine observed with excessive lent build up. Metal aspect of the dialysis chair with dust build up observed on 2 out of 3 chairs. Full trash cans stored alongside clean dialysis chairs (inside the dialysis station) at the end of the treatment day. The full trash can was stored in the dialysis station for the housekeeper to empty after the dialysis unit is closed. An interview was conducted with Staff # 1 on 03/12/2025 at 5:30 PM confirmed the infection control issues found in the clinical areas of the facility. Staff # 1 was present during the tour of the clinical areas.”

“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: 30377 Based on direct observation and staff interview the staff failed to ensure their hands were washed or sanitized between glove changes, when moving from station to station, and after touching patients per facility policy. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by increasing the potential of cross-contamination between patients. Findings: During observation of care of the facility’s in-center treatment area on 03/12/25 the following was observed: Between 09:55 and 10:05 AM: The patient care technician staff member # 5 was observed multiple times not performing hand hygiene post glove removal and prior to placing on new gloves. At 10:08 AM: Staff # 6 observed gloved assisting patient place on face mask. The staff member removed and disposed of the gloves. She proceeded to the computer cart and placed on new gloves. The staff member did not perform hand hygiene prior to exiting station and after gloves removed. At 10:22 AM: Staff # 4 conducting a pre-assessment with no gloves on. At 10:35 AM: Staff # 4 conducting a pre-assessment with no gloves on. In an interview conducted, with staff #1, on 3/12/25 at 11:00 AM confirmed that staff were required to wash or sanitize hands between glove changes, when moving from station to station, and after touching patients to prevent cross contamination.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 30377 Based on review of hemodialysis flow sheets and staff interview the nursing staff failed to evaluate the appropriateness of the dialysis prescription by failing to complete a post dialysis assessment. The findings included: Observation of the in-center treatment floor on 03/12/25 from 09:25 AM to 10:45AM revealed the following: Patient # 2 observed on dialysis treatment with rinse back initiated at 09:42 AM. The patient was observed leaving the in-center area at 09:55 AM with no post assessment being completed by the registered nurse. Patient # 3 observed on dialysis treatment with rinse back initiated at 09:34 AM. The patient was observed leaving the in-center treatment area at 09:46 with no post assessment being completed by the registered nurse. Review of flow sheets dated for 03/12/25 at 3:07 PM revealed that patient #2 and #3 both had post assessments documented including lung field sounds and heart rate and rhythms. An interview conducted with the staff #4 on 03/12/25 at approximately 5:30 PM following her own review of the findings confirmed that she did not assess patient #2 and or #3 prior to their discharge from the facility. Staff #4 confirmed that she documented auscultation of lung fields and heart sounds for patient #2 and #3. Staff # 4 stated she sometimes does not have time to complete post assessments prior to patient being discharged from the facility.”

“PA-ASSESS LAB PROFILE CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: (3) Laboratory profile, This Standard is not met as evidenced by: 30377 Based on review of medical records and staff interview the facility’s nursing staff failed to address elevated potassium lab values and adjust dialysate formula per the physician order in a timely manner. The findings included: Review of Patient #1’s medical records on 3/12/25 at 10:00 AM in the facility conference room revealed the following elevated potassium levels. Patient # 1 01/20/25 Potassium level was 6.3 02/03/25 Potassium level was 6.9 02/07/25 Potassium level was 6.4 02/17/25 Potassium level was 7.0 03/03/25 Potassium level was 6.7 03/10/25 Potassium level was 6.4 Review of Physician Progress Note revealed the following documentation: 01/08/25 Assessment and Plan: Nutrition: Council patient on low K+ diet, RD to reeducate, Low potassium bath. (To note: The patient was receiving dialysis on a standard dialysis bath) 01/13/25: Assessment and Plan: Nutrition: Talk about low K diet. Other: Patient tolerated dialysis very well. Continue current prescription (To note: The patient remained on a standard dialysis bath) 02/05/25: Assessment and Plan: Nutrition: Talked about the importance of watching potassium intake (To note: The patient remained on a standard dialysis bath) 02/17/25: Assessment and Plan: Nutrition: Talked about the importance of watching potassium intake. 1 K+ bath Re-educate Repeat (To note: The patient remained on a standard dialysis bath) 02/24/25: Assessment and Plan: Nutrition: Talked about the importance of watching potassium intake. 1 K+ bath Re-educate Repeat (To note: The patient remained on a standard dialysis bath) As of 3/12/25 the patient remained on standard dialysis bath and not a low potassium bath as directed by the physician in January and February 2025. Interview conducted with Staff #1 on 3/12/25 at 1:15 PM after her own review confirmed the above findings. Staff # 1 stated that she does not always have time to review labs timely. Staff #1 confirmed that the attending physician documented in January 2025 and February 2025 that the patient should receive dialysis on a low potassium (1K+) bath.”

“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: 30377 Based on review of Quality Assessment and Improvement Performance (QAPI) meeting minutes and staff interview the facility failed to analyze, make recommendation, and develop action plans including root cause analysis to minimize events that occurred in the facility and take appropriate action to reduce future events. These deficient practices identified have the potential to cause harm to all patients at the facility. Findings were: Review of Quality Assessment and Improvement Performance meeting minutes from February 2024 to January 2025 on 3/12/25 in the facility’s conference room revealed the following: Hospitalization Improvement Plan-January 2025 revealed that from September 2024 to January 2025 the facility’s trend for hospitalization increased month after month. The following was observed. September 2024 eight hospitalizations were identified. October 2024 nine hospitalizations were identified. November 2024 twelve hospitalizations were identified. December 2024 twelve hospitalizations were identified. January 2025 seventeen hospitalizations were identified. There was no documentation presented that the facility conducted a root cause analysis of the hospitalizations. There was no documentation presented that the facility developed action plans to minimize hospitalizations. An interview conducted with the staff # 2 on 3/12/25 at 2:30 PM following her own review of the findings confirmed the above. Staff # 2 confirmed that the facility did not present documentation to demonstrate that a root cause analysis was completed. Staff # 2 also confirmed that action plans were not developed to address the increase in hospitalizations. At the time of the interview no evidence of compliance was presented where non-compliance was found.”

“MD RESP-QAPI PROGRAM CFR(s): 494.150(a) Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program. This Standard is not met as evidenced by: 30377 Based on review of Quality Assessment and Improvement Performance (QAPI) meeting minutes and staff interview the medical director failed to ensure that all required members attending the monthly QAPI meetings. The medical director failed to ensure that the facility analyze, make recommendation, and develop action plans including root cause analysis to minimize events that occurred in the facility and take appropriate action to reduce future events. These deficient practices identified have the potential to cause harm to all patients at the facility. Findings were: Review of Quality Assessment and Improvement Performance meeting minutes from February 2024 to January 2025 on 3/12/25 in the facility’s conference room revealed the following: Review of QAPI Meeting Participants and Signatures form revealed the following. QAPI Attendance Sheet dated 02/18/25 (Review of January 2025 data) The Biomed was not in attendance. QAPI Attendance Sheet dated 01/20/25 (Review of December 2024 data) The Registered Dietician, Clinical Coordinator, and Biomed was not in attendance. QAPI Attendance Sheet dated 11/16/24 (Review of October 2024 data) The Biomed was not in attendance. QAPI Attendance Sheet dated 09/27/24 (Review of August 2024 data) The Biomed and Social Worker was not in attendance. Hospitalization Improvement Plan-January 2025 revealed that from September 2024 to January 2025 the facility’s trend for hospitalization increased month after month. The following was observed. September 2024 eight hospitalizations were identified. October 2024 nine hospitalizations were identified. November 2024 twelve hospitalizations were identified. December 2024 twelve hospitalizations were identified. January 2025 seventeen hospitalizations were identified. There was no documentation presented that the facility conducted a root cause analysis of the hospitalizations. There was no documentation presented that the facility developed action plans to minimize hospitalizations. An interview conducted with the staff # 2 on 3/12/25 at 2:30 PM following her own review of the findings confirmed the above. Staff # 2 confirmed that the facility did not present documentation to demonstrate that a root cause analysis was completed. Staff # 2 also confirmed that action plans were not developed to address the increase in hospitalizations. At the time of the interview no evidence of compliance was presented where non-compliance was found.”