Davita Keller Dialysis

“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 record review and staff interview, the facility staff failed to ensure 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 on 3 (Patient # 1, #2 and # 3) of 8 patient medical records reviewed. The facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. Findings include: Review of hemodialysis flow sheets on 01/13/2026 in the facility conference room revealed the following discrepancies: Patient #1 Flow Sheet dated 01/07/2026 Dialysis Prescription Treatment Time: 4.0 hours Pre Treatment Vitals: Time: 05:07 AM Blood Pressure: 192/97 Heart Rate: 73 Post Treatment Vitals: Time: 09:12 AM Blood Pressure: 156/85 Heart Rate: 72 There was no documentation provided at time of review that the registered nurse was notified that the initial blood pressure was 192/97. Treatment Initiated Time: 05:07 AM Blood Pressure: 177/96 Heartrate 75. There was no documentation provided that a registered nurse completed a nursing round that included a prescription verification within the first hour of treatment. 07:31 AM Blood Pressure: 196/97 Heart Rate 73 with direct patient care technician documenting “ .....blood pressure elevated.” There was no documentation provided at time of review that the registered nurse was notified that the patient was hypertensive. 08:00 AM Blood Pressure: 193/99 Heart Rate 78 with direct patient care technician documenting “ ....at this time blood pressure remains elevated: LVN aware.” There was no documentation provided at time of review that the registered nurse was notified that the patient was hypertensive. 11: 36 AM Post Treatment Assessment: The registered nurse documented “Patient leaving stable, no complaints. asymptomatic hypertension present ...” There was no documentation provided at time of review that the registered nurse addressed the hypertension during the dialysis treatment. Patient #2 Flow Sheet dated 12/29/2025 Dialysis Prescription Treatment Time: 4.15 hours Pre Treatment Vitals: Time: 05:04 AM Blood Pressure: 219/103 Heart Rate: 82 Post Treatment Vitals: Time: 09:39 AM Blood Pressure: 151/90 Heart Rate: 83 Treatment Initiated Time: 05:15 AM Blood Pressure: 217/103 Heartrate 81. 05:15 AM Blood Pressure: 217/103 Heart Rate 81 with the direct patient care technician documenting “ .....Registered nurse aware of elevated blood pressure.” There was no documentation provided at time of review that the registered nurse addressed the initial blood pressure prior to the patient being placed on the dialysis machine. 05:32 AM Blood Pressure: 200/103 Heart Rate 76 with the direct patient care technician documenting “ Patient monitored: eyes closed: patient resting.” 05:57 AM the registered nurse documented “Prescription verified ....patient placed on profile 2 due to elevated blood pressure: Patient asymptomatic: Blood pressure within treatment parameters.” 06:23 AM Pre-Treatment assessment completed with the registered nurse documenting “Blood Pressure elevated: Patient asymptomatic” Patient #3 Flow Sheet dated 01/09/2026 Dialysis Prescription Treatment Time: 4.0 hours Pre Treatment Vitals: Time: 05:40 AM Blood Pressure: 101/65 Heart Rate: 73 Post Treatment Vitals: Time: 10:01 AM Blood Pressure: 118/66 Heart Rate: 78 Treatment Initiated Time: 06:02 AM Blood Pressure: 91/57 Heartrate 72. 09:01 AM Blood Pressure: 83/53 Heart Rate 75 with direct patient care technician documenting “ Patient awake alert and states no complaint at this time recheck blood pressure.” There was no documentation provided at time of review that the registered nurse was notified of the hypotensive episode during treatment. 09:04 AM Blood Pressure: 67/43 Heart Rate 73 with direct patient care technician documenting “readjusted cuff: Ultra filtration off due to low blood pressure.” There was no documentation provided at time of review that the registered nurse was notified that the patient was hypotensive and that the Ultrafiltration on the dialysis machine was turned off. 09:06 AM Blood Pressure: 87/56 Heart Rate 74 with direct patient care technician documenting “ Patient awake alert and states no complaints at this time blood pressure remains low.” There was no documentation provided at time of review that the registered nurse was notified that the patient was hypotensive. 09:15 AM Blood Pressure: 97/59 Heart Rate 73 with direct patient care technician documenting “ Blood pressure improving: Ultra Filtration remains off.” There was no documentation provided at time of review that the registered nurse was notified that the patient remained hypotensive and that the Ultrafiltration had been stopped on the dialysis machine. A review of the facility policy, “ Data Collection and Patient Assessment Reporting Guidelines.” Revealed 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 Dialysis: Blood Pressure: Systolic: < 90 or > 180 Diastolic: < 45 or > 110 Pulse: < 60 or > 110 Temperature: > 100.5 F Any Complaints made by the patient Intra Dialysis: Blood Pressure: >20 mmHg decrease from prior blood pressure check at anytime during treatment. Increase to > 180/110 An interview conducted with Staff Member #2 and Staff Member #3 on 01/13/26 following their own review of the findings revealed they were unaware of the discrepancies found in the flow sheets. Staff Member #2 and Staff Member #3 confirmed the above findings.”