Davita Heights 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: 37322 Based on observation and interview the facility failed to ensure empty oxygen were secured in a rack. NFPA (National Fire Protection Association) 99 requires empty cylinders to be stored separately from full cylinders this means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. Findings: Facility Policy, revised April 2020. “Emergency Equipment Checks” 7. The oxygen tank(s) will be checked for an adequate amount of oxygen (500 psi or more) and stored in compliance with locate and/or state regulations. Observation on 06/13/2024 at 3:30 p.m. during the facility tour of the oxygen room revealed the storage of 14 E oxygen tanks revealed, empty oxygen tanks were stored together and without a rack. Interview during the tour 06/13/2024 at 3:30 p.m. the clinical coordinator (ID#B) validated the findings.”

“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 and interview, the facility staff failed to monitor patients’ vascular accesses to ensure patient safety, citing 2 of 12 patients ( #s 16, 20), during patients’ dialysis treatment were not visible to staff. 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. Reviewed on 06/11/2024 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 and observation of the facility patient treatment area along with staff #B on June 11 & 12, 2024 the following was observed: Findings: Patient ID #16 at station #6 was observed on 6/11/2024 at 1500 to be receiving his dialysis treatment utilizing a left forearm arterial venous fistula with a blood flow rate of 400 ml/minute. Patient #16 had his vascular accesses covered with a blanket and not visible during their dialysis treatment. Patient ID #20 at station #8 was observed on 6/12/2024 at 1100 to be receiving his dialysis treatment utilizing a right central venous catheter with a blood flow rate at 350 ml/minute. Patient #20 had his vascular accesses covered with a blanket and not visible during their dialysis treatment. This finding was confirmed in an interview with the staff member #B on 06/12/2024 at 1500.”

“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 observation, interview and record review the facility’s Medical Director failed to ensure that employees followed the facility’s current policy and procedure. The facility has a current patient census of 83 hemodialysis patients that could be affected by failing to ensure that employees follow the facility’s policy and procedures. 1. Pre-nursing assessment were not completed within the first hour of initiation of hemodialysis treatment for 5 of 10 selected patient records reviewed. (Patient ID#s 5, 9, 10, 21 & 22). 2.The registered nurse was notified of any abnormal finding outside of any patient specific order parameter discovered during, pre-treatment, intradialytic or post treatment for 4 of 10 records reviewed (patient ID# 2, 5, 9,and 21). 3.Expired items were disposed of prior to expiration date and were not available for use. Policy Reviewed: Review on 6/11/2024 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 Date April 2023. 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. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). a.The assessment includes the following components: i. Review of the patient reports, data collection complaints and response to treatment. ii. Verification that machine safety checks have been completed and documented. iii. Verification of prescription including machine parameters. iv. Verification that the patient access is visible, and face not covered. v. Review of documentation for accuracy, completion, and patient data. vi. A physical assessment of the patient which includes: 1. Apical heart rate and rhythm 2. Auscultation of the lungs 3. Evaluation of volume status including edema 4. Bruising or bleeding 5. Patient statement of well-being, level of pain or discomfort 6. And other components which if observed/informed will be documented including but not necessarily limited to: changes in normal level of consciousness, mobility or mental status, complaints of nausea, vomiting, diarrhea, constipation, skin changes, headache, respiratory distress, angina, weakness fever, cramping dizziness reports of illness and/or injuries, falls conditions/complications or other problems patient has experienced since the last dialysis treatment Pre-Treatment Data Collection Assessment: 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one hour of dialysis treatment initiation or sooner as required by state law. 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. 11. 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. Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Fluid Status: Pre-treatment: o Any weight loss from last post weight o If unable to obtain patient weight, the nurse is to contact physician for orders o Removal goal not to exceed maximum ordered by physician Post-treatment: o If patient is above or below 1 kg from the target weight Blood pressure: Pre-dialysis: o Systolic greater than 180 mm Hg or less than 90 mm Hg o Diastolic greater than or equal to 100 mm Hg Blood Pressure-Intradialytic: o Difference of 20 mm Hg increase or decrease from patient’s last intradialytic treatment BP reading o Signs/symptoms of hypotension may include o Nausea and vomiting o Cold and clammy skin o Restlessness o Rapid, shallow respirations o Excessive yawning o Diaphoretic Blood Pressure Post Treatment: o If the patient can stand: o Standing systolic BP greater than 140 mm Hg or less than 90 mm Hg o Standing diastolic BP greater than 90 mm Hg or less than 50 mm H If patient is not able to stand, document reason and sitting BP o Sitting BP for patient’s that cannot stand: o Sitting systolic BP greater than 140 mm Hg or less than 90 mm Hg o Sitting diastolic BP greater than 90 mm Hg or less than 50 mm Hg Heart or Pulse Rate Pre/Intra/Post: o Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat Temperature Pre/Post/PRN: o Greater than 100 F or 2 degree rise over baseline Respirations Pre/PRN: o Patient complaints of shortness of breath, difficulty breathing Policies Reviewed: Review of the current facility policy titled, “Infection Control for Dialysis Facilities”, policy: 1-05-01, last revision date October 2022. Purpose: To minimize the spread of infections or blood born pathogens in the dialysis facility environment. Teammate/Patient Safety 20. The expiration date will be checked on all disposable supplies before the package is opened and the contents are used. 21. The contents of packages will not be used beyond the expiration date on the package. Policy Reviewed: Review of the current facility policy titled, “Medication Policy”; Policy: 1-06-01, last revision date October 2023. Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medication. Policy: All opened or unopened medication packages are stored according to the manufacturer’s directions. Do not use any medication that has been stored improperly or has expired. Findings: Review on 06/12/2024 of patient hemodialysis treatment records identified the following nursing pre-assessments not completed within the first hour of treatment: Patient ID #5’s hemodialysis record: 06/03/2024 hemodialysis treatment initiated at 9:44 AM Pre-assessment completed at 12:29 PM 06/05/2024 hemodialysis treatment initiated at 9:58 AM Pre-assessment completed at 17:12 PM 06/07/2024 hemodialysis treatment initiated at 9:45 AM Pre-assessment completed at 12:09 AM 06/10/2024 hemodialysis treatment initiated at 9:42 AM Pre-assessment completed at 11:42 AM Patient #9’s hemodialysis record: 05/11/2024 hemodialysis treatment initiated at 15:20 PM Pre-assessment completed at 16:30 PM 05/28/2024 hemodialysis treatment initiated at 15:51 PM Pre-assessment completed at 17:43 PM 06/03/2024 hemodialysis treatment initiated at 15:09 PM Pre-assessment completed at 16:20 PM 06/06/2024 hemodialysis treatment initiated at 15:40 PM Pre-assessment completed at 17:15 PM Patient #10’s hemodialysis record: 05/29/2024 hemodialysis treatment initiated at 15:27 PM Pre-assessment completed at 18:54 PM 05/30/2024 hemodialysis treatment initiated at 15:27 PM Pre-assessment completed at 19:02 PM 06/06/2024 hemodialysis treatment initiated at 15:34 PM Pre-assessment completed at 17:08 PM Patient ID #21’s hemodialysis record: 06/05/2024 hemodialysis treatment initiated at 11:32 AM Pre-assessment completed at 17:29 PM 06/07/2024 hemodialysis treatment initiated at 11:04 AM Pre-assessment completed at 16:29 PM Patient ID #22’s hemodialysis record: 06/07/2024 hemodialysis treatment initiated at 13:28 PM Pre-assessment completed at 14:59 PM 06/10/2024 hemodialysis treatment initiated at 10:06 AM Pre-assessment completed at 11:48 AM Interview on 06/13/2023 with staff ID #A confirmed the initial nursing assessments were not completed within the first hour of dialysis for the above findings. Review of the following hemodialysis records identified patient’s reportable abnormal parameters that were either not reported to the registered nurse or when reported there was no documentation of reassessment by the registered nurse. Patient ID #2’s hemodialysis treatment record: 06/01/2024 - Treatment initiated by Licensed Vocational Nurse, Staff #D at 11:06 with blood pressure of 154/68, at 13:00 Staff ID #D noted BP 170/80, 13:30 Patient Care Technician, Staff #E noted BP 168/78, 14:33 Staff #E noted BP 192/79. There was no documentation the registered nurse was notified of the patient’s elevated blood pressure and no documented re-assessment of the patient by the registered nurse. Patient ID #5’s hemodialysis treatment record: 06/07/2024 - Treatment initiated by Patient Care Technician, Staff #F at 09:48 AM with BP 151/59 at 12:32 BP documented by Staff #F as 171/63. There was no documentation the registered nurse was notified of the patient’s elevated blood pressure and no documented re-assessment of the patient by the registered nurse. Patient ID #9’s hemodialysis treatment record: 05/11/2024 - Treatment initiated by Patient Care Technician, Staff #E at 15:23 PM with BP 160/83, pulse 59, 16:03 BP 154/68, pulse 53, 16:33 PM BP 143/62, pulse 55, 17:02 PM documented by Licensed Vocational Nurse, Staff #D pulse 49, 17:30 documented by Staff #D BP 155/85, pulse 63 with note “Patient awake; alert and states no complaints at this time; HR improved”. 17:32 BP 133/62, pulse 53, 18:32 Staff #E documents BP 106/57, pulse 48. There was no documentation the registered nurse was notified of the patient’s reportable abnormal parameters and no documented re-assessment of the patient by the registered nurse. 06/06/2024 - Treatment initiated at 15:41 PM by registered Nurse, Staff #G with BP 158/75, pulse 63. 17:03 noted by Patient Care Technician #E BP 113/54, pulse 54, 17:33 BP 105/51, pulse 52, 18:03 BP 103/56, pulse 51. There was no documentation the registered nurse was notified of the patient’s reportable abnormal parameters and no documented re-assessment of the patient by the registered nurse. Patient ID #21’s hemodialysis treatment record: 06/07/2024 - Treatment initiated at 11:15 AM by Patient Care Technician, Staff #F with BP 144/56, pulse 66, 12:02 BP 108/48, pulse 53, 13:01, BP 144/57, pulse 48, Staff #F note “ Patient HR low; No distress noted; will recheck”. 13:05 BP 137/59, pulse 45, Staff #F note, “Recheck HR; HR remains low; No distress noted: Notified Nurse Monica”. 14:02 Staff #F BP 166/57, pulse 48, note Patient HR remains low; no distress noted; Nurse Monica aware. 14:32 Staff #F BP 167/68, pulse 48 note “Patient HR remains low; no distress noted; Nurse Monica aware. There was no documentation the registered nurse was notified of the patient’s reportable abnormal parameters and no documented re-assessment of the patient by the registered nurse. Observation and tour of the patient treatment area on /6/11/2024 at 15:00 PM along with Staff #B the following expired items were observed available for use: 1. One 17-ounce container of Alcavis 50 High-Level Disinfection Solution with an expiration date of 09/14/2014. Container was observed labeled with a handwritten open date of 11/22/2023 and expiration date 05/22/2024. Instructions per the manufacturer’s state the product is stable for up to 6 months after first opening. 2. One 16-ounce container 3% Hydrogen Peroxide Solution, Lot #60954, expiration 01/2024. Contain was observed labeled with a handwritten open date of 02/10/2024. Interview with Staff #B on 06/11/2024 at 15:15 PM confirmed the above findings and they should have been discarded and not available for use”

“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, record review and interview the facility failed to ensure that: 1. 1 of 4 portable oxygen tank cylinders observed on the treatment floor were properly secured. 2. 3 oxygen tanks identified as previously opened were not identified as full or empty. 3. Oxygen tanks were stored in an area that identified tanks that were full or empty. The facility failed to safely store oxygen in accordance with National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Policy Reviewed: Review of the current facility’s policy titled: “Emergency Equipment Checks”; Policy # 1-02-08; Revised April 2022. Purpose: To verify that emergency equipment is maintained in a ready-to use condition. 7. The oxygen tank(s) will be checked for an adequate amount of oxygen (500 psi or more) and stored in compliance with local and/or state regulations. Review of the facility’s Policy and Procedure on titled Monthly OSHA and Safety Checklist; Procedure 408-03A; Revision Date: October 2018 reads: Check list form should be reviewed and approved by the Facility Administrator, reviewed monthly during the Safety Committee Meeting and reported on during FHM. General: Are all medical gas cylinders properly secured to prevent fall?” Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified and full or empty and stored separately. Findings: Observation of the patient care area on 02/27/2024 at 13:00 PM along with the clinical coordinator, staff ID #A, one of four oxygen tanks observed in the patient treatment area were not secured in a tank rack, holder, or chained. This tank was observed to be standing unsecured near the emergency cart in the patient treatment area leaving the cylinder with a potential to fall. In addition, three oxygen tanks were not labeled as full or empty and oxygen cylinders were not stored in an area that identified them as full or empty, Interview with staff #A on 02/27/2024 at 13:30 PM confirmed the oxygen tanks were not secured as required and the oxygen tanks were not able to be identified if they were full or empty. Based on observation, record review and interview the facility failed to ensure that: 1. 1 of 5 portable oxygen tank cylinders observed on the treatment floor were properly secured. 2. 3 oxygen tanks identified as previously opened were not identified as full or empty. 3. Oxygen tanks were stored in an area that identified tanks that were full or empty. The facility failed to safely store oxygen in accordance with National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Record Reviewed: Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified and full or empty and stored separately. Review of the facility’s current Policy and Procedure on 03/04/2024 titled Monthly OSHA and Safety Checklist; Procedure 408-03A; Revision Date: October 2018 reads: Check list form should be reviewed and approved by the Facility Administrator, reviewed monthly during the Safety Committee Meeting and reported on during FHM. General: Are all medical gas cylinders properly secured to prevent fall?” Finings: Observation of the patient care area on 02/27/2024 at 13:00 PM along with the clinical coordinator, staff ID #A, one of five oxygen tanks observed in the patient treatment area were not secured in a tank rack, holder, or chained. This tank was observed to be standing unsecured near the emergency cart in the patient treatment area leaving the cylinder with a potential to fall. In addition, three oxygen tanks were not labeled as full or empty and oxygen cylinders were not stored in an area that identified them as full or empty, Interview with staff #A on 02/27/2024 at 13:30 PM confirmed the oxygen tanks were not secured as required and the oxygen tanks were not able to be identified if they were full or empty.”

“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: 30124 Based on observation, interview and record review the facility failed to follow their current infection control policy and procedures and failed to maintain a sanitary environment in that hemodialysis dialysis stations and equipment was not properly cleaned and disinfected after use to minimize the transmission of infectious agents. The facility currently has a census of 70 incenter patients. This deficient practice placed all patients in the facility at risk for the likelihood of harm by placing them at a risk of serious illness and possible subsequently death. 1. Nine patient recliners (station #s 1, 4, 7, 8, 10, 11, 12, 14, and 15) in the patient treatment area were observed to have visible sticky tap and tape residue on the treatment chairs and patient fold down tables. Strips of tape was observed to be adhered directly to multiple patient side tables. 2. One rolling stool had visible rust on the bottom legs and wheel casters. Cushion was observed to be worn and had cracked and torn areas. 3. Clean equipment area was observed to have one Hoyer lift with and accumulation of dust and debris on the bottom legs and rails. 4. Four IV poles in the clean equipment area were observed to have dust and debris on the bottom lateral leg surface along with large whitish stains. 5. Brownish red dried splatter was found on the lateral wall of station # 7 and station # 15. 6. Multiple computers rolling desk were observed to have and accumulation of dust and debris on the lower arms of the wheel casters and on the back lateral surfaces of the computer monitor. Policy Reviewed: Review on 02/27/2024 of the facilities current policy titled: Infection Control for Dialysis Facilities; Policy: 1-05-01; Last revision April 2023. Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Disinfection: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood. i. For visible blood or gross blood spills, a 1:10 bleach solution must be utilized. ii. After all visible blood is cleaned with the 1:10 bleach solution, teammates are to use a new disposable towel soaked with 1:10 bleach solution and clean a second time. iii. Cleaning of visible blood should be performed when first observed. b. Use an appropriate disinfectant such as 1:100 bleach solution for routine disinfection of environmental services. i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfection should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant time contact. iv. Items disinfected via submersion will be fully submerged. c. Spray bottles containing cleaning solutions are single use and cannot be reused or refilled. This practice does not include contracted housekeeping services. 13. 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 chairs, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel. c. Dialysis delivery systems with computers/keyboards mounted on top, the computer keyboard are considered “dirty equipment. 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 item cannot be cleaned and disinfected it will be dedicated for use on a single patient. 15. The chair side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas. a. Wipe-able keyboard covers, or medical grade keyboards are to be utilized. b. The chair side cart components will be cleaned at the end of each treatment day. c. Sharps containers are not stored on the chair side cart. d. Disposable gloves and alcohol-based hand rub containers may be stored on the chair side cart shelves but not stored on counters where terminals are mounted. e. The monitor screen is cleaned as needed and daily at end of each treatment day using a disposable wipe moistened with 65 - 70% isopropyl alcohol solution. Findings: Observation of the patient treatment area on the afternoon of 02/27/2024 along with the Manager of Clinical Services, staff ID #F the following was observed at station #7 dried reddish brown droplet splatter on the adjacent lateral wall of the dialysis station. Staff ID #F when observed the splatter on the above chair immediately obtained a bleach towel and was able to wipe the reddish-brown splattered droplets off the equipment. Staff ID #F confirmed the above finding and stated area not been properly cleaned and disinfected. Observation of the patient treatment area on the afternoon of 02/07/2024 along with the facility administrator, staff ID #A reddish brown droplet splatter was the observed on the back wall of hemodialysis station #15. Interview with staff ID #A confirmed the droplet splatter and stated the station had not been properly cleaner. Further observation of the patient treatment area one rolling stool was observed with visible rust on the bottom legs and wheel casters. The top cushion was observed to be worn with cracked and torn areas on the top surface. Area designated as the clean equipment storage area contained one Hoyer lift and four IV poles that had an accumulation of dust on the lateral surface and leg segments. Multiple computers rolling desk were identified with visible dust on the lateral surfaces and the lower arms of the wheel casters were observed to have dust. Interview on at 13:30 PM on 02/27/2024 with staff the facility’s Clinical Services Manage ID #F confirmed the above findings.”

“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 and interview, the facility staff failed to monitor patients’ vascular accesses to ensure patient safety, citing 1 of 10 stations (stations #4)), during patients’ dialysis treatment were not visible to staff. 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 October 2023. 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 02/27/2024 at 13:00 PM along with staff #A the surveyor observed patients ID #12 at station #4 to be receiving her dialysis treatment. Patient #12 had their vascular accesses covered with blankets and not visible during their dialysis treatment. This finding was confirmed in an interview with the staff member #12 on 02/27/2024 at 13:00 PM.”

“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 observation, record review and interview the facility’s medical director failed to ensure nursing staff followed the facility’s policy and procedures to prevent or reduce complications pre, during or post treatment in that: 1. Abnormal finding outside of any patient specific ordered parameters discovered during pre-treatment, intradialytic or post treatment was immediately reported to the licensed nurse to ensure the nurse assess the patient to see if clinical interventions are necessary in 3 of 8 patients. (Patient ID #s 7, 9,11). 2. The nurse completed the initial nursing assessment within the first hour of treatment of 3 of 8 records reviewed. (Patient ID #s 7, 9, 11). Policy Reviewed: Review on 02/28/2024 of the facility’s current policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” Policy: 1-03-08, Last revision October 2023. 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 a nursing assessment is permitted by state law, a Licensed practical Nurse (PN) / Licensed Vocational Nurse (LVN). 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. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation. 9. Intradialytic treatment monitoring and date collection which will be performed by the PCT, or licensed nurse includes: a. Vital signs and treatment monitoring: i. For non-nocturnal treatments is completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure, ii. Heart or pulse rate, iii Blood and dialysate flows, arterial and venous pressures, iv Patient subjective statement(s), i.e., patient reports on overall health, any complaints. c. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment. 11. Abnormal findings or finding outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. 13. All findings, interventions and patient response will be documented in the patient’s medical record. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Patient Evaluations Reportable by Direct Patient Care Staff to the Registered Nurse PRE HD-Treatment Weight - No weight gain OR weight gain > 5 KGS BP - Systolic >180 or <100; Diastolic BP >100 or <50 Temperature - >100 degrees Pulse - >100 or <60 Respirations - > 20 or patient; <12 respirations per minute During Treatment - Intradialytic Reportable to the Registered Nurse BP - Systolic >160 or <100; or any significant change in pressure. Diastolic BP > 100 or <60 Pulse - HR > 100 or <50 Temperature Increase of 2 degrees over incoming temp Respirations - > 20 or patient; <12 respirations per minute OR any significant change in respirations. Any SOB or dyspnea, Post HD-Treatment Weight - 1 KG > or < target weight BP - Systolic BP >160 or <100 Diastolic BP >100 or < 50 Temperature - 100 F or greater, or increase of 2 degrees over incoming temp Pulse - >100 or <60, irregular HR, Signs of cyanosis or chest pain. Respirations - > 20 or patient; <12 respirations per minute Reportable to the Registered Nurse Findings: Review on February 28, 2024, of selected patient hemodialysis records along with Facility Administrator, staff ID #A the following items were identified in the patient records: Review of patient ID #7’s hemodialysis record: 02/20/2024 treatment initiated 09:59, pre-nursing assessment 15:10. 02/17/2024 treatment initiated 09:56, pre-nursing assessment 17:48. 02/13/2024 treatment initiated 09:59, pre-nursing assessment 11:48. 02/15/2024 - hemodialysis treatment record documents pre-treatment BP 134/80, pulse 64, treatment initiated by patient care technician staff ID #D at 10:05 BP 140/76, pulse 72, 10:32 BP 121/75, pulse 57, 11:32 BP 107/60 pulse 55. At 12:02 license vocational nurse (LVN), staff ID #B documented BP 112/61, pulse 57. There was no documentation noted that the registered nurse (RN) was notified of heart rate below the parameters and no intervention or reassessment by the RN. Review of patient ID #9’s hemodialysis record: 02/20/2024 treatment initiated 11:06, pre-nursing assessment 16:23. 02/24/2024 - hemodialysis treatment record documents pre-treatment BP 122/56, pulse 59, treatment initiated by patient care technician staff ID #G at 11:19 with BP 122/56, pulse 59, Patient care technician staff ID #H documented at12:01 BP 137/57, pulse 59. There was no documentation noted that the registered nurse (RN) was notified of heart rate below the parameters and no intervention or reassessment by the RN. 02/15/2024 - hemodialysis treatment records documents pre-treatment BP 191/81, pulse 67. Hemodialysis treatment initiated at 11:25 by patient care technician staff #G with BP 190/90, pulse 68. There was no documentation the RN was notified of an elevated BP prior to the initiation of treatment by the PCT. 02/13/2024 - hemodialysis treatment records documents pre-treatment BP 135/58, pulse 54. Hemodialysis treatment initiated at 11:30 by PCT staff #G with BP 117/54, pulse 53. There was no documentation the registered nurse (RN) was notified of HR parameter out of reportable range prior to initiation of hemodialysis treatment. Review of patient ID #11s hemodialysis record: 02/15/2024 02/25/2024 treatment initiated at 10:04 by licensed vocational nurse staff ID #B, patient prescription verified by RN at 11:26, pre-nursing assessment completed at 16:21. 02/15/2024 - hemodialysis treatment records documents pre-treatment BP 110/61, pulse 47. Hemodialysis treatment initiated at 11:30 by PCT staff #G with note “treatment started without complications; Heparin infusion started; Patient awake; alert; and states no complaints at this time; Hr low noted; asymptomatic CN (charge nurse) notified, BP 108/63, pulse 47, 10:31 BP 109/62, pulse 49. 10:56 note from RN staff ID # I,BP 113/64, pulse 55, “Treatment paused; patient using restroom”. 11:06 RN note BP 118/67, Pulse 55, “Treatment resumed; patient states no complaints”. Pre- nursing assessment was completed at 11:26 by RN staff ID # I where she notes “Bradycardia noted. Patient asymptomatic. UF goal of 3.5 KG as tolerated.” Treatment initiated at 10:11 with nursing pre-assessment not completed within first hour. There is no documentation the physician was notified of the decreased heart rate. Interview on 02/28/2024 with staff ID #A confirmed the above findings and abnormal finding outside of any patient specific ordered parameters pre-treatment, intradialytic or post treatment was immediately reported to the licensed nurse.”