Davita Renal Center of Flower Mound

“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: 50181 Based on medical record review, policy review and staff interview the facility failed to ensure the direct patient care (DPC) staff reported patient status changes during treatment to the Registered Nurse (RN) to ensure a reassessment was performed and documented with appropriate interventions and/or physician notification, if required. The assessment should include evaluation of the patient’s pre/intra/post and interdialytic blood pressures, interdialytic weight gains, target weight, and related intradialytic symptoms. Findings included: A review of facility policy titled, “CWOW-Pre-intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a revision date of April 2021 includes the following guidance: “ ...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. 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. If any abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to initiation of dialysis. INTRADIALYTIC DATA COLLECTION/ASSESSMENT 11. Abnormal findings or findings outside of any patient-specific physician-ordered parameters will be reported to the licensed nurse immediately (refer to the ‘abnormal findings’ section of 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 responses will be documented in the patient’s medical record...” Patient #3 treatment record dated 03/18/2024 indicates the following: 06:00: Blood Pressure (BP): 89/55 and HR: 47bpm 06:00 Events and Comments; Treatment started without complications. There is no documentation acknowledging this BP and HR were reportable findings and were reported to the RN by the DPC staff. Patient’s estimated dry weight (EDW) for treatment record 03/18/2024 is 52 kg per the physician’s order. The treatment record indicates the patient’s pre-weight is 57.2kg which calculates at 5.2kg over the EDW and calculates to a 10.2% interdialytic weight gain requiring a pre-assessment from the RN per the facility’s reporting protocol. The pre-assessment was completed by the RN at 06:21 after the treatment initiation time of 06:01. There was no documentation in the RN assessment that the weight gain was identified and reported to the physician for this treatment. The patient’s fluid removal goal was set to 3500mL which exceeds the ordered maximum Ultrafiltration (UF) rate of 13.0mL/kg/hour by the physician. 08:30: HR: 57 08:30 Events and Comments: Patient face; vascular access; and blood line connections visible There is no documentation acknowledging this heart rate was a reportable finding and was reported to the RN by the DPC staff. Patient #4 treatment records dated 03/18/2024 indicates the following: Patient’s EDW: 91kg per physician’s order The treatment record indicates the patient’s pre-weight is 96.9kg which calculates to 5.9kg over the EDW calculating a removal goal of 6400mL to achieve the patient’s EDW. The machine goal was set to remove 4000mL. There is no RN documentation in the pre-assessment acknowledging the adjustment to the patient’s goal for the treatment. Patient left 2.7kg above the EDW for the treatment. Patient #7 treatment records dated 03/18/2024 indicates the following: Patient’s EDW: 77.5kg per physician’s order The treatment record indicates the patient’s pre-weight is 84.7kg which calculates to 7.2kg over the EDW and calculates to a 5.5% intradialytic weight gain requiring a pre-assessment from the RN per the facility’s reporting protocol. The pre-assessment was completed by the RN at 05:49 after the treatment initiation time of 05:46. There was no documentation in the RN assessment that the weight gain was identified and reported to the physician for this treatment. The patient’s fluid removal goal was set to 2000mL with no documentation of a physician order for this goal. Patient #5 treatment record dated 03/18/2024 indicates the patient’s heart rate (HR) was 52bpm at 05:17 and 52bpm at 08:00. There is no documentation acknowledging this heart rate was a reportable finding and was reported to the RN by the DPC staff. On 03/20/2024, an interview with the FA confirmed the facility’s reportable parameters and documentation required for out of parameter findings pre/intra/post dialysis treatment by the DPC staff and licensed nurse providing care to the patient.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50181 Based on record review, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The patients’ dialysis prescriptions (dialyzer, blood flow rate, dialysate flow rate, length of treatment time) and the efficacy of the vascular access affect the dose of dialysis delivered. Review of Patient #3 treatment record for 03/18/2024 revealed the BFR was ordered to run at 350mL/min. Review of the intradialytic records revealed the BFR ran at 270 mL/min from 08:30-09:00, then the BFR ran at 300mL/min from 09:00-10:00 with no documentation reporting the change to the charge nurse (staff #5) by the patient care technician (staff #6) and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #4 treatment record for 03/18/2024 revealed the DFR was ordered to run at 800mL/min. Review of the intradialytic records revealed the DFR ran at 500mL/min from 05:21-05:29, then the DFR ran at 800ml/min from 05:59 until treatment was terminated at 08:29. There is no evidence of documentation reporting the change to the charge nurse (staff #5) by the patient care technician (staff #7) and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment.”