Davita Cdc Sterling Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 42043 Based on observation and facility document review, the staff failed to follow the facility policy related to emergency evacuation kit and remove outdated items from the kit. The findings included: On 4/9/24 at 2:30 pm Staff Member #1 assisted surveyor with inspection of the facility’s emergency evacuation kit. The sealed kit contained documentation of monthly audits being performed by designated staff. The surveyor found a bag of more than twenty sterile 5 cc BD syringes with 21 g needles attached with expiration date 7/31/2023. Staff Member #1 removed the expired items from the kit and stated that items will be replaced with in-date supplies immediately. Review of facility policy 4-07-01, titled “Facility Emergency Management Plan (ICHD, HOME), revision date April 2023 found in part, “Emergency Evacuation Kit....7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly...” Staff Member #1 witness the above noted findings at the time of discovery and the management team was notified of the above at the time of exit conference on 4/10/24.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 42043 Based on observations and facility document review, it was determined that the facility staff failed to maintain a safe environment for dialysis patients, staff, and the public by not labeling two (2) open medication vials as per the facility’s policy. The findings include: On 4/9/24 at 2:30 pm, the surveyor conducted a inspection of the facility evacuation kit and medications in fridges and med cabinets with the assistance of Staff Member #1. The surveyor found one open 30 ml mulitdose vial of Heparin 1000 units/ml with expiration 1/4/2025 without a label noting the date the vial was opened and by whom. The surveyor also found one open 1 ml vial of high potency Diphenhydramine 50 mg/ml with expiration date 08/2024 lacking documentation of the date the vial was opened and by which staff. Staff Member #1 immediately discarded both vials. A review of the facility’s policy titled, “Medication Policy”, Policy: 1-06-01, last revised October 2022, stated in part: ...29. Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle puncture), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer as in the case of vaccines or state specific pharmacy regulations. Each vial is labeled with the initials of the person opening the vial and expiration date...” The above concerns were discussed with Staff Members #1 at the time of discovery and again with facility management team at the exit conference on 4/10/24.”

“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: 42043 Based on observations and facility document review, it was determined the facility staff failed to ensure the access site for two (2) patients remained visible while receiving dialysis treatment. The findings included: On 4/10/24 at 8:34 am, the surveyor observed a patient receiving dialysis treatment at station #9 having access site completely covered with a blanket. Patient receiving treatment in station #10 had access site completely covered with a blanket as well. At 8:43 am the machine at station #9 sounded an alarm and Staff Member #9 walked over, talked to the patient, uncovered access site and started discontinuation of dialysis treatment. After patient vacated the chair, Staff Member #9 stated to the surveyor that the patient repeatedly refused to keep access site uncovered and that they noted this event it in the patient’s treatment record. Patient in station #10’s access site remained completely covered covered until 9:10 am when the machine sounded an alarm. Staff Member #9 performed hand hygiene, donned clean gloves and started to discontinue the dialysis treatment and uncovered the access site. A review of the facility’s policy 1-03-08, last revised on April 2024, titled, “Intradialytic Data Collection/Assessment”, read in part: “Intradialytic Data Collection/Assessment.... 9... c. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment.” Staff Member #1 explained during an interview on 4/10/24 that the facility policy regarding access site requires the access to be visible at all times during a dialysis treatment and added that there are several patients that do not follow the rule despite multiple reminders from staff. Staff Member #1 stated that they are looking into possible solution of the problem. The above noted findings were shared with Staff Member #1 at the time of discovery and discussed again during exit conference on 4/10/24 with the facility management team.”

“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: 42043 Based on medical record and facility document review, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) and DFR (dialysis flow rate) for four (4) of four (4) in-center dialysis patients included in the sample. The findings include: The survey team reviewed on 4/9/24 and 4/10/24 dialysis treatment flowsheets for four (4) patients included in the sample. (Patient #1-4) Patient #1: The surveyor reviewed 13 dialysis treatment records from 02/23/24 through 04/06/24 . Patient #1’s treatment prescription was a DFR (Dialysis Flow Rate) value of 500 mL/min and a BFR (Blood Flow Rate) value of 400 mL/min. One (1) of 13 treatment records for Patient #1 evidenced the DFR value different from the prescribed DFR. The treatment sheets evidenced the following: On 04/01/24, the DFR was documented as 700 mL/min . One (1) of 13 treatment records for Patient #1 evidenced the BFR value different from the prescribed BFR. The treatment sheets evidenced the following: On 04/06/24, the BFR was documented as 350 mL/min. Patient #1’s clinical record failed to contain evidence of documentation explaining why the DFR and BFR were not administered as prescribed. Patient #2: The surveyor reviewed 14 dialysis treatment records from 02/22/24 through 04/08/24. Patient #2’s treatment prescription was a DFR value of 500 mL/min and a BFR value of 400 mL/min. Three (3) of 14 treatment records for Patient #2 evidenced the DFR value different from the prescribed DFR On 03/01/24, the DFR was documented as 600 mL/min. On 03/06/24 and 04/03/24, the DFR was documented as 700 mL/min. Eight (8) of 14 treatment records for Patient #2 evidenced the BFR value different from the prescribed BFR. On 02/22/24, the BFR was documented as 200 and 350 mL/min. On 02/23/24 the BFR was documented as 200, 300, and 350 mL/min. On 02/26/24, the BFR was documented as 250, 300, 285, and 200 mL/min. On 02/28/24, the BFR was documented as 300 mL/min. On 03/01/24, the BFR was documented as 350 mL/min. On 03/11/24, the BFR was documented as 300 and 350 mL/min. On 04/01/24, the BFR was documented as 200 and 350 mL/min. On 04/08/24, the BFR was documented as 300 and 350 mL/min. Patient #2’s clinical record failed to contain evidence of documentation explaining why the DFR and BFR were not administered as prescribed. Patient #3: The surveyor reviewed fourteen (14) dialysis treatment records from 2/19/24 through 4/8/24. Four (4) of 14 treatment records for Patient #3 evidenced DFR value different form the prescribed DFR of 500. The treatment sheets evidenced the following: On 2/21/24, the DFR was documented as 700. On 3/13/24, the DFR was documented as 600. On 3/20/24, the DFR was documented as 800. On 4/5/24, the DFR was documented as 800. Six (6) of 14 treatment records for Patient #3 evidenced the BFR value different from the prescribed BFR of 350. On 02/19/24, the BFR was documented as 320, and 350 mL/min. On 02/21/24, the BFR was documented as 380 mL/min. On 03/13/24, the BFR was documented as 375 mL/min. On 03/20/24, the BFR was documented as 400 mL/min. On 03/25/24, the BFR was documented as 300 mL/min. On 03/27/24, the BFR was documented as 330 mL/min. Patient #3’s clinical record failed to contain evidence of documentation explaining why the DFR and BFR were not administered as prescribed. Patient #4: The surveyor reviewed twenty-one (21) dialysis treatment records from 2/19/24 through 4/08/24. Sixteen (16) of 21 treatment records for Patient #4 evidenced DFR and BFR values different form the prescribed DFR of 600. The treatment sheets evidenced the following: On 2/19/24, the DFR was documented as 500. On 2/26/24, the DFR was documented as 500. On 3/4/24, the DFR was documented as 700. On 3/8/24, the DFR was documented as 500. On 3/11/24, the DFR was documented as 500. On 3/13/24, the DFR was documented as 500. On 3/18/24, the DFR was documented as 500. On 3/20/24, the DFR was documented as 500. On 3/22/24, the DFR was documented as 500. On 3/25/24, the DFR was documented as 500. On 3/27/24, the DFR was documented as 500. On 3/29/24, the DFR was documented as 500. On 4/1/24, the DFR was documented as 500. On 4/3/24, the DFR was documented as 500. On 4/5/24, the DFR was documented as 500. On 4/8/24, the DFR was documented as 500. Patient #4’s clinical record failed to contain evidence of documentation explaining why the DFR was not administered as prescribed. A review of the facility’s policy “Intradialytic Data Collection/Assessment”, revised 4/2024, stated in part: “...10. If the dialysis prescription is not being met (including dialysis flow rate or changed to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...”. During an interview on 4/9/24 Staff Member #1 confirmed that staff should document the reason why DFR and/or BFR is changed from dialysis order and who they notified of the change. The findings were discussed with Staff Members #1 at the time of review and again with the facility managment team at the exit conference on 4/10/24.”