Davita Martinsville Dialysis

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 46466 Based on interview, medical record and facility documentation review, the facility failed to provide evidence of quarterly patient fire safety training and annual emergency preparedness training for ten (10) of eleven (11) patient records sampled. The findings include: On July 22, 2025, a review of eleven (11) sampled patient medical records (MR) was conducted. There was no documented evidence in MR’s #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 that these patients received fire safety training in the first and second quarter of year 2025 and annual emergency preparedness training. On July 22, 2025, Employee #2 confirmed that the medical records did not contain evidence of fire safety and emergency preparedness training. A review of the facility’s policy “Facility Emergency Management Plan (ICHD, Home)”, revised October 2024, indicated in part: “...Training and Education...b. Patients i. Annually 1. Facility specific emergency response procedures ...ii. Quarterly: 1. Fire Safety Preparedness 2. Emergency Take-off procedures...”.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 19883 Based on observation, and facility document review, the facility staff failed to ensure that soap and paper towels were available at a clean sink in the treatment area. The findings are: Upon entry into the dialysis treatment area on July 21, 2025, at approximately 12:00 PM, the clean sink was observed by the surveyor to be void of soap and paper towels. Review of the facility’s policy titled: “Infection Control for Dialysis Facilities” with a revision date of April, 2023, reads in part as follows: “...Soap and a supply of paper towels protected from contamination must be available at each clean sink.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 19883 Based on observations and document review, the facility staff failed to maintain aseptic technique for a CVC (central venous catheter) dressing change for one (1) of eleven (11) patients included in the survey sample. The findings are: On 7/22/2025, while preparing Patient #5’s CVC for dialysis, Staff Member #6 cleansed the two CVC hubs for less than 10 seconds before connecting syringes to the catheter ports. Review of the facility’s policy titled: “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” with a revision date of April 2025) reads in part: “...Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting form the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason.” On 7/22/2025, during an interview Staff Member #2 confirmed CVC hubs should be cleansed for 15 seconds before connecting or disconnecting from blood lines.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 46466 Based on interview, medical record review and facility document review, the facility failed to follow facility policy related to development and implementation of patient plans of care (POC) for two (2) of thirteen (13) patient records (MR) sampled. The findings include: On July 22, 2025 a review of 13 sampled patient records was conducted. MR2’s medical record revealed a POC dated June 26, 2025 signed by only the Social Worker and Medical Director. The POC did not contain the patient’s signature and/or note why the patient refused to sign/acknowledge that the POC was discussed with the patient. MR3’s medical record revealed that MR3’s last, stable POC was completed on April 22, 2024. Employee #2 (EMP2) stated that a POC for Patient #3 was completed in April, 2025, but could not be found. A review of the facility’s policy “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revised October, 2024, indicated in part: “...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: - At least annually for stable patients...14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided...”.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46466 Based on interview, medical record review, and facility document review, the facility staff failed to measure and document standing blood pressures in six (6) of thriteen (13) medical records (MR) sampled. The findings include: On July 22, 2025, a review of 13 patient records was conducted. MR3’s medical record revealed that the patient was ambulatory, however, Patient #3’s standing blood pressures were not measured pre and/or post treatment on July 7, 11, 14, 16, 17 and 18, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR7’s medical record revealed that the patient was ambulatory, however, Patient #7’s standing blood pressures were not measured pre and/or post treatment July 4, 7, 9, 11, 14 and 16, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR8’s medical record revealed that the patient was ambulatory, however, Patient #8’s standing blood pressures were not measured pre and/or post treatment July 9, 11, 14, 16, 18, and 21, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR9’s medical record revealed that the patient was ambulatory, however, Patient #9’s standing blood pressures were not measured pre and/or post treatment July 15, 17 and 19, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR10’s medical record revealed that the patient was ambulatory, however, Patient #10’s standing blood pressures were not measured pre and/or post treatment July 9, 18 and 21, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR12’s medical record revealed that the patient was ambulatory, however, Patient #12’s standing blood pressures were not measured pre and/or post treatment July 21, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. MR13’s medical record revealed that the patient was ambulatory, however, Patient #13’s standing blood pressures were not measured pre and/or post treatment July 21, 2025. There was no documentation to evidence a reason why standing blood pressures were not obtained. In an interview on July 22, 2025 at 1:30 PM Employee #2 (EMP2) stated that patients should have standing blood pressures performed if they were ambulatory and able to stand. A review of the facility’s policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, revised April, 2024, indicated in part: “...Policy...ii. Measurement of Blood Pressure (BP) 1. sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...”.”

“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: 19883 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) for three (3) of eleven (11) patient records sampled. The findings included: Patient #5: The surveyor reviewed six (6) dialysis treatment records from 07/08/25 through 07/19/25 for patient #5. The treatment sheets evidenced an order for a BFR of 350. The treatment records evidenced the following: On 07/08/25, the BFR was documented as 400. Patient #5’s clinical record failed to contain evidence of documentation explaining why the BFR was not administered as prescribed. Patient #7: The surveyor reviewed six (6) dialysis treatment records from 07/04/25 through 07/16/25 for patient #7. The treatment sheets evidenced an order for a BFR of 350. The treatment records evidenced the following: On 07/07/25, the BFR was documented as 230, 300, and 340. On 0714/25, the BFR was documented as 230 and 280. Patient #7’s clinical record failed to contain evidence of documentation explaining why the BFR was not administered as prescribed. Patient #9: The surveyor reviewed three (3) dialysis treatment records from 07/15/25 through 07/19/25 for patient #9. The treatment sheets evidenced an order for a BFR of 400. The treatment records evidenced the following: Patient #9 was a new patient and had their first dialysis treatment on 07/15/25. On 07/15/25, Patient #9’s BFR was documented as 300 and 350. On 07/17/25, Patient #9’s BFR was documented as 200 and 350. On 07/19/25, Patient #9’s BFR was documented as 200, 300, and 360. Patient #9’s treatment record failed to contain evidence of documentation explaining why the BFR was not administered as prescribed. Review of the facility’s policy titled: “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” with a revision date of April 2024 revealed in part: “...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.””

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 46466 Based on observation and facility document review, facility staff failed to care for patient arteriovenous (AV) grafts/fistulas according to the facility’s policy. The findings included: On July 21, 2025 at 12:35 PM, the patient (MR12) at station #15 was observed with one (1) vascular access clamp over the graft/fistula site on their left arm. A staff member removed the clamp at 12:56 PM and due to continued bleeding of the site, placed the clamp back on the same site and kept it in the same location until 1:15 PM. The staff member was not observed checking the bruit or thrill at any time while the clamp remained on the patient’s arm. The staff member was not observed manually holding pressure on the access site after removing the clamp and determining that the bleeding had not stopped. Review of the treatment flowsheet on July 21, 2025, in the post treatment nurse assessment Patient #12’s bleeding stop time was “less than or equal to 10” (minutes). The dialysis treatment flowsheet didn’t include documentation of the episode of prolonged bleeding from the access site post-treatment and/or interventions used by staff members or the nurse. On July 21, 2025 at 1:10 PM, a staff member was observed initiating cannulation of a patient’s AV graft/fistula at station #1. The staff member applied antiseptic to the patient’s skin over the cannulation site, palpated the site and inserted the needle. The staff member did not disinfect the site after palpating. The staff member repeated the same process when cannulating the second site. A review of the facility’s policy “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose”, revised April 2025, indicated in part: “...13. Do not palpate insertion site once area has been prepped...Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation”. A review of the facility’s policy “Utilizing Vascular Access Clamp Procedure”, revised April, 2023, indicated in part: “..8. Clamp may remain in placed for 5-10 minutes before checking to see if bleeding has stopped. 9. Bruit and thrill must be re-checked a minimum of every 10 minutes while using access clamps...11. If bleeding has not stopped, reapply clamp checking for thrill and bruit above and below the clamp. 12. Access clamp should not be left on longer than 20 minutes...13. If bleeding persists, teammate should manually hold pressure on the access site for at least 10 minutes...”. A review of the facility’s policy “Prolonged Bleeding of Cannulation Sites”, revised April, 2023, indicated in part: “...2. Prolonged bleeding of cannulation sites is defined as bleeding more than 30 minutes post needle removal...5. The licensed nurse verifies that sites are checked at appropriate intervals...10. Document findings and interventions in patient’s electronic health record...”.”