Davita Henrico County Dialysis

“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: 49355 Based on observation, interview and document review, it was determined the facility staff failed to follow the facility’s policy on infection control concerning sinks and the storage of clean supplies. Findings: On 02/05/2024 at 12:53 p.m., the surveyor witnessed a sink area labeled “handwashing sink” adjacent to a bin containing clamps labeled “clean clamps.” The bin with the clean clamps was close enough to the sink where spray from the sink left droplets on the bin containing the clean clamps. In an interview with Staff Member (SM)1 at 2:33 p.m., there was agreement that the bins need to be moved further from the sink or, as noted in the facility’s policy, a splash guard needs to put on the sink. A review of the facility’s policy entitled “Infection Control For Dialysis Facilities,” Policy: 1-05-01, last revision date April 2023, reads, in part: “... Facility Hygiene ... 19. Sinks should be easily accessible and readily available in the treatment area and in other appropriate areas such as the medication area, home training room, and isolation area/room. ... b. Clean supplies or equipment will not be placed adjacent to a sink unless a splash guard is in place.” The above concern was discussed at the exit conference on 02/05/2024 at 2:45 p.m. with SMs 1, 3 and 5.”

“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: 49355 Based on observations, interview and document review, it was determined the facility staff failed to ensure the access sites for two (2) patients were visible during their dialysis treatment. Findings: On 02/05/2024 at 12:45 p.m., while performing observations on the treatment floor, this surveyor witnessed a patient at station #10 with an accessed central venous catheter (CVC) site completely covered by the patient’s jacket during treatment. At 12:54, this surveyor witnessed another patient, at station #5, with the accessed CVC site completely covered during the patient’s treatment. This issue was discussed with SM1 at 2:33 p.m. during an interview and there was agreement that access sites should be visible at all times during treatments. A review of the facility’s policy entitled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” Policy: 1-03-08, last revision date October 2023, states, in part: “... Intradialytic Data Collection/Assessment ... c. The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment.” The above concern was discussed at the exit conference on 02/05/2024 at 2:45 p.m. with SMs 1, 3 and 5.”

“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: 49355 Based on medical record reviews, interview and document review, it was determined the facility staff failed to document notification to the licensed nurse of target weight not being met for three (3) out of five (5) patients sampled and conduct a pre-treatment assessment by the licensed nurse within one hour of treatment initiation for one (1) out of five (5) patients sampled. Findings: On 02/05/2024, this surveyor reviewed six (6) flowsheets for five (5) in-center hemodialysis patients. A review of the thirty (30) flowsheets determined that documentation was absent indicating notification to the registered nurse concerning post treatment weights above or below one (1) kilogram (kg) of the desired target weight in three (3) out of five (5) patients. Patient #1: On 08/30/2023, the post treatment weight was measured as 64.7 kg, as compared to the target weight of 66.0 kg, a 1.3 kg difference below the desired target weight. Patient #2: On 01/24/2024, the post treatment weight was measured as 72.9 kg, as compared to the target weight of 74.0 kg, a 1.1 kg difference below the desired target weight. Patient #3: On 01/29/2024, the post treatment weight was measured as 68.1 kg, as compared to the target weight of 64.5 kg, a 3.6 kg difference above the desired target weight. On 02/02/2024, the post treatment weight was measured as 66.1 kg, as compared to the target weight of 64.5 kg, a 1.6 kg difference above the desired target weight. During the review of these thirty (30) flowsheets, the surveyor determined that a pre-treatment assessment was late, according to this facility’s policy, in one (1) out of five (5) patients. Patient #4: On 01/24/2024, the pre-treatment nursing assessment for the patient was completed at 4:56 p.m. when the patient’s treatment was started at 2:48 p.m., a difference of two (2) hours and eight (8) minutes. On 01/26/2024, the pre-treatment nursing assessment for the patient was completed at 4:34 p.m. when the patient’s treatment was started at 3:10 p.m., a difference of one (1) hour and twenty-four (24) minutes. A review of the facility’s policy, titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,: Policy: 1-03-08, last revision date October 2023, states, in part: “... Policy ... 2. The Nursing assessment will be performed and documented by a licensed nurse.... ... 3. Patient identity, prescriptions and machine settings.... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment.... ... Intradialytic Data Collection/Assessment ... 8. The licensed nurse will round on those patients...and complete the nursing assessment within one (1) hour of dialysis treatment initiation. ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Post-treatment: ... If patient is above or below 1 kg from the target weight During an interview at 2:33 p.m., SM1 agreed that the expectation is for documentation of differences in post weight and targeted weight in the patient’s treatment notes and for the licensed nurse to be notified. SM1 also agreed that pre-assessment nursing notes should be completed within one hour of the initiation of treatment. The above information was reviewed with Staff Members #1, 3, and 5 during the exit conference at 2:45 p.m. on 02/05/2024.”

“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: 49355 Based on medical record reviews, interview and document review, it was determined the facility staff failed to document the reason, and to notify the licensed nurse of any change in blood flow rate (BFR) and dialysis flow rate (DFR) from the prescribed treatment for two (2) of five (5) patients sampled. Findings: On 02/05/2024, the surveyor conducted a review of flowsheet for five (5) in-center hemodialysis patients sampled. A review of six flowsheets per sampled patient, for a total of thirty (30) flowsheets, determined that the facility staff failed to administer the prescribed order, to include documentation as to the reason why the order was not followed and notify the licensed nurse of the change in BFR and/or DFR for Patients #1 and #3. Patient #1: On 08/25/2023, the BFR was run at 400 mL/min for approximately the first hour of treatment, which is the prescribed rate, but then the BFR was decreased to 350 mL/min for the remainder of the 3.5 hour treatment. The DFR was run at 500 mL/min for the entire 3.5 hour treatment, instead of the prescribed rate of 800 mL/min. On 08/30/2024, the BFR was run at 400 mL/min, as prescribed, for the first 30 minutes of the treatment, then decreased to 350 mL/min for the remainder of the 3.5 hour treatment. Patient #3: On 01/24/2024, the BFR was run at 349 mL/min for the last 3 hours of the 3.5 hour treatment instead of the prescribed 400 mL/min rate. On 01/29/2024, the BFR was run at 349 mL/min for the entire 3.5 hour treatment instead of the prescribed rate of 400 mL/min. On 01/31/2024, the BFR was run at 350 mL/min for the entire 3.5 hour treatment instead of the prescribed rate of 400 mL/min. On 02/02/2024, the BFR was run at 400 mL/min, as prescribed, for the first 2 hours of the treatment, then decreased to 340 mL/min, then 324 mL/min, and eventually finishing the treatment at 249 mL/min for the remainder of the 3.5 hours of treatment. In an interview on 02/05/2024 at 2:33 p.m., SM1 stated that any changes from the prescribed BFR and/or DFR rates should be noted in the record and the licensed nurse notified of the difference and why it was done. The above concerns were discussed with Staff Members #1, #3 and #5 at the exit conference on 02/05/24 at 2:45 p.m.”