Davita Greater Portsmouth Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 45736 Based on interviews, medical record, and facility document review, the facility failed to perform patient emergency drills as per facility policy to ensure patient safety. The findings include: On 11/14/23, the survey team reviewed of twelve (12) patient medical records sample. Review of Patient #1’s (P1) medical record did not find documentation that P1 received “Fire Safety Preparedness Training in the third (3rd) quarter of 2023. Review of Patient #5’s (P5) medical record did not find documentation that P5 received “Fire Safety Preparedness Training in the third (3rd) quarter of 2023. On 11/14/23 at 11:02 a.m., the surveyor interviewed Patient #13 (P13). When P13 was questioned on when they last received fire safety preparedness, P13 replied that P13 did not remember the last time when P13 was educated about it. P13 also stated that P13 felt that the facility staff should provide fire safety training more often. On 11/14/23 at 2:30 p.m., a review of P13’s medical chart was conducted. The last documented Fire Safety Training that P13 received was the in the fourth (4th) quarter of 2022. On 11/14/23 at 3:30 p.m., a request was made to Staff Members #2 and #7 for most current documentation of P1, P5 and P13’s fire safety training. They were not able to provide any further evidence to support that they received fire safety training as per facility policy. A review of the facility’s “Emergency Management Plan” (EMP), Policy: 4-07-01, revised October 2023, stated in part: “...3. Fire safety drills: ...b. Required on a QUARTERLY basis c. One drill to be conducted for each shift of patients... e. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency”. The above concerns were discussed with Staff Members #1, #2 and #7 at the exit conference on 11/15/23 at 9:45 a.m.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 45736 Based on medical record and facility document review, the facility failed to provide evidence that patients were provided the Hepatitis B vaccine in one (1) of ten (12) hemodialysis patient records sampled. The findings include: On 11/14/23, the surveyors reviewed twelve (12) medical records of hemodialysis patients. A review of the medical record for Patient #3 (P3) did not contain evidence that the hepatitis B vaccine was offered and there was no Hepatitis B declination form in the patient’s chart. The Patient Summary Report documented that P3 was tested for Hepatitis B antigen and antibodies on 10/2/23 and was determined to be not immune. There was no documented physician order for P3 to receive the vaccine. On 11/14/23, a request was made to Staff Members #3 and #7 about the missing documentation but both were unable to locate P3’s vaccination consent or declination prior to the exit conference. A review of the facility’s policy “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance”, policy: 1-05-02, last revised October 2023, stated in part: ...10. An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in Patient Registration Packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient’s health record”. The above concerns were discussed with Staff Members #1, #2 and #7 at the exit conference on 11/15/23 at 9:45 a.m.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 45736 Based on observations and facility document review, it was determined the facility failed to maintain a safe environment for dialysis patients and staff. Findings: On 11/13/23 at 11:30 a.m., the surveyors entered the lobby of the facility to find the treatment floor door propped open. There was no one at the facility’s front desk. A surveyor entered through the opened door and walked onto the treatment floor. A few moments later, the surveyor was discovered and greeted by a Staff Member #1. At 12:45 p.m., the surveyor observed that the treatment floor door was still propped open. A review of the facility’s policy “Physical Environment”, Policy: 8-04-01, revised April 2018, stated in part: “...1. The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates and the public... 9. ...Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only...”. The above concerns were discussed with Staff Members #1, #2 and #7 at the exit conference on 11/15/23 at 9:45 a.m.”

“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: 45736 Based on staff interview and document review, it was determined the facility failed to adequately manage patient volume status for seven (7) of twelve (12) patients included in the survey sample. Specifically, the facility failed to ensure abnormal weights were documented as reported to the licensed nurse per facility policy and failed to monitor patients per facility policy by not documenting pre and/or post treatment standing blood pressure. Findings: Twelve (12) medical records were reviewed on 11/13/23 and 11/14/23. 1. The seven (7) most recent treatment records for patient #2 were reviewed. One (1) of seven (7) treatment records from 10/18/23 to 11/1/23 reviewed contained a documented post dialysis weight of one (1) or more kilograms (kg) above or below the target weight with no documentation that a nurse was notified. On 11/6/23, patient #2’s prescription target weight was 86kg and their post treatment weight was documented as 91.6kg. P2 did not have standing blood pressures conducted during pre-treatment and post -treatment vitals on 10/18/23, 10/20/23, 10/23/23, 10/25/23, 10/27/23 and 10/30/23 The mobility observation documented for P1 was “Mobility- walker, Ambulatory - Ambulatory device needed” for each date. There was documentation on 10/2/23 that P2 was a “critical-fall risk” and P2’s mobility level was “dependent”, however, this was not documented on any of the flow sheets. 2. The six (6) most recent treatment records for patient #4 were reviewed. Two (2) of six (6) treatment records reviewed contained a documented post dialysis weight of one (1) or more kg above or below the target weight with no documentation that a nurse was notified. On 11/1/23, patient #4’s prescription target weight was 94.5kg and their post treatment weight was documented as 98.1kg. Four (4) of six (6) treatment records reviewed did not contain a pre and post treatment standing blood pressure (bp) on 10/30/23, 11/1/23, 11/8/23 and 11/10/23. One (1) of six (6) treatment records reviewed did not contain a pre treatment standing bp on 11/6/23. 3. The six (6) most recent treatment records for patient #6 were reviewed. Two (2) of six (6) treatment records reviewed did not contain a post treatment standing blood pressure (bp). Dates were 11/1/23 and 11/10/23. 4. The six (6) most recent treatment records for patient #8 were reviewed. Two (2) of six (6) treatment records reviewed contained a documented post dialysis weight one (1) or more kg above or below the target weight with no documentation that a nurse was notified. On 11/2/23, patient #8’s prescription target weight was 68.5kg and their post treatment weight was documented as 71.8kg. On 11/11/23, patient #8’s prescription target weight was 68.5kg and their post treatment weight was documented as 72.3kg. Six (6) of six (6) treatment records reviewed did not contain a pre and post treatment standing blood pressure (bp) on 10/31/23, 11/2/23, 11/4/23, 11/7/23, 11/9/23 and 11/11/23. 5. The six (6) most recent treatment records for patient #9 were reviewed. One (1) of six (6) treatment records reviewed contained a documented post dialysis weight of one (1) or more kg above or below the target weight with no documentation that a nurse was notified. On 11/10/23, patient #9’s prescription target weight was 92kg and their post treatment weight was documented as 90.4kg. Two (2) of six (6) treatment records reviewed did not contain a pre and post treatment standing blood pressure (bp) on 11/8/23 and 11/11/23. One (1) of six (6) treatment records reviewed did not contain a pre treatment standing bp on 11/6/23. 6. The six (6) most recent treatment records for patient #10 were reviewed. Three (3) of six (6) treatment records reviewed contained a documented post dialysis weight of one (1) or more kg above or below the target weight with no documentation that a nurse was notified. On 10/11/23, patient #10’s prescription target weight was 54.5kg and their post treatment weight was documented as 56.5kg. On 10/13/23, patient #10’s prescription target weight was 54.5kg and their post treatment weight was documented as 60.2kg. On 10/18/23, patient #10’s prescription target weight was 54.5kg and their post treatment weight was documented as 56kg. 7. The surveyor reviewed Patient #1’s (P1) six (6) dialysis treatment flowsheet records from 10/31/23 to 11/11/23. P1 did not have standing blood pressures conducted during pre-treatment vitals on 10/31/23, 11/4/23, 11/7/23, 11/9/23 and 11/11/23. P1 did not have standing blood pressures conducted during post-treatment vitals on 10/31/23, 11/2/23, 11/4/23, 11/7/23, 11/9/23 and 11/11/23. The mobility observation documented for P1 was “Ambulates-no assistance needed”, and ambulatory observation stated “Ambulatory - No assistance needed” for each date. There was no documentation for a reason why P1 could not have performed standing blood pressures. During and interview on 11/14/23 at 2:30 p.m., with Staff Member #12 (SM#12), a Certified Clinical Hemodialysis Technician (CCHT), when asked about assessing pre and post treatment standing blood pressures, they stated that taking standing blood pressures is part of their responsibility. Patients will sit down in the chair before getting the standing blood pressure and then will not get up. There used to be an option in the other documentation system to document if a patient refused and in the new system there is not an option to document this. The facility’s policy, Pre-Intra-Post treatment Data Collection, Monitoring, and Nursing Assessment, last revision date October 2023, reviewed and partially reads as follows, “1. Patient date will be obtained and documented by the patient care technician (PCT) or a licensed nurse. A. Data collection includes but is not limited to: ...ii. Measurement of Blood Pressure (BP 1. Sitting and standing BP measurement required pre and post treatment (if patient unbale to stand, document reason in the patient electronic record or flow sheet)...Post Treatment Data Collection/Assessment...16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse...Abnormal Findings...Fluid Status:...Post-treatment: If patient is above or below 1kg from target weight...” These findings were discussed with Staff Member (SM) #1 (Regional Operations Director), SM#2 (Facility Administrator) and SM#7 (Manager of Clinical Services) at the exit conference on 11/15/23 at approximately 9:45 a.m.”

“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: 45736 Based on clinical record review and staff interview, the facility staff failed to ensure three (3) of ten (10) in-center patients dialysis prescription were followed to ensure the adequacy of dialysis. Patient #’s 1 (P1), #3 (P3) and #5 (P5). The findings included: 1. P1: Six (6) dialysis treatment records were reviewed from 10/31/23 to 11/11/23. One (1) of six (6) treatment records for P1 evidenced a physician’s order for BFR of 400. The treatment records evidenced the following: 11/11/23 - The BFR was changed at 6:36 a.m. from 400 to 350. There was no documentation as to why the BFR was changed from the physician’s order. 2. P3: Seven (7) dialysis treatment records were reviewed from 10/18/23 to 11/1/23. Five (5) of seven (7) treatment records for P3 evidenced a physician’s order for BFR of 400 and a DFR of 600. The treatment records evidenced the following: 10/20/23 - The BFR was set at 350 at 9:53 a.m. and changed to 300 at 11:02 a.m. 10/23/23 - The DFR was set at 500 at 9:56 a.m. 10/25/23 - The DFR was set at 500 at 10:16 a.m. 10/27/23 - The DFR was set at 500 at 9:37 a.m. 10/30/23 - The DFR was set at 500 at 10:07 a.m. There was no documentation in any of P3’s treatment records as to why the BFR or DFR was changed from the physician’s order. 3. P5: Six (6) dialysis treatment records were reviewed from 10/31/23 to 11/11/23. One (1) of six (6) treatment records for P5 evidenced a physician’s order for BFR of 350. The treatment records evidenced the following: 11/9/23 - The BFR was changed to 200 at 11:54 a.m. There was no documentation as to why the BFR was changed from the physician’s order. A review of the facility’s policy “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, Policy: 1-03-08, revised October 2023, stated in part: “ ...INTRADIALYTIC DATA COLLECTION/ASSESSMENT 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 ...”. The above concerns were discussed with Staff Members #1, #2 and #7 on 11/14/23 and again at the exit conference on 11/15/23 at 9:45 a.m.”