Davita Oceana Dialysis

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to conduct periodic audits of Staff Members (SM) compliance by conducting actual observation of collecting samples, performing water testing, and dialysate mixing in the water room for four (4) of four (4) Staff Members, SM # 3, # 6, # 7 and # 8. The findings include: On January 18, 2024, document reviews revealed there were no documented audits of observations of SMs # 3, # 6, # 7 and # 8 collecting samples and performing water testing and dialysate mixing in the water room. On January 18, 2024 at 12:30 p.m., an interview with SM # 4 revealed “there are no audits documented.” On January 18, 2024, a review of the facility policy titled “Auditing of Clinical Practice requirements for water and dialysate concentrate” reads in part “initial training will be completed after new hire and annually thereafter. Periodic audits of the the teammate’s compliance with procedures should be performed. These audits should be completed at least annually or more frequently if needed.” On January 18, 2024 at approximately 1:30 p.m., the findings were discussed with SM # 4, # 5 and # 9 during the exit interview.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to: obtain patient pre-treatment weights for three (3) of three (3) Patients (P) (P # 6, # 7 and # 8) and post-treatment weights for four (4) of four (4) patients (Patients # 5, # 9, # 10 and # 11); complete the Registered Nurse (RN) assessment within an hour of treatment initiation for three (3) of four (4) Patients (P # 1, # 3 and # 4); complete the RN treatment verification within an hour of treatment initiation for two (2) of four (4) Patients (P # 2 and # 3); ensure intradialytic vitals to include blood pressure (BP) were completed every thirty minutes during treatment for two (2) of four (4) patients (P # 1 and # 2); and obtain pre and post standing blood pressure for two (2) of four (4) Patients (P # 1 and # 3). The findings include: On January 17, 2024 between 10:00 a.m. and 12:30 p.m., the following was observed during initiation and termination of treatments: At 10:00 a.m., P # 9 was observed obtaining post-treatment weight with no Staff Member (SM) present. At 10:05 a.m., P # 5 was observed obtaining post-treatment weight with no SM present. At 10:15 a.m., P # 10 was observed obtaining post-treatment weight with no SM present. At 10:45 a.m., P # 11 was observed obtaining post-treatment weight with no SM present. At 10:30 a.m., P # 6 was observed being weighed by transport staff pre-treatment with no SM present. At 10:40 a.m., P # 7 was observed obtaining pre-treatment weight with no SM present. At 10:45 a.m., P # 8 was observed being weighed by transport staff pre-treatment with no SM present. On January 18, 2024 between 10:30 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 1- The flowsheet dated January 3, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “110/60”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 5, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “165/83”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 8, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “N/A”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The post-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 12, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post-treatment standing BP was documented as “152/73”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The treatment was initiated at 9:46 a.m. and the RN assessment was documented at 10:49 a.m. (greater than one hour). The flowsheet dated January 15, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post-treatment standing BP was documented as “N/A”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The post-treatment ambulatory status was documented as “ambulates - no assistance needed”. The treatment was initiated at 10:29 a.m. and the RN assessment was documented at 11:54 a.m. (greater than one hour). There was no intradialytic vitals to include blood pressure between 10:30 a.m. and 11: 15 a.m. (greater than thirty minutes). P # 2- The flowsheet date January 10, 2024 revealed the treatment was initiated at 7:28 a.m. and the RN treatment verification was documented at 8:35 a.m. (greater than one hour). There was no intradialytic vitals to include blood pressure between 8:03 a.m. and 8:40 a.m. (greater than thirty minutes). P # 3- The flowsheet dated January 5, 2024 revealed the pre treatment standing BP was documented as “N/A”. The post treatment standing BP was documented as “134/58”. The pre treatment ambulatory status was documented as “ambulates - no assistance needed”. The treatment was initiated at 8:16 a.m. and the RN treatment verification was documented at 9:51 a.m. (greater than one hour). The RN assessment was documented at 10:07 a.m. (greater than one hour). The flowsheet dated January 8, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “N/A”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The post-treatment ambulatory status was documented as “ambulates - no assistance needed”. The treatment was initiated at 7:25 a.m. and the RN treatment verification was documented at 9:13 a.m. (greater than one hour). The RN assessment was documented at 9:14 a.m. (greater than one hour). The flowsheet dated January 10, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “N/A”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The post-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 12, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “156/82”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 8, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “128/67”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. The flowsheet dated January 15, 2024 revealed the pre-treatment standing BP was documented as “N/A”. The post- treatment standing BP was documented as “128/67”. The pre-treatment ambulatory status was documented as “ambulates - no assistance needed”. P # 4- The flowsheet dated January 8, 2024 revealed the treatment was initiated at 12:08 p.m. and the RN assessment was documented at 6:32 p.m. (greater than one hour). On January 18, 2024, a review of the facility policy titled “Pre-Intra-Post treatment data” reads in part “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Patient Weight. Sitting and Standing BP measurement required pre and post treatment. Vital signs and treatment monitoring: For non-nocturnal treatments is completed at least every thirty (30) minutes. The licensed nurse will round on those Patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation and verification of prescription.” On January 18, 2024 at approximately 1:30 p.m., the findings were discussed with SM # 4, # 5 and # 9 during the exit interview.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to develop a plan of care for two (2) of four (4) Patients (P) (P # 3 and # 4). The findings include: On January 18, 2024 between 10:30 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 3- P # 3 was admitted to the facility on September 1, 2023. The initial plan of care meeting was documented as October 30, 2023 (greater than 30 days). P # 4- P # 4 was admitted to the facility on December 4, 2023. There was no documented plan of care. On January 18, 2024 at 12:00 p.m., an interview with Staff Member (SM) # 5 revealed “it has not been done. It is scheduled for January 30, when the Physician can be here.” On January 18, 2024, a review of the facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” reads in part “The comprehensive Interdisciplinary Assessment and plan of care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician, qualified master’s social worker and qualified registered dietitian. The Plan of Care must be signed at the time of the interdisciplinary team meeting for those attending in person or if attending remotely within 30 days of the interdisciplinary team meeting. A comprehensive assessment and plan of care will be conducted on all new patients within 30 calendar days.” On January 18, 2024 at approximately 1:30 p.m., the findings were discussed with SM # 4, # 5 and # 9 during the exit interview.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to complete and sign per facility policy a plan of care for one (1) of four (4) Patients (P) (P # 1). The findings include: On January 18, 2024 between 10:30 a.m. and 12:00 p.m., clinical record reviews revealed the following: P # 1- P # 1’s plan of care meeting was documented as July 19, 2023. The Physician, Registered Nurse (RN) and Social Worker (SW) signed on August 30, 2023. The Registered Dietitian (RD) signed on July 31, 2023. The Patient signed on September 27, 2023. The signature dates do not reflect participation in the plan of care meeting. On January 18, 2024, a review of the facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” reads in part “The comprehensive Interdisciplinary Assessment and plan of care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician, qualified master’s social worker and qualified registered dietitian. The Plan of Care must be signed at the time of the interdisciplinary team meeting for those attending in person or if attending remotely within 30 days of the interdisciplinary team meeting. A comprehensive assessment and plan of care will be conducted on all new patients within 30 calendar days.” On January 18, 2024 at approximately 1:30 p.m., the findings were discussed with Staff Members # 4, # 5 and # 9 during the exit interview.”

“POC-PT/FAMILY EDUCATION & TRAINING CFR(s): 494.90(d) The patient care plan must include, as applicable, education and training for patients and family members or caregivers or both, in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to education, train and encourage Patients to perform hand hygiene after termination of the treatment for one (1) of three (3) Patients (P) (P # 5). The findings include: On January 17, 2024 between 10:00 a.m. and 12:30 p.m., the following was observed during initiation and termination of treatments: At 10:05 a.m. P # 5 was observed holding access sites after termination of the dialysis treatment. P # 5 was observed exiting the treatment area without performing hand hygiene. No Staff Member (SM) was observed encouraging P # 5 to perform hand hygiene before exit. On January 18, 2024, a review of the facility policy titled “Infection Control” reads in part “Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. Perform hand hygiene after treatment before leaving the treatment area.” On January 18, 2024 at approximately 1:30 p.m., the findings were discussed with SM # 4, # 5 and # 9 during the exit interview.”