Davita Port Warwick 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: 46466 Based on interviews, medical record and facility document reviews, the staff failed to provide fire safety drill training for patients on a quarterly basis. The findings include: On 3/26/24 surveyor reviewed six (6) patient records included in the sample. Patients #4 and #6’s records revealed that their last fire safety drill training was conducted in August, 2023. On 3/26/24 at 1:45 p.m., Staff Member #14 confirmed that Patients #4 and #6’s records did not have evidence to support that fire safety drills were conducted after August, 2023. A review of the facility’s policy “Facility Emergency Management Plan”, last revised 10/2023, stated in part: “...Fire safety drills...b. Required on a QUARTERLY basis...”. The findings were discussed with Staff Members #1, #2 and #14 at the exit conference on 3/26/24 at 2:00 p.m..”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 46466 Based on observations, interviews and facility document review, facility staff failed to wear proper attire while caring for patients on the treatment floor. The findings include: On 3/25/24 at 11:25 a.m., Staff Member #5 (SM5) was observed on the treatment floor, caring for patients while wearing Crocs (Crocs are a closed-cell resin shoes that have 13 holes on top of the shoe, side ventilation holes and a heel strap). On 3/25/24 at approximately 11:45 a.m., an interview was conducted with Staff Member #10 (SM10). SM10 stated that Crocs shoes are not appropriate to wear on the treatment floor. A review of the facility documentation on work attire stated in part: “...Teammates who work in a facility, including facility administrators and support teammates, must wear slip-resistant, closed-toe shoes...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”

“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: 46466 Based on observations and facility document review, the facility staff failed to appropriately label two (2) syringes that were previously drawn with medication per the facility’s policy. The findings include: On 3/25/24 at 10:55 a.m., two (2) syringes with medications were found laying on a clean counter. Both syringes were labeled with patient information but did not include the time and the initials of the staff member who drew the medications. A review of the facility’s “Medication Policy”, revised 10/2023, stated in part “...20...If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the...time prepared...and initials of teammate preparing the medication...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 46466 Based on interviews and facility document review, the facility staff failed to document daily water treatment system monitoring per facility policy. The findings include: On 3/25/24 at 12:15 p.m., a review of the facility’s “Water Monitoring Log Summary” was conducted. The log evidenced that facility staff did not record the first manual check of the water on 1/3/24, 1/12/24, 1/19/24, 1/22/24, 1/26/24 and 2/2/24. An interview with Staff Member #9 (SM9) was conducted on 3/25/24 at 12:30 p.m. SM9 stated that staff members were supposed to record the first manual water check of the day into the facility’s computer system. An interview with Staff Member #10 (SM10) was conducted on 3/25/24 at 1:30 p.m. SM10 also confirmed that that staff members were required to input the first manual test result into the facility’s computer system in addition to writing it onto the paper log. A review of the facility’s policy “Daily Water Treatment System Monitoring”, revised 4/2023, stated in part: “...1. All observations and test results must be recorded on the approved Daily Water Treatment Log and required IT Clinical System entries...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.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: 46466 Based on clinical record and facility document review, the facility staff failed to (A) document notification of abnormally high and/or low blood pressure readings to the Charge Nurse and (B) record standing blood pressures pre and post treatment per facility policy in six (6) of six (6) treatment records included in the survey (Patients #1-6). The findings include: A review of treatment records for six (6) sampled patients revealed the following: Patient #1 (Pt. #1): Six (6) treatment flowsheets from 3/7/24 through 3/23/24 were reviewed. (A) Pt. #1’s flowsheet from 3/23/24 documented intradialytic blood pressures with a difference of 20 mm Hg or higher from the last blood pressure reading. There was no documentation that the charge nurse was notified of the abnormal findings. (B) All six (6) treatment flowsheets did not include documentation that a standing blood pressure was performed or a reason why it wasn’t obtained. Pt. #1’s mobility status was documented as “Ambulates-No Assistance Needed”. Patient #2 (Pt. #2): Six (6) treatment flowsheets 3/7/24 through 3/23/24 were reviewed. (B) All six (6) treatment flowsheets did not include documentation that a standing blood pressure was performed or a reason why it wasn’t obtained. Pt. #2’s mobility status was documented as “Ambulates-Assistance Needed”, Ambulates-Device Needed” or “Ambulates-Cane”. Patient #3 (Pt. #3): Six (6) treatment flowsheets from 3/11/24 through 3/22/24 were reviewed. (A) Pt. #3’s flowsheet from 3/22/24 documented intradialytic blood pressures with a difference of 20 mm Hg or higher from the last blood pressure reading. There was no documentation that the charge nurse was notified of the abnormal findings. (B) All six (6) treatment flowsheets did not include documentation that a standing blood pressure was performed or a reason why it wasn’t obtained. Pt. #3’s mobility status was documented as “Mobility-Wheelchair”, Mobility-Ambulates-No Assistance Needed”, “Mobility-Walker” and “Ambulatory - Ambulatory - No Assistance Needed”. Patient #4 (Pt. #4): Six (6) treatment flowsheets from 3/11/24 through 3/22/24 were reviewed. (A) Pt. #4’s flowsheets from 3/11/24, 3/15/24, and 3/18/24, documented abnormal findings in pre-treatment and intradialytic blood pressure readings. There was no documentation that the charge nurse was notified of the abnormal findings. (B) All six (6) treatment flowsheets did not include documentation that a standing blood pressure was performed or a reason why it wasn’t obtained. Pt. #4’s mobility status was documented as “Mobility-Wheelchair”, Mobility-Ambulates-No Assistance Needed”, “Mobility-Walker” and “Ambulatory - Ambulatory - No Assistance Needed”. Patient #5 (Pt. #5): Six (6) treatment flowsheets from 3/11/24 through 3/22/24 were reviewed. (A) Pt. #5’s flowsheets from 3/13/24, 3/15/24, and 3/18/24 documented an intradialytic blood pressure reading greater than 20 mm Hg from the last reading. There was no documentation that the charge nurse was notified of the abnormal finding. (B) Two (2) of six (6) treatment flowsheets (3/18/24 and 3/22/24) did not include documentation that a standing blood pressure was performed or a reason why it wasn’t obtained. Pt. #5’s mobility status was documented as “Mobility-Ambulates-No Assistance Needed”. Patient #6 (Pt. #6): Six (6) treatment flowsheets from 3/11/24 through 3/22/24 were reviewed. (B) Three (3) of six (6) treatment flowsheets (3/13/24, 3/15/24 and 3/20/24), did not include documentation that a standing blood pressure were performed or a reason why it wasn’t obtained. Pt. #6’s mobility status was documented as “Mobility-Ambulates-No Assistance Needed”. A review of the facility’s policy “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, last revised October 2023, stated in part: “...Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse... 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). ...PRE-TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during the pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis ... 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated ... INTRADIALYTIC DATA COLLECTION/ASSESSMENT 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy) ... ABNORMAL FINDINGS ...Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. ...Blood pressure: Pre dialysis: - Systolic greater than 180 mm/Hg or less than 90 mm/Hg - Diastolic greater than or equal to 100 mm/Hg... Blood pressure: Intradialytic: - Difference of 20 mm Hg increase or decrease from patient’s last intradialytic treatment BP reading...” The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.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: 46466 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 six (6) in-center dialysis patients included in the sample. The findings include: Patient #1 (Pt. #1): The surveyor reviewed six (6) dialysis treatment records from 3/7/24 through 3/23/24. Two (2) of six (6) treatment records for Pt. #1 evidenced DFR value different form the prescribed DFR of 600. The treatment sheets evidenced the following: On 3/12/24, the DFR was documented as 500. On 3/14/24, the DFR was documented as 500. Pt. #1’s clinical record failed to contain evidence of documentation explaining why the DFR was not being administered as prescribed. Patient #3 (Pt. #3): The surveyor reviewed six (6) dialysis treatment records from 3/11/24 through 3/22/24. Three (3) of six (6) treatment records for Pt. #3 evidenced DFR value different form the prescribed DFR of 800. The treatment sheets evidenced the following: On 3/11/24, the DFR was documented as 500. On 3/15/24, the DFR was documented as 500. On 3/20/24, the DFR was documented as 500 and changed to 0. Pt. #3’s clinical record failed to contain evidence of documentation explaining why the DFR was not being administered as prescribed. Patient #4 (Pt. #4): The surveyor reviewed six (6) dialysis treatment records from 3/11/24 through 3/22/24. Four (4) of six (6) treatment records for Pt. #4 evidenced DFR and BFR values different form the prescribed BFR of 550 and DFR of 800. The treatment sheets evidenced the following: On 3/11/24, the BFR was documented as 450 and 500. On 3/13/24, the BFR was documented as 500. On 3/15/24, the DFR was documented as 500. On 3/18/24, the BFR was documented as 250 and the DFR was documented as 500. Pt. #4’s clinical record failed to contain evidence of documentation explaining why the BFR and DFR were not being administered as prescribed. Patient #5 (Pt. #5): The surveyor reviewed six (6) dialysis treatment records from 3/11/24 through 3/22/24. One (1) of six (6) treatment records for Pt. #5 evidenced DFR value different form the prescribed DFR of 600. The treatment sheets evidenced the following: On 3/18/24, the DFR was documented as 500. Pt. #5’s clinical record failed to contain evidence of documentation explaining why the DFR was not being administered as prescribed. A review of the facility’s policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, revised 10/2023, 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...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”

“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 policy review, the facility staff failed to use aseptic technique when accessing an arteriovenous (AV) fistula/graft. The findings included: On 3/25/24 at 11:15 a.m., Staff Member #4 (SM4) was observed preparing to access an AV site on a patient in pod four (4). SM4 wiped the AV site with antiseptic, then palpated the access site. SM4 inserted the cannulation needle without reapplying antiseptic to the AV site after palpating. A review of the facility’s policy “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Loading Dose”, revised 10/2022 stated in part: “...13. Do not palpate insertion site once area has been prepped...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 46466 Based on observations and facility document review, facility staff failed to verify a lab specimen label matched the correct patient. The findings include: On 3/25/24 at approximately 3:00 p.m., Staff Member #5 (SM5) was observed obtaining a blood specimen from a patient’s CVC (Central Venous Catheter) prior to the initiation of the patient’s treatment. SM5 collected the blood and then laid the blood tube on the patient’s chairside table. The patient picked up the blood specimen vial and told SM5 that the label on the vial was not the patient’s identification. SM5 returned to the patient’s station and then took the vial away from the station. A review of the facility’s policy “Obtaining Patient Lab Specimens”, revised 10/2023, stated in part: “...7. All lab specimens drawn will be verified by the teammate collecting the patient specimen to verify that the lab specimen label name matches the correct patient, the printed label reflects the actual requisition number, and that the label is applied to correct tube type...”. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 46466 Based on interviews and medical record review, facility staff failed to complete patients medical records promptly for three (3) of six (6) patient records sampled. The findings include: On 3/26/24 six (6) in-center patient medical records were reviewed. Patient #2 (Pt. #2): On 3/9/24, Pt. #2’s treatment flowsheet indicated that Pt. #2 initiated dialysis treatment at 5:30 a.m. Pt. #2’s pre-treatment vitals were documented at 4:06 a.m. Patient #3 (Pt. #3): On 3/13/24 and 3/15/24, Pt. #3’s flowsheets documented that Pt. #3 discontinued treatment early. The reason documented “AMA” (against medical advice). There was no evidence found to support that Pt. #3 signed an AMA form for either of the days listed. Patient #4 (Pt. #4): On 3/11/24, Pt. #4’s treatment flowsheet indicated that Pt. #4 initiated dialysis treatment at 10:05 a.m. Pt. #4’s pre-treatment vitals were documented at 6:48 a.m. In the entrance conference on 3/25/24 at 10:30 a.m., Staff Member #2 (SM2), SM2 stated that facility staff arrive to open the facility at 4:00 a.m. every morning and patient shifts begin at 5:15 a.m. An interview was conducted with Staff Member #14 (SM14) on 3/26/24 at 12:00 p.m. The above findings were discussed with SM14. SM14 was not able to provide a response as to why the pre-treatment vitals were documented more than one hour earlier than the patient’s treatment start times. SM14 stated that they were unable to find the signed AMA forms for Pt. #3 for the dates listed above. SM14 stated that patients should be signing AMA forms when they decide to discontinue treatment early. The findings were discussed with Staff Members #1, #2, and #14 on 3/26/24 at 2:00 p.m.”