Davita Kempsville Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure Staff perform hand hygiene after glove removal for one (1) of five (5) Staff Members (SM), SM # 3. The findings include: On March 27, 2024 between 10:45 a.m. and 12:15 p.m. the following was observed in the treatment area: At 11:15 a.m., SM # 3 was observed at Station # 13 during the initiation of treatment with a central venous catheter (CVC). SM # 3 removed dirty gloves and donned clean gloves without performing hand hygiene. At 11:20 a.m., SM # 3 was observed at Station # 13 removing one dirty glove from the left hand while documenting on the machine with the right hand. SM # 3 then removed the dirty glove from the right hand and donned clean gloves without performing hand hygiene. At 12:02 p.m., SM # 3 was observed at Station # 15 removing dirty gloves and donning clean gloves without performing hand hygiene. On March 28, 2024 at 12:00 p.m., a review of the facility policy titled “Infection Control” reads in part “All teammates, Physicians and Non-Physician will perform hand hygiene prior to gloving and immediately after removal of gloves.” On March 28, 2024 at 1:30 p.m., the findings were discussed with SM # 1 and # 7 during the exit interview.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Physician ordered blood flow rate (BFR) was achieved or if unable to achieve, the Physician and/or Registered Nurse (RN) was notified for one (1) of six (6) Patients, P # 2. The findings include: On March 28, 2023 at 9:30 a.m., a review of the clinical record for P # 2 revealed the following: The flowsheet dated March 12, 2024 documented the BFR as 300 from 1:01 p.m. to 2:31 p.m. and as 250 from 2:58 p.m. to the end of the treatment. The Physician ordered BFR was 350. There was no documented reason for the decreased BFR and no documentation that the Physician and/or RN was notified. The flowsheet dated March 14, 2024 documented the BFR as 300 from 1:01 p.m. to the end of the treatment. The Physician ordered BFR was 350. There was no documented reason for the decreased BFR and no documentation that the Physician and/or RN was notified. The flowsheet dated March 22, 2024 documented the BFR as 260 from 1:34 p.m. to the end of the treatment. The Physician ordered BFR was 350. There was no documented reason for the decreased BFR and no documentation that the Physician and/or RN was notified. On March 28, 2024 at 12:00 p.m., a review of the facility policy titled “Pre-Intra-Post Treatment Data” reads 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.” On March 28, 2024 at 1:30 p.m., the findings were discussed with Staff Members # 1 and # 7 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 document review and interview, it was determined that the facility failed to obtain and document standing blood pressures (BP) for four (4) of six (6) In Center Hemodialysis (ICHD) Patients (P), P # 2, # 3, # 5 and # 6; failed to complete nursing assessments by the Registered Nurse (RN) within an hour of treatment initiation for three (3) of six (6) Patients, P # 2, # 3 and # 5; and failed to verify the treatment prescription by the Registered Nurse (RN) within an hour of treatment initiation for four (4) of six (6) Patients, P # 1, # 2, # 3 and # 5. The findings include: On March 28, 2024 between 9:30 a.m. and 1:00 p.m. during clinical record reviews, the following was revealed: P # 1- The flowsheet dated March 16, 2024 revealed the nurse prescription verification documented at 7:21 a.m. The initiation of the treatment was documented at 6:07 a.m. (more than one hour). P # 2- The flowsheet dated March 14, 2024 revealed the nurse prescription verification documented at 12:13 p.m. The initiation of the treatment was documented at 10:53 a.m. (more than one hour). The flowsheet dated March 16, 2024 revealed pre-treatment standing blood pressure (BP) as N/A and post-treatment BP as N/A. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. The flowsheet dated March 19, 2024 revealed pre-treatment standing BP as N/A and post-treatment BP was 155/86. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. The flowsheet dated March 21, 2024 revealed the nurse prescription verification documented at 7:50 a.m. The pre-treatment nursing assessment was documented at 7:51 a.m. The initiation of the treatment was documented at 6:38 a.m. (more than one hour). The flowsheet dated March 22, 2024 revealed the nurse prescription verification documented at 11:58 a.m. The initiation of the treatment was documented at 10:54 a.m. (more than one hour). The pre-treatment standing BP was 163/71 and post-treatment BP as N/A. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. P # 3- The flowsheet dated March 18, 2024 revealed the nurse prescription verification documented at 12:55 p.m. The pre-treatment nursing assessment was documented at 12:55 p.m. The initiation of the treatment was documented at 11:41 a.m. (more than one hour). The flowsheet dated March 22, 2024 revealed the pre-treatment standing BP as N/A and post-treatment BP was 123/69. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. P # 5- The flowsheet dated March 18, 2024 revealed the nurse prescription verification documented at 12:57 p.m. The pre-treatment nursing assessment was documented at 12:57 p.m. The initiation of the treatment was documented at 11:02 a.m. (more than one hour). The flowsheet dated March 22, 2024 revealed the pre-treatment standing BP was 123/61 and post-treatment BP as N/A. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. The nurse prescription verification documented at 12:30 p.m. The pre-treatment nursing assessment was documented at 12:30 p.m. The initiation of the treatment was documented at 11:05 a.m. (more than one hour). The flowsheet dated March 25, 2024 revealed the pre-treatment standing BP was 146/74 and post-treatment BP as N/A. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. P # 6- The flowsheet dated March 13, 2024 revealed the pre-treatment standing BP as N/A and post-treatment BP was 129/54. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. The flowsheet dated March 15, 2024 revealed the pre-treatment standing BP as N/A and post-treatment BP was 118/64. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. The flowsheet dated March 20, 2024 revealed the pre-treatment standing BP as N/A and post-treatment BP was 138/55. The pre-treatment and post-treatment nurse assessment for observations reads “ambulates - no assistance needed”. On March 28, 2024 at 12:00 p.m., a review of the facility policy titled “Pre-Intra-Post Treatment Data” reads in part “Data collection includes but is not necessarily limited to sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flowsheet). The licensed nurse will round on those patients without reported abnormal findings and completed the nursing assessment within one (1) hour of dialysis treatment initiation. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation.” On March 28, 2024 at 1:30 p.m., the findings were discussed with Staff Members # 1 and # 7 during the exit interview.”

“PA-ASSESS RENAL BONE DISEASE CFR(s): 494.80(a)(5) The patient’s comprehensive assessment must include, but is not limited to, the following: (5) Evaluation of factors associated with renal bone disease. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure medications were given as ordered by the Physician for chronic kidney disease (CKD) mineral and bone disorders for one (1) of six (6) Patients (P), P # 2. The findings include: On March 28, 2023 at 9:30 a.m., a review of the clinical record for P # 2 revealed the following: The flowsheet dated March 23, 2024 revealed no documentation of Calcitriol (medication to treat low calcium caused by kidney disease) given. P # 2 receives treatments on Tuesday, Thursday and Saturday (TTS). The Physician’s order reads Calcitriol 0.75 mcg, three times per week. On March 28, 2024 at 12:00 p.m., a review of the facility policy titled “Medication Policy” reads in part “Medications are administered as prescribed and then documented in the patient’s medical record.” On March 28, 2024 at 1:30 p.m., the findings were discussed with Staff Members # 1 and # 7 during the exit interview.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to maintain an accurate clinical record for one (1) of six (6) Patients (P), P # 4. The findings include: On March 28, 2023 at 10:30 a.m., a review of the clinical record for P # 4 revealed the following: The flowsheets dated March 14, 16, 19, 21, 23 and 26, 2024 documented post treatment assessment: mobility: wheelchair, ambulatory: ambulatory - no assistance needed. On March 28, 2024 at 10:55 a.m., an interview with Staff Member (SM) # 1 revealed [P # 4] is in a wheelchair and can pivot to the chair but is unable to ambulate. On March 28, 2024 at 1:20 p.m., an interview with SM # 7 revealed there was no policy for an accurate assessment, it is expected by all nurses. On March 28, 2024 at 1:30 p.m., the findings were discussed with SM # 1 and # 7 during the exit interview.”