Davita Seven Hills Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, the facility failed to ensure that an emergency medication, EpiPen was not expired. The findings include: On March 17, 2025 during an inspection of the facility’s emergency cart, the surveyor discovered an EpiPen with an expiration date of January, 2025 included in the cart, available for use in an emergency. On March 17, 2025, Staff Member #1 confirmed that the EpiPen had expired and stated that it should have been removed from the cart and replaced. Review of the emergency cart’s monthly checklist revealed that the cart was inspected daily during the months of January, and February, and daily from March 1 through March 17, 2025. Review of the facility’s policy titled: Emergency Equipment Checks (revision date of October 2024) reads in part: “...the FA (Facility Administrator) or designee will review the contents of the emergency evacuation kit (s) and replace missing or expired supplies at least monthly.””

“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: 19883 Based on medical record and facility document review, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis DFR (dialysate flow rate) and or BFR (blood flow rate) for two (2) of fifteen (15) in-center dialysis patients included in the survey sample, (Patient #7 and Patient #8). The findings include: Patient #7: The surveyor reviewed six (6) dialysis treatment records from March 4, 2025 through March 15, 2025. The flowsheets evidenced an order for a BFR of 350 and a DFR of 600. On March 6, 2025, the BFR in the flowsheets was documented as 340, and the DFR was documented as 500 and 610. Patient #7’s clinical record failed to contain evidence of documentation explaining why the DFR and BFR was not administered as prescribed. Patient #8: The surveyor reviewed six (6) of Patient #8’s dialysis treatment records from March 3, 2025 through March 14, 2025. The flowsheets evidenced an order for a BFR of 350 and a DFR of 600. On March 3, 2025, the BFR was documented as 310 and the DFR was documented as 500 and 510. Patient #8’s clinical record failed to contain evidence of documentation explaining why the BFR and/or DFR was not administered as prescribed. Review of the facility’s policy titled: “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” (revision date: April 2024) 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.””