Davita Downtown Spokane Renal Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to implement and follow facility policies and standards of practice to ensure a safe and sanitary environment that minimizes the transmission of infectious agents. Failure to ensure a safe and sanitary environment risks transmission of infectious diseases to patients and staff, with the resultant risk of serious harm. The cumulative effect of these systemic problems results in the facility’s inability to provide care in a safe manner and is evidence that this Condition for Coverage is NOT MET. (Reference Tags V113, V117, V142, V147). .”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to demonstrate documentation of training in emergency preparedness policies and procedures for all new and existing staff in 5 of 6 personnel files reviewed (Staff #106, #110, #112, #115, and #120). Failure to document complete emergency preparedness training for all new and existing staff places patients and staff at risk for harm during emergencies related to inadequately prepared staff. Findings included: 1. Document review of the facility document titled “Facility Emergency Management Plan,” last revised 10/24, and undated facility document titled “Teammate requirements per Role 2024,” showed that all staff must receive education pertaining to the facility’s emergency management plan upon hire and then annually. 2. Document review of personnel files showed no evidence of facility emergency management plan training for the following: - A Social Worker (Staff #106) hired 07/11/16. - A Registered Nurse (RN) (Staff #110), hired 02/08/16, had no training since 02/04/23. - An RN (Staff #112) hired 07/22/24. - A Patient Care Technician (PCT) (Staff #115) hired 05/06/24. - A PCT (Staff #120) hired 06/12/23. 3. On 01/09/25 at 5:02 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding staff emergency preparedness training. Staff #101 acknowledged that personnel file review showed no evidence of documentation of facility emergency management plan training on hire or annually in 5 of 6 files reviewed. .”

“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: 45888 . Based on document review and interview, the facility failed to document emergency preparedness training for patients in 3 of 6 patient medical records reviewed (Patients #141, #147, and #171). Failure to provide emergency preparedness training to patients places patients at risk for harm during emergencies related to inadequate knowledge of emergency procedures. Findings included: 1. Document review of the facility document titled “Facility Emergency Management Plan,” last revised 10/24, showed that all patients must receive annual emergency preparedness education. 2. Document review of patient medical records showed the following: - Patient #141, receiving dialysis at the facility since 09/22/21, had no emergency preparedness education documented since 10/07/22. - Patient #147, receiving dialysis at the facility since 08/29/22, had no emergency preparedness education documented. - Patient #171, receiving dialysis at the facility since 1/29/23, had no emergency preparedness education documented since 04/01/23. 3. On 01/10/25 at 8:05 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and the facility Manager of Clinical Services (Staff #102) regarding patient emergency preparedness training. Staff #101 and #102 confirmed that patient medical record review showed no evidence of annual emergency preparedness training in 3 of 6 records reviewed. .”

“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: 45888 . Based on document review, observation, and interview, the facility failed to ensure that all staff followed facility policies and procedures for glove use and hand hygiene while in the patient treatment area (1) and during arteriovenous access site care (2). Failure to change gloves and perform hand hygiene places patients at risk for exposure to and transmission of infectious agents. Findings included: Item #1 - Patient Treatment Area 1. Document review of the facility policy titled “Infection Control for Dialysis Facilities,” last revised 04/23, showed that all staff must perform hand hygiene with either soap and water or an alcohol-based hand rub for the following: -Before gloving and immediately after removal of gloves. -After contact with contaminated or infectious material. -Between patients even if contact is casual. -Before touching clean areas. -After interacting with the dialysis machine. -When exiting the patient’s treatment area. 2. On 01/06/25 between 1:50 PM and 3:45 PM, Surveyor #1 observed patient care on the treatment floor. The observations showed the following: - A Patient Care Technician (PCT) (Staff #115) partially covered their index finger with a glove when silencing the dialysis machine at Station #7. Staff #115 readjusted the same glove to silence the dialysis machine at Station #14. - A PCT (Staff #115) doffed gloves and silenced the dialysis machine at Station #4 without performing hand hygiene. - A PCT (Staff #115) doffed personal protective equipment (PPE) (glove, mask, and gown) and excited the treatment area without performing hand hygiene. - A PCT (Staff #116) typed on a computer at Station #7, then silenced the dialysis machines at Station #14 without performing hand hygiene. - A Registered Nurse (Staff #110) donned gloves at Station #6 without performing hand hygiene. - The Group Facility Administrator (Staff #103) silenced the dialysis machine at Station #3 without performing hand hygiene. 3. On 01/07/25 at 4:15 PM, Surveyor #1 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding the observed glove use and missed hand hygiene by staff members. Staff #101 and Staff #102 acknowledged the observations. 4. This is a repeat citation. DOH previously cited the facility for this tag in the preceding 04/20/23 End Stage Renal Disease Facility Recertification Core Survey. Item #2 - Access Site Care 1. Document review of the facility policies titled “Infection Control for Dialysis Facilities,” last revised 04/23, and “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” last revised 04/23, showed that staff are to use hand hygiene, including hand hygiene after contact with contaminated material, use appropriate personal protective equipment during access site care, and must dispose of needles in a sharps container. 2. On 01/06/25 at 3:15 PM, Surveyor #6 observed a PCT (Staff #120) remove a needle from Patient #161’s fistula. When Staff #120 placed the needle in a sharps container, their gloved finger touched the opening of the sharps container. Staff #120 did not remove the glove or perform hand hygiene. Staff #120 used the same gloved hand to hold pressure over the fistula. 3. On 01/06/25 at 3:20 PM, Surveyor #6 observed a PCT (Staff #115) remove a needle from Patient #165’s fistula. When Staff #115 placed the needle in a sharps container, two gloved fingers touched the opening of the sharps container twice. Staff #115 did not remove the glove or perform hand hygiene. Staff #115 used the same gloved hand to hold pressure over the fistula. 4. On 01/06/25 at 5:05 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding staff touching sharps containers during needle removal and not performing hand hygiene and glove replacement before touching a patient. Staff #101 and Staff #102 confirmed that if staff touched the sharps container, they should complete hand hygiene and don new gloves before touching the patient per facility policy. .”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to ensure that staff followed policies and procedures for the safe handling and storage of clean supplies from adjacent contaminated areas. Failure to ensure staff follow policies and procedures for safe handling and storage of supplies places patients at risk of harm from cross-contamination and exposure to infectious agents. Findings included: 1. Document review of the facility policy titled, “Bleach Policy,” last revised 10/23, showed that bleach solutions used for the disinfection of vascular access clamps and hemostats should be placed in designated dirty areas. - Document review of the facility policy titled, “Infection Control for Dialysis Facilities,” last revised 04/23, showed that staff must perform hand hygiene after contact with contaminated or infectious material, after removing gloves, and before touching clean areas or supplies. 2. On 01/06/25 between 3:05 PM and 3:57 PM, Surveyor #1 observed patient care on the treatment floor. The observations showed the following: - On 01/06/25 at 3:05 PM, a Patient Care Technician (PCT) (Staff #120) placed a contaminated hemostat into the dirty bleach container and then added clean disinfecting wipes into the clean bleach solution with the same gloved hand. Staff #120 failed to remove gloves and perform hand hygiene before touching clean supplies. - On 01/06/25 at 3:55 PM, A PCT (Staff #120) placed a contaminated hemostat into the dirty bleach container and then added clean disinfecting wipes into the clean bleach solution with the same gloved hand. 3. On 01/06/25 at 3:57 PM, a Registered Nurse (RN) (Staff #110) placed a contaminated hemostat into the dirty bleach container and then added clean disinfecting wipes into the clean bleach solution with the same gloved hand. 4. On 01/06/25 at 5:05 PM, Surveyor #1 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding the contamination of the clean bleach solutions. Staff #101 and Staff #102 acknowledged the observation. .”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to implement infection control policies and activities consistent with Centers for Disease Control and Prevention (CDC) guidelines by failing to ensure all personnel completed a baseline tuberculosis (TB) risk assessment in 4 of 6 personnel files reviewed (Staff #106, #107, #112, and #120). Failure to implement infection control policies and activities consistent with CDC TB guidelines places patients and staff at risk for exposure to TB. Reference: Centers for Disease Control and Prevention. “Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers and Association and CDC,” (2019). “The 2005 CDC recommendations for baseline testing U.S. health care personnel have been updated and now include: TB Screening with an individual risk assessment and symptom evaluation at baseline, TB testing with an interferon-gamma release assay (IGRA) or a (2 step) TB skin test.” Findings included: 1. Document review of the facility policy titled “Tuberculosis Monitoring and Follow-Up,” last revised 10/24, showed that all staff will complete a baseline TB test, as well as a baseline and annual TB Risk Assessment and Symptom Evaluation Questionnaire. 2. Document review of personnel files showed no TB risk assessment documented for the following: - A Social Worker (Staff #106) hired 07/11/16. - A Registered Dietician (Staff #107) hired 04/16/19. - A Registered Nurse (Staff #112) hired 07/22/24. - A Patient Care Technician (Staff #120) hired 06/12/23. 3. On 01/08/25 at 4:26 PM, Surveyors #1, #3, and #6 interviewed the facility Manager of Clinical Services (Staff #102) regarding staff TB screening. Staff #102 stated that the facility’s parent company provided a staff TB screening form that did not include a TB risk assessment, and confirmed that personnel file review showed no evidence of a TB risk assessment in 4 of 6 files reviewed. 4. This is a repeat citation. DOH previously cited the facility for this tag in the preceding 04/20/23 End Stage Renal Disease Facility Recertification Core Survey. .”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to ensure that staff members followed infection prevention technique standards, policies, and procedures during central venous catheter (CVC)-related care. Failure to ensure that staff members follow infection prevention technique standards, policies, and procedures when working with a patient’s CVC risks infection of the access site, which can result in serious patient harm. Findings included: 1. Document review of the facility policies titled “Central Venous Catheter (CVC) Care,” last revised 10/22, showed that CVC care requires staff to use hand hygiene, appropriate personal protective equipment, moisture-proof barriers under catheter limbs, effective contact time of 15 seconds when cleaning CVC hubs, and aseptic technique while performing CVC related procedures. 2. On 01/07/25 at 11:50 AM, Surveyor #6 observed a Patient Care Technician (PCT) (Staff #116) during a CVC dressing change on Patient #171. Staff #116 failed to secure clothing away from Patient #171’s CVC site. Patient #171’s clothing contacted the clean site during cleanser drying time. Staff #116 placed a clean dressing over the contaminated CVC site. Staff #116 failed to use the effective contact time of 15 seconds when cleaning CVC hubs. 3. On 01/07/25 at 12:00 PM, Surveyor #6 observed a PCT (Staff #118) during a CVC dressing change on Patient #163. Staff #118 cleaned Patient #163’s CVC site and failed to secure clothing away from the clean site. Patient #163’s clothing touched the drying CVC site multiple times. Staff #118 touched the clothing and CVC site without changing gloves, performing hand hygiene, or re-cleaning the CVC site. Staff #118 applied a clean dressing to the contaminated CVC site. Staff #118 failed to use the effective contact time of 15 seconds when cleaning CVC hubs. 4. On 01/07/25 at 4:34 PM, Surveyor #6 observed a PCT (Staff #120) during a CVC dressing change on Patient #135. Staff #120 failed to place a moisture-proof barrier under the CVC catheter limbs. The CVC catheter limbs rested on Patient #135’s skin and clothing during the CVC dressing change. 5. On 01/07/25 at 4:15 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding CVC-related procedures. Staff #101 and Staff #102 stated that hand hygiene, appropriate personal protective equipment, moisture-proof barriers under catheter limbs, an effective contact time of 15 seconds when cleaning CVC hubs, and an aseptic technique are required while performing CVC-related procedures per facility policy. .”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to restrict access to the water purification and storage system to only authorized users responsible for monitoring and maintaining the system. Failure to restrict access to the water purification and storage system only to authorized personnel who monitor and maintain them can lead to unauthorized access, water contamination, and harm to dialysis patients. Findings included: 1. Document review of the facility’s policy titled “Water Treatment Systems Minimum Component Requirements,” last revised 10/21, showed that access to the water treatment system should be restricted to those personnel responsible for monitoring and maintaining the system and supply ordering. 2. On 01/06/25 at 10:20 AM, Surveyors #1, #3, and #6 observed that the water purification and storage system door was unlocked. Surveyor #3 entered the water treatment system room without using a key code. 3. On 01/06/25 at 10:24 AM, Surveyors #1, #3, and #6 interviewed the facility Biomedical Staff (Staff #105) regarding access to the water purification and storage system room. Staff #105 observed and acknowledged the unlocked door, entered the room without using a keycode, and reset the keycode lock. 4. On 01/06/25 at 5:05 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding the unlocked water purification and storage system room. Staff #101 and Staff #102 stated that the room is to remain locked to prevent unauthorized access per facility policy. .”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to appropriately label reusable concentrate containers with sufficient information to differentiate the contents from other concentrate formulations used at the facility. Failure to correctly identify the contents of reusable concentrate containers can expose patients to incorrect concentrates and result in serious patient harm. Findings included: 1. Document review of the facility’s policy titled “Acid Concentrate System, Incoming Acid Concentrate and Use of Acid Concentrate Containers,” last revised 10/24, showed that concentrate container contents must be correctly identified, labeled for a specific acid concentrate, and have a Hazardous Material Identification Guide (HMIG) sticker. 2. On 01/06/26 at 11:32 AM, Surveyors #1, #3, and #6 toured the facility’s water room and storage area. Observations during the tour showed that the facility carried dialysate concentrates of several different potassium and calcium preparations. 3. On 01/07/25 at 11:20 AM, Surveyor #6 observed black ink written directly on a reusable concentrate container stating “2K.” The container was attached to a dialysis machine being prepared for use by a Patient Care Technician (PCT) (Staff #120) for Patient #163. A second reusable concentrate container labeled with black ink stating “3K” was sitting nearby. Staff #120 confirmed the containers were marked “2K” and “3K” with no other identifying labels indicating the contents of other electrolytes such as calcium in the acid concentrations or a HMIG sticker. 4. On 01/07/25 at 4:15 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and Clinical Services Manager (Staff #102) regarding the incomplete labeling of reusable concentrate containers. Staff #101 and Staff #102 confirmed that the observed concentrate containers were not correctly labeled per facility policy. .”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to maintain all equipment in accordance with manufacturer’s recommendations by failing to discard test strips, blood glucose lancets, and medications per the manufacturer’s expiration date. Failure to maintain equipment in accordance with manufacturer’s recommendations, including expiration dates, places patients at risk of harm and injury from the use of expired products. Findings included: 1. Document review of the facility policy titled, “Medication Policy,” last revised 10/23, showed that expired medication and supplies are not to be used. -Document review of the facility policy titled, “Infection Control for Dialysis Facilities,” last revised 04/23, showed that expiration dates must be verified before use. 2. On 01/06/25 at 1:40 PM, Surveyor #1 toured the medication area. The observation showed the following: - 6 vials of vancomycin with an expiration date of 01/01/25. - An open box of lancets with an expiration date of 06/30/24. - A bottle of blood leak test strips with an expiration date of 12/24. 3. At the time of the observation, a Registered Nurse (Staff #110) verified that the identified medication and medical supplies were expired and removed the expired items from the treatment area. .”

“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: 45888 . Based on document review and interview, the facility failed to provide the necessary care and services to manage patients’ dose of dialysis by failing to manage patient blood pressure (BP) and heart rate (HR) per facility protocol in 3 of 6 patient medical records reviewed (Patients #135, #147, and #171) (1), failing to ensure nursing assessments occurred per facility policy in 2 of 6 patient medical records reviewed (Patients #135 and #141) (2), failing to conduct complete assessments prior to discharge in 3 of 6 patient medical records reviewed (Patients #135, #143, and #149) (3), and failing to adhere to patients’ dose of dialysis orders in 1 of 6 patient medical records reviewed (Patient #171) (4). Failure to provide the necessary care and services to manage patients’ dose of dialysis places patients at risk for ineffective treatments and at risk for undetected complications. Findings Included: Item #1 - BP and HR Management 1. Document review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/24, showed that the facility defined intradialytic systolic blood pressure (SBP) greater than 180 millimeters of mercury (mm/Hg) or less than 90 mm/Hg, a diastolic blood pressure (DBP) greater than 100 mm/Hg or less than 50 mm/Hg, and HR greater than 100 beats per minute (BPM) as abnormal findings. Patient Care Technicians (PCTs) must report abnormal BP and HR findings to a licensed nurse. 2. Document review of patient medical records showed no evidence of reporting sustained and/or excessively abnormal BP and HR findings to a licensed nurse in the following: - On 12/18/24, a PCT (Staff #117) failed to document nurse notification of a DBP less than 50 mm/Hg on Patient #147 in 2 of 11 BP measurements (22 mm/Hg and 14 mm/Hg). - On 12/20/24, PCTs (Staff #115 and #120) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #135 in 5 of 9 BP measurements. - On 12/20/24, PCTs (Staff #115 and #120) failed to document nurse notification of a HR greater than 100 BPM on Patient #147 in 6 of 12 HR measurements. - On 12/22/24, PCTs (Staff #115 and #119) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #135 in 6 of 10 BP measurements. - On 12/23/24, a PCT (Staff #120) failed to document nurse notification of a SBP less than 90 mm/Hg and HR greater than 100 BPM on Patient #171 in 4 of 8 BP and HR measurements. - On 12/24/24, PCTs (Staff #115 and #119) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #135 in 6 of 10 BP measurements. - On 12/24/24 a PCT (Staff #119) failed to document nurse notification of a DBP less than 50 mm/Hg and greater than 100 mm/Hg on Patient #147 in 3 of 11 BP measurements (24 mm/Hg, 38 mm/Hg, and 119 mm/Hg). - On 12/31/24, a PCT (Staff #119) failed to document nurse notification of a HR greater than 100 BPM on Patient #171 in 1 of 10 HR measurements (120 BPM). - On 01/01/25, PCTs (Staff #117, #118, and #120) failed to document nurse notification of a DBP greater than 100 mm/Hg on Patient #135 in 6 of 10 BP measurements. - On 01/03/25, PCTs (Staff #103 and #120) failed to document nurse notification of a DBP greater than 100 mm/Hg and HR greater than 100 BPM on Patient #135 in 9 of 9 BP and HR measurements. - On 01/06/25, PCTs (Staff #115 and #120) failed to document nurse notification of a SBP less than 90 mm/Hg, a DBP less than 50 mm/Hg, and a HR greater than 100 BPM on Patient #147 in 5 of 9 BP and HR measurements. 3. On 01/09/25 at 4:36 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding abnormal VS reporting. Staff #101 acknowledged that patient medical record review showed missing documentation of nurse notification of abnormal VS for the above medical record dates. Item #2 - Nursing Assessments 1. Document review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/24, showed that the facility defined intradialytic SBP greater than 180 mm/Hg or less than 90 mm/Hg, and DBP greater than 100 mm/Hg, as abnormal findings. Licensed nurses must assess patients with reported abnormal BP and HR and determine if clinical intervention is necessary. 2. Document review of patient medical records showed no evidence of nurses assessing patients with reported abnormal BP and HR in the following: - On 12/18/24 at 6:07 AM and 6:55 AM, a PCT (Staff #116) documented notification to a Registered Nurse (RN) (Staff #110) of a SBP greater than 180 and a DBP greater than 100 mm/Hg on Patient #141(SBP 201 mm/Hg and 190 mm/Hg, and DBP 112 mm/Hg and 113 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #141. - On 12/22/24 at 12:37 PM and 1:07 PM, a PCT (Staff #115) documented notification to an RN (Staff #110) of a DBP greater than 100 mm/Hg on Patient #135 (110 mm/Hg and 115 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #135. - On 12/22/24 at 5:45 AM and 6:00 AM, a PCT (Staff #116) documented notification to an RN (Staff #110) of a SBP greater than 180 mm/Hg and a DBP greater than 100 mm/Hg on Patient #141 (SBP 192 mm/Hg and 198 mm/Hg, and DBP 169 mm/Hg and 117 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #141. - On 12/24/24 at 6:01 AM and 6:57 AM, a PCT (Staff #116) documented notification to an RN (Staff #110) of a SBP greater than 180 mm/Hg and less than 90 mm/Hg on Patient #141 (SBP 195 mm/Hg and 79 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #141. - On 01/01/25 6:01 AM, 6:26 AM, and 6:55 AM, a PCT (Staff #116) documented notification to an RN (Staff #110) of a SBP greater than 180 mm/Hg and a DBP greater than 100 mm/Hg on Patient #141 (SBP 212 mm/Hg, and DBP 127 mm/Hg, 123 mm/Hg, and 103 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #141. - On 01/06/25 at 12:08 PM, 12:38 PM, 1:08 PM, and 1:38 PM, PCTs (Staff #115 and #120) documented notification to an RN (Staff #110) of a SBP greater than 180 mm/Hg and a DBP greater than 100 mm/Hg on Patient #135 (SBP 226 mm/Hg and 200 mm/Hg, and DBP 165 mm/Hg, 151 mm/Hg, 150 mm/Hg, and 146 mm/Hg). Staff #110 failed to document a subsequent assessment of Patient #135. 3. On 01/09/25 at 4:36 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding nursing assessments of abnormal VS. Staff #101 acknowledged that patient medical record review showed no evidence of nurses assessing patients with reported abnormal VS for the above medical record dates and times. Item #3 - Discharge Monitoring 1. Document review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/24, showed that patients must have a standing BP taken at the end of dialysis treatment if the patient is ambulatory. 2. Document review of patient medical records showed the following: - Facility staff documented that Patient #135 left all dialysis treatments ambulatory between 12/18/24 and 01/07/25. There was no evidence of a post-dialysis standing BP after dialysis on 12/27/24. - Facility staff documented that Patient #143 left all dialysis treatments ambulatory between 12/18/24 and 01/07/25. There was no evidence of a post-dialysis standing BP after dialysis on 12/22/24, 12/24/24, 12/27/24, and 01/03/25. On 11/18/24, 12/2/24, and 12/18/24, RNs (Staff #110 and #111) documented that Patient #143 has a history of falls and hypotension upon standing and scored Patient #143 as a critical fall risk. - Facility staff documented that Patient #149 left all dialysis treatments ambulatory between 12/18/24 and 01/07/25. There was no evidence of a post-dialysis standing BP after dialysis on 12/21/24, 12/23/24, 12/28/24, and 01/04/25. 3. On 01/09/25 at 4:36 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding monitoring for hypotension upon discharge. Staff #101 acknowledged that patient medical record review showed no evidence of standing BP assessed prior to discharge for ambulatory patients for the above medical record dates. Item #4 - Dose of Dialysis Orders 1. Document review of the facility policies titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/24, and “Treatment Initiation Utilizing B Braun Dialog+ Dialysis Delivery Systems with All Single Use Dialyzer Tyes and Streamline Blood Lines,” last revised 10/24, showed that staff must adhere to each patient’s dialysis treatment orders, and that a licensed nurse must verify each patient’s dialysis prescription is correct every dialysis treatment. 2. Document review of patient medical records showed that facility staff set patient ultrafiltration fluid removal outside of prescribed parameters for the following: - Patient #171’s dialysis treatment orders between 12/18/24 and 01/07/25 included an order with a maximum fluid removal for each treatment of 3 Liters (L). - On 12/19/24, an RN (Staff #110) documented verification of Patient #171’s treatment prescription. Patient #171’s treatment included a fluid removal of 3.2 L. Patient #171 experienced hypotension during the treatment. - On 12/28/24, an RN (Staff #123) documented verification of Patient #171’s treatment prescription. Patient #171’s treatment included a fluid removal of 3.5 L. - On 01/04/25, an RN (Staff #110) documented verification of Patient #171’s treatment prescription. Patient #171’s treatment included a fluid removal of 3.5 L. Patient #171 experienced cramping and hypotension during the treatment. 3. On 01/09/25 at 4:36 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding adherence to dose of dialysis orders. Staff #101 acknowledged that patient medical record review showed no evidence of adhering to patient dose of dialysis orders for the above medical record dates. .”

“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: 45888 . Based on document review and interview, the facility failed to include the patient in each patient’s plan of care by failing to document patient review of the plan of care in 3 of 6 patient medical records reviewed (Patients #135, #143, and #149). Failure to include patients in their plan of care places patients at risk for unmet dialysis, health, and safety needs, and for missed opportunities to improve care. Findings included: 1. Document review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” last revised 10/24, showed that each patient’s plan of care will be completed by the interdisciplinary team, including the patient or patient’s representative. 2. Document review of patient medical records showed the following: - On 09/24/24, the facility’s interdisciplinary team met to complete Patient #143’s plan of care. The plan of care stated, “Not reviewed with patient. Patient not present at meeting.” The plan of care signature page contained no date indicating subsequent review with the patient. - On 09/24/24, the facility’s interdisciplinary team met to complete Patient #149’s plan of care. The plan of care stated, “Not reviewed with patient. Patient not present at meeting.” The plan of care signature page contained no date indicating subsequent review with the patient. - On 12/18/24, the facility’s interdisciplinary team met to complete Patient #153’s plan of care. The plan of care stated, “Not reviewed with patient. Patient not present at meeting.” The plan of care signature page contained no date indicating subsequent review with the patient. 3. On 01/09/25 at 4:36 PM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding patients’ plans of care. Staff #101 acknowledged that patient medical record review showed no evidence of patients’ review of their plan of care in 3 of 6 records reviewed. .”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to measure, analyze, and track quality indicators influencing or relating to desired patient outcomes by failing to address mortality contributory factors related to care received at the facility (1) and failing to review data related to patient outcomes, including patient medical records, to identify opportunities for improving care (2). Failure to measure, analyze, and track quality indicators influencing or relating to desired patient outcomes impairs the development of effective action plans to improve patient outcomes. Findings included: Item #1 - Mortality 1. Document review of the facility policy titled “Continuous Quality Improvement Program,” last revised 01/21, showed that the facility must measure, analyze, and track quality indicators including mortality events. 2. Document review of mortality data within the facility’s quality assessment and performance improvement (QAPI) documentation and online dashboard showed no evidence that the facility identified or analyzed the cause of death in 5 of 20 patient deaths between 01/01/24 and 12/31/24. 3. On 01/10/25 at 11:16 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and the facility Manager of Clinical Services (Staff #102) regarding quality indicator measurement, analyzation, and tracking. Staff #101 and #102 acknowledged that the facility did not identify patient cause of death within its QAPI program in 5 of 20 deaths. Item #2 - Medical Records 1. Document review of the facility policy titled “Medical Record Quality Assurance,” last revised 10/24, showed that the facility administrator (FA) must review 10% of all facility patient medical records each month to monitor for staff documentation compliance and that the results of the monthly medical record audits must be presented at least quarterly within the facility’s quality assessment and performance improvement QAPI program. 2. Document review of data within the facility’s QAPI documentation and online dashboard showed no evidence of medical record audit review information or results. 3. On 01/10/25 at 11:16 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) regarding medical record documentation review. Staff #101 stated that a Patient Care Technician (Staff #118) conducted the monthly medical record review, not the FA, and confirmed that medical record audits were not presented or documented within the facility’s QAPI program. . .”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to measure, analyze, and track infection control quality indicators by failing to analyze infection incidences and identify trends (1) and failing to maintain oversight of immunization within its quality assessment and performance improvement (QAPI) program (2). Failure to measure, analyze, and track infection control quality indicators places patients and staff at risk for infection from preventable diseases. Findings included: Item #1 - Infection Trends 1. Document review of the facility policy titled “Continuous Quality Improvement Program,” last revised 01/21, showed that the facility must measure, analyze, and track infection control quality indicators, including infection and vascular access events. 2. Document review of infection data within the facility’s QAPI documentation and online dashboard showed no evidence of the following: - Identification or analyzation of types of infections, infecting organism, culture site, or antibiotic use for each reported infection. - Calculation or analyzation of infection rates differentiated by vascular access including central venous catheters, arteriovenous fistulas, and arteriovenous grafts. 3. On 01/10/25 at 11:16 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and the facility Manager of Clinical Services (Staff #102) regarding infection quality indicator measurement, analyzation, and tracking. Staff #101 and #102 confirmed that the facility did not identify types of infections or differentiate infections by vascular access. Item #2 - Immunization 1. Document review of the facility policies titled “Continuous Quality Improvement Program,” last revised 01/21, and “Teammate Health Monitoring Program,” last revised 04/19, showed that the facility must monitor staff for infectious disease and immunization status, and must track vaccination rates for immunizations such as Hepatitis B and influenza within the facility’s QAPI program. 2. Document review of the facility’s QAPI documentation and online dashboard showed no evidence that the facility tracked staff immunization status within its QAPI program. 3. On 01/10/25 at 11:16 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and the facility Manager of Clinical Services (Staff #102) regarding immunization tracking. Staff #101 and #102 stated that the facility did not track staff immunization status within its QAPI program. .”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 45888 . Based on document review and interview, the facility failed to implement its internal grievance process by failing to document review of grievances, steps taken to resolution, and how patients or patient representatives were informed of the resolution. Failure to implement internal grievance processes places patients at risk for unevaluated and unresolved complaints and grievances. Findings included: 1. Document review of the facility policy titled “Patient Grievance,” last revised 10/24, and undated facility document titled “Grievance Meeting Report,” showed that upon receiving an internal patient grievance, the facility administrator (FA) must meet with the affected patient within 10 days, and if resolution is not reached, the facility’s regional operations manager (ROD) and medical director (MD) must be brought into a grievance conference, with escalation to the divisional vice president (DVP) as necessary. A written resolution or resolution steps addressing the grievance should be provided to the patient within a subsequent 10 days. 2. Document review of the facility’s patient grievance logs and grievance documentation within the facility’s quality assessment and performance improvement program from 01/01/24 to 12/31/24 showed no evidence of the following: - Meeting between the FA and affected patient in 4 of 6 documented grievances. - The need for or conduction of a grievance conference with the ROD and MD in 5 of 6 documented grievances. - The need for or conduction of escalation of grievances to the DVP in 5 of 6 documented grievances. -Grievance resolution and notice of resolution to the affected patient in 5 of 6 documented grievances. 3. On 01/10/25 at 11:16 AM, Surveyors #1, #3, and #6 interviewed the Facility Administrator (Staff #101) and the facility Manager of Clinical Services (Staff #102) regarding grievances processes. Staff #101 and #102 acknowledged that review of grievance documentation showed no evidence of applicable staff discussions with affected patients, grievance resolution, or patient notification of resolution. 4. This is a repeat citation. DOH previously cited the facility for this tag in the preceding 04/20/23 End Stage Renal Disease Facility Recertification Core Survey. .”