032564 Maryvale Dialysis (Fmc)

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 45999 Based on a review of facility policy and procedures, observation, and staff interview, the Department determined that the facility failed to ensure that supplies and medications had not expired, which poses the potential risk of loss of efficacy of medication, decreased sterility of supplies and delayed care if not immediately available. Findings include: Facility policy, “Storage of Supplies” revealed: “...Storage areas must be kept clean and in order at all times...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not contaminated or damaged....” Facility policy, “Expiration Dates of Sterile Supplies” revealed: “...Sterile items will be checked before use to ensure that they have not expired...Appropriately dispose of sterile items that have reached the expiration date...Expiration dates of sterile supplies contained in emergency boxes or code carts should be noted and logged as per facility protocol....” During an observation on June 17, 2024 the following expired items were discovered: 20- Harmony AV Fistula Needle Set, expired 05/11/2023 Employee #1 confirmed during an interview on June 17, 2024 that supplies and medications were not disposed of, and/or stored as required per facility policy.”

“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: 45999 Based on a review of policy and procedure, medical records, and staff interviews, the Department determined the facility failed to: 1. Ensure staff performed safety checks every 30 minutes per facility guidelines for five (5) of six (6) patients (Patients #2, #3, #4, #5, #6). Failure to monitor patients every 30 minutes during dialysis treatment has the potential risk of patient harm due to delay in being able to recognize and provide necessary interventions for issues that patients may experience during dialysis treatment. 2. Based on a review of facility policy, medical records, and staff interviews, the Department determined that the administrator failed to require clinical staff to notify the nurse and provide a documented intervention for (5) out of (6) patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range per the facility policy. Lack of notification and documented intervention poses the potential risk of cardiovascular compromise and hospitalization. 1. Findings include: The “Patient Assessment and Monitoring” facility policy requires: “...During Treatment...Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 [sic] or more often as needed but not to exceed 45 minutes or per state regulations....” Patient #2 June 4, 2024 Patient #2’s treatment sheet dated June 4, 2024, revealed blood pressure/safety checks completed at the following times: 14:08 to 14:47 Time between 14:08 and 14:47 is greater than 30 minutes. Patient #3 May 31, 2024 Patient #3’s treatment sheet dated May 31, 2024, revealed blood pressure/safety checks completed at the following times: 07:07 to 07:48 Time between 07:07 and 07:48 is greater than 30 minutes. Patient #4 Patient #4’s treatment sheet dated June 3, 2024, revealed blood pressure/safety checks completed at the following times: 08:20 to 08:53 Time between 08:20 and 08:53 is greater than 30 minutes. Patient #5 June 4, 2024 Patient #5’s treatment sheet dated June 4, 2024, revealed blood pressure/safety checks completed at the following times: 11:40 to 12:18 13:28 to 14:04 Time between 11:40 and 12:18 is greater than 30 minutes. Time between 13:28 and 14:04 is greater than 30 minutes. June 6, 2024 Patient #5’s treatment sheet dated June 6, 2024, revealed blood pressure/safety checks completed at the following times: 12:22 to 13:22 15:02 to 15:33 Time between 12:22 and 13:22 is greater than 30 minutes. Time between 15:02 and 15:33 is greater than 30 minutes. June 11, 2024 Patient #5’s treatment sheet dated June 11, 2024, revealed blood pressure/safety checks completed at the following times: 06:31 to 07:05 Time between 06:31 and 07:05 is greater than 30 minutes. June 13, 2024 Patient #5’s treatment sheet dated June 13, 2024, revealed blood pressure/safety checks completed at the following times: 12:26 to 13:01 Time between 12:26 and 13:01 is greater than 30 minutes. June 15, 2024 Patient #5’s treatment sheet dated June 15, 2024, revealed blood pressure/safety checks completed at the following times: 13:39 to 14:11 Time between 13:39 and 14:11 is greater than 30 minutes. Patient #6 May 28, 2024 Patient #6’s treatment sheet dated May 28, 2024, revealed blood pressure/safety checks completed at the following times: 10:13 to 10:47 11:44 to 12:27 12:44 to 13:31 Time between 10:13 and 10:47 is greater than 30 minutes. Time between 11:44 and 12:27 is greater than 30 minutes. Time between 12:44 and 13:31 is greater than 30 minutes. May 11, 2024 Patient #6’s treatment sheet dated May 11, 2024, revealed blood pressure/safety checks completed at the following times: 18:04 to 18:45 Time between 18:04 and 18:45 is greater than 30 minutes. Employee #1, confirmed during an interview conducted on June 18, 2024, that blood pressure/safety checks were not performed and/or documented every 30 minutes as required by regulation and facility policy. 2. Findings include: Facility policy titled, “...Patient Assessment and Monitoring....” published December 2022, revealed: “...Monitoring During Treatment...Report to the nurse: Systolic blood pressure greater than 180 mm/Hg, Diastolic blood pressure greater than 100 mm/Hg, Blood Pressure less than or equal to 100 mm/Hg systolic...Heart rates that have dropped below 60 or risen above 100 ...Report to the nurse any significant findings....” “...Treatment Sheets....” revealed the following instances where vital signs were out of range per facility policy: Patient # 1 May 25, 2024 15:05 BP 99/53 No notification or intervention documented for 15:05 BP with systolic reading less than 100mm/Hg. June 4, 2024 14:00 HR 58 14:24 HR 54 14:45 HR 53 15:29 HR 55 15:49 HR 54 16:04 HR 57 No notification or intervention documented for 14:00 HR less than 60 bpm. No notification or intervention documented for 14:24 HR less than 60 bpm. No notification or intervention documented for 14:45 HR less than 60 bpm. No notification or intervention documented for 15:29 HR less than 60 bpm. No notification or intervention documented for 15:49 HR less than 60 bpm. No notification or intervention documented for 16:04 HR less than 60 bpm. June 6, 2024, revealed: 13:22 HR 53 14:23 HR 54 14:21 HR 52 14:38 HR 52 No notification or intervention documented for 13:22 HR less than 60 bpm. No notification or intervention documented for 14:23 HR less than 60 bpm. No notification or intervention documented for 14:21 HR less than 60 bpm. No notification or intervention documented for 14:38 HR less than 60 bpm. Patient #3 June 3, 2024 07:42 BP 178/101 No notification or intervention documented for 07:42 BP with diastolic reading greater than 100mm/Hg. Patient #4 June 14, 2024 06:27 HR 59 06:40 HR 57 09:24 BP 189/74 No notification or intervention documented for 06:27 HR less than 60 bpm. No notification or intervention documented for 06:40 HR less than 60 bpm. No notification or intervention documented for 09:24 BP with systolic reading greater than 180mm/Hg. April 26, 2024 13:44 BP:99/71 No notification or intervention documented for 13:44 BP reading with systolic reading less than 100mm/Hg. June 17, 2024 06:23 HR 59 No notification or intervention documented for 06:23 HR less than 60 bpm. Patient #5 June 4, 2024 11:27 BP 144/104 14:26 BP 141/110 14:42 BP 140/102 15:22 BP 146/101 No notification or intervention documented for 11:27 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 14:26 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 14:42 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 15:22 BP with diastolic reading greater than 100mm/Hg. June 6, 2024 11:23 BP 162/116 11:41 BP 148/102 12:03 BP 154/107 12:22 BP 166/104 14:22 BP 136/111 14:45 BP 138/103 No notification or intervention documented for 11:23 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 11:41 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 12:03 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 12:22 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 14:22 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 14:45 BP with diastolic reading greater than 100mm/Hg. June 8, 2024 11:37 BP 155/108 12:00 BP 160/111 12:40 BP 159/111 13:01 BP 169/101 13:40 BP 171/106 15:59 HR 56 No notification or intervention documented for 11:37 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 12:00 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 12:40 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 13:01 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 13:40 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 15:59 HR less than 60 bpm. June 11, 2024 06:05 BP 151/107 06:31 BP 154/111 07:05 BP 156/107 07:44 BP 155/108 09:21 BP 145/105 09:41 BP 149/102 No notification or intervention documented for 06:05 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 06:31 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 07:05 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 07:44 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 09:21 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 09:41 BP with diastolic reading greater than 100mm/Hg. June 13, 2024 15:41 HR 52 No notification or intervention documented for 15:41 HR less than 60 bpm. June 15, 2024 12:46 BP 158/108 13:20 HR 53 13:39 HR 50 No notification or intervention documented for 12:46 BP with diastolic reading greater than 100mm/Hg. No notification or intervention documented for 13:20 HR less than 60 bpm. No notification or intervention documented for 13:39 HR less than 60 bpm. Patient #6 May 25, 2024 10:02 HR 56 10:45 HR 54 11:13 HR 53 11:23 HR 55 11:45 HR 57 No notification or intervention documented for 10:02 HR less than 60 bpm. No notification or intervention documented for 10:45 HR less than 60 bpm. No notification or intervention documented for 11:13 HR less than 60 bpm. No notification or intervention documented for 11:23 HR less than 60 bpm. No notification or intervention documented for 11:45 HR less than 60 bpm. May 28, 2024 11:02 HR 59 11:22 HR 59 No notification or intervention documented for 11:02 HR less than 60 bpm. No notification or intervention documented for 11:22 HR less than 60 bpm. June 16, 2024 19:23 BP 185/82 20:00 BP 189/91 No notification or intervention documented for 19:23 BP with systolic reading greater than 180mm/Hg. No notification or intervention documented for 20:00 BP with systolic reading greater than 180mm/Hg. During an interview on June 18, 2024, Employee #1 confirmed that no ntification or intervention was documented for out of range vitals as required in facility policy.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 50568 Based on review of policies and procedures, medical records and interview with staff, the Department determined the facility failed to ensure that the Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was updated in a timely fashion to reflect changes in a patient’s health status for two (2) patients. The failure to identify, assess and update the CIPA can pose a serious risk to the patient, and may have the potential to lead to an increase in hospitalization, readmissions, and death. Findings include: 1. Patient #2 was designated as unstable following an interdisciplinary Plan of Care meeting dated 02/29/2024 with subsequent Plan of Care meetings held on 03/29/2024 and 04/30/2024. In the Plan of Care meeting dated 02/29/2024, the following electronic dated signatures were noted: “ ... Approved by Physician ... 04/22/2024 16:52 Jamal A.Atalla .... Approved by RN 02/29/2024 07:58 Allison W. Pulchan, RN ... Approved by SW 02/29/2024 10:24 Marianne M Zeun, SW ... Approved by RD 03/19/2024 16:13 Pamela J.Doherty, RD ...” The Plan of Care meeting was signed by the Physician 53 days after the meeting occured, which does not demonstrate that the Plan of Care was reviewed and updated according to the needs of the patient at least every 30 days for a patient whose medical condition is not stable. 2. Patient #3 was designated as unstable following an interdisciplinary Plan of Care meeting dated 11/30/2023. The next Plan of Care, provided for this patient was dated 05/28/2024 and designated the patient as stable. The documented Plan of Care meeting dated 05/28/2024 occured 180 days after designating patient #3 as unstable, which does not demonstrate that the Plan of Care was reviewed and updated according to the needs of the patient at least every 30 days for a patient whose medical condition is not stable. During an interview with Employee #1 on June 18, 2024, Employee #1 confirmed the dates of the Plan of Care meetings and that no documentation of unstable Plan of Care meetings every 30 days as required by facility policy was available.”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 50568 Based on review of facility documentation, staff interview and Network staff interviews, it was determined that the dialysis facility’s Governing Body did not require that the Medical Director adhere to requirements for lost to follow up, by failing to participate with the local ESRD Network in providing Patient #7 with a timely notice of lost to follow up. Findings include: Facility policy titled,” Routine and Involuntary Patient Discharge Procedure”, states that, “ ... Documentation ... In the cases of non-immediate involuntary transfer or discharge, there shall be evidence in the patient’s medical record of ... Contact with the local ESRD Network and State survey agency to include the date and time notice and to whom notification was made ...” Review of Patient #13’s file contained a document titled “DISCHARGE CHECKLIST” which was dated 04/19/2024. Reason listed on the Discharge Checklist was “lost to follow up”. Social Worker, Registered Nurse and Registered Dietitian notes dated 05/20/2024 support the Lost to Follow-up discharge designation. Signatures on the “DISCHARGE SUMMARY” include a Registered Nurse, dated 05/23/2024, no date is provided for the signature of the attending physician. During an interview conducted on June 18 2024, Employee #1 confirmed that Patient #13 was designated as Lost to Follow-up Discharge. State Agency’s electronic correspondence with Employee #17 (ESRD Network Staff) on June 17, 2024, revealed the facility did not contact the Network at any time to inform them of Patient #13 Lost to Follow-up discharge. During an interview conducted on June 18, 2024, Employee #1 confirmed that no documentation of Network notification was provided, as required by facility policy.”