032578 Apache Junction 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: 49430 Based on a review of facility policies and procedures, observation on tour, and interview with staff, it was determined that the facility failed to require that; 1. staff monitor and keep the arterial drip chamber 85-95% full, which has the potential for air entering the bloodlines which can lead to a patient’s injury or death, due to an air embolism. 2. medications, supplies, and equipment have not expired. Failure of staff to follow facility policy regarding equipment and supply expiration dates has the potential risk of using expired supplies and equipment for patients which could lower the efficacy of the equipment or supplies and could expose patients to risk of infection. Findings include: 1. A review of facility policy titled, “ Initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer” revealed: “...The arterial chamber is 85-95% full ... monitor pressure changes in the arterial chamber to ensure adequate blood flow ... ensure that arterial chamber is filled to 85-95%....” 2. Facility Policy titled, “ Expiration Dates Sterile Supplies” states, “...Expired supplies will be removed from stock and/or disposed of appropriately....” 1. Observation on a tour of the facility on May 6,, 2024,revealed arterial drip chambers on the dialysis machines at stations #5, #7, # 8, #10, #11 and #12 were filled less than 50% full. 2. Observation on tour conducted on May 06, 2024 revealed the following expired supplies; Male to Male Lure Adapters- 1 expired 02/07/2021, 6 expired 12/18/2022, 17 expired 03/01/2024 Path Tech Cultures- 5 expired 02/15/2024, 299 expired 05/02/2024 Yankauer- 1 expired 01/06/2024 1. Employee #1 confirmed during an interview on May 6, 2024, that the drip chambers should be filled to 85-95 % full. 2. Employee #1 visually verified that the stocked supplies were expired during the tour on May 06, 2024. Employees #1 acknowledged in the exit interview on May 07, 2024 that the supplies were expired and not removed and/or disposed of per facility policy.”

“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: 50568 Based on review of facility policy, medical records, and interview with staff it was determined that the facility failed to ensure: registered nurse notify the patient’s physician/extender when the patient’s weight deviated one (1) or more kilograms from the estimated dry weight (EDW) in 3 of 4 patients. The lack of reporting EDW not achieved and neglecting to assess and respond to hypertension increases the risk for inadequate treatments, fluid overload, dehydration, hospitalizations, stroke and death. Lack of notification to the patient’s nephrologist also interrupts the continuum of patient. Findings include: The facility policy titled “Patient Assessment and Monitoring” states that, “ If the PCT/LPN notes any changes or abnormal findings in the patient’s condition ... the registered nurse must assess the patient ... The RN will notify the patient’s physician/physician’s extender of any abnormal findings ...” 1. Patient #3 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 2. Patient #6 medical records reveal leaving (2) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 3. Patient #4 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. An interview with employee #1 conducted on May 8, 2024 confirmed instances of no documentation of notification to the MD/extender regrading discrepancies regarding patients weights.”

“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: 50568 Based on a review of facility policy, medical records, and staff interviews, the Department determined that the facility failed to require clinical staff to notify the nurse and provide a documented intervention for 4 out of 4 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range per the facility policy, which poses the potential risk of cardiovascular compromise and hospitalization. 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 data that was not reported to a licensed nurse: Patient # 3 April 22, 2024, revealed: 11:21 HR 56 11:41 HR 55 12:01 HR 56 12:20 HR 55 12:42 HR 55 13:03 HR 53 13:19 HR 55 13:40 HR 54 14:00 HR 54 14:20 HR 54 14:40 HR 54 14:53 HR 53 There was no documentation of the RN being made aware of vital signs out of range. April 24, 2024, revealed: 10:41 HR 58 11:00 HR 54 11:21 HR 54 11:40 HR 54 12:00 HR 55 12:23 HR 53 12:42 HR 54 13:01 HR 54 13:21 HR 53 13:40 HR 53 14:02 HR 51 14:21 HR 55 14:26 HR 55 There was no documentation of the RN being made aware of vital signs out of range. April 26, 2024, revealed: 11:00 HR 57 11:20 HR 56 11:41 HR 54 12:02 HR 55 12:21 HR 53 12:40 HR 50 13:21 BP 97/57 HR 56 14:00 BP 97/50 HR 51 14:21 HR 52 14:38 HR 52 There was no documentation of the RN being made aware of vital signs out of range. April 29, 2024 revealed: 10:47 HR 59 11:01 HR 54 11:21 HR 51 11:43 H4 49 12:24 HR 51 12:40 HR 51 13:00 HR 51 13:42 HR 51 14:40 HR 51 14:44 HR 52 There was no documentation of the RN being made aware of vital signs out of range. May 1, 2024, revealed: 11:21 HR:58 11:44 HR 58 12:00 HR 53 12:21 HR 54 12:40 HR 54 13:00 HR 53 13:26 HR 58 14:00 HR 54 14:41 HR 55 14:56 HR 57 There was no documentation of the RN being made aware of vital signs out of range. May 3, 2024, revealed: 11:00 HR 58 11:23 HR 54 11:41 HR 54 12:01 HR 59 12:21 HR 55 13:22 HR 58 13:41 HR 56 14:01 HR 54 14:40 HR 55 14:39 HR 56 There was no documentation of the RN being made aware of vital signs out of range. Patient #4 April 24, 2024, revealed: 10:48 BP 160/107 There was no documentation of the RN being made aware of vital signs out of range. May 3, 2024, revealed: 13:20 BP 176/101 There was no documentation of the RN being made aware of vital signs out of range. Patient #5 April 19, 2024, revealed: 12:20 BP 100/67 13:02 BP 99/64 There was no documentation of the RN being made aware of vital signs out of range. April 26, 2024, revealed: 13:44 BP:99/71 There was no documentation of the RN being made aware of vital signs out of range. April 29, 2024, revealed: 13:01 BP 95/68 There was no documentation of the RN being made aware of vital signs out of range. May 1, 2024, revealed: 12:10 BP 168/142 13:42 BP 99/62 15:04 BP 90/60 There was no documentation of the RN being made aware of vital signs being out of range. Patient #6 April 15, 2024, revealed: 12:40 BP 170/100 There was no documentation of the RN being made aware of vital signs out of range. April 19, 2024, revealed: 12:02 BP 186/89 There was no documentation of the RN being made aware of vital signs out of range. April 22, 2024, revealed: 12:21 BP 155/121 There was no documentation of the RN being made aware of vital signs out of range. April 26, 2024, revealed: 16:02 BP 129/107 There was no documentation of the RN being made aware of vital signs out of range. May 3, 2024, revealed: 09:57 BP 182/97 11:01 BP 137/100 11:20 BP 162/104 11:45 BP 128/113 There was no documentation of the RN being made aware of vital signs out of range. In an interview on May 8, 2024, Employee #1 confirmed that staff did not follow policy and procedures to inform the RN of vital signs being out of range.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 49430 Based on document review, observation, and staff interview, it was determined that the facility failed to ensure staff stored patient medical records in a secure manner. Failure to store patient medical records per facility policy poses the potential risk of unauthorized use. Findings include: The facility document titled “Medical Record Guidelines” requires: “...All storage areas for paper medical records must be: Locked when personnel are not present. At a minimum, medical records must be locked in a file frawer or medical records room....”. Observation on 05/06/2024 revealed an area that stores wheel chairs, a hoyer lift, and a book shelf, an extra patient chair within a common area that is accessable to all patients and staff. On the chair was a box containing multiple patient schedules. A hard written list of patients containing the first and last names, was found on a clipboard on top of the crash cart which was accessable to all staff and patients. Employee #13 confirmed on 05/06/2024 that the medical records were not secured.”