032614 Douglas Dialysis Center (Dci)

“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 a review of facility policy, medical records, and staff interviews, it was determined that the facility administrator failed to ensure that staff followed the attending physicians prescribed hemodialysis (HD) order for blood flow rate (BFR) and or dialysis flow rate (DFR) setting for each individual patient. Failure to follow physician orders and not reporting abnormalities poses the potential risk of inadequate dialysis, decreased clearances and hospitalizations. Findings include: Facility Policy titled, “ Staff Reporting Parameters” that states, “ ...During Treatment: Vascular Access: Unable to maintain ordered BFR ... Staff Reports: Yes...”. The document fails to provide guidelines for staff regarding patients being unable to maintain, or changes to, the prescribed dialysis flow rate (DFR). Patient #11 Treatment flow sheets: 7/5/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610) with no documentation from the RN on duty. 7/10/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610) with no documentation from the RN on duty. 7/12/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610) with no documentation from the RN on duty. Patient #10 Treatment flowsheet: 6/28/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610) with no documentation from the RN on duty. 7/3/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 590, 610) with no documentation from the RN on duty. 7/5/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610, 760) with no documentation from the RN on duty. 7/5/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 610) with no documentation from the RN on duty. Patient #12 Treatment flowsheet: 3/22/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 590, 580) with no documentation from the RN on duty. 3/25/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 590) with no documentation from the RN on duty. The Blood flow rate was altered from the prescribed rate (prescribed at 400, with settings alternating to 300) with no documentation from the RN on duty. 3/27/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 590, 580) with no documentation from the RN on duty. 3/29/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 590, 580) with no documentation from the RN on duty. 4/1/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 570, 590) with no documentation from the RN on duty. 4/3/2024 The Dialysis flow rate was altered from the prescribed rate (prescribed at 600, with settings alternating to 580, 590) with no documentation from the RN on duty. The Blood flow rate was altered from the prescribed rate (prescribed at 400, with settings alternating to 300, 350,) with no documentation from the RN on duty. During an interview conducted on July 16,2024, Employee #1 confirmed that the prescribed rates for Blood and/or Dialysis flow rate for patient treatments was not followed per physician orders.”

“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 a review of facility policy, medical records, and staff interviews, it was determined that facility failed to ensure: 1. Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was updated to reflect changes in a patient’s health status. 2. CIPA was conducted in every thirty days for patients designated with a health status of unstable. The failure to identify, assess and update the CIPA can pose a serious risk to the patient, and may lead to an increase in hospitalization, readmissions, and death. Findings include: Facility policy titled, “ Care Plan Process” that states, “ ... Should the patient become Unstable, then a monthly Unstable Care Plan is done until the patient is again determinded to be stable. A stable care plan must be done ...” 1. Review of Patient #9 Chart revealed: An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 02/28/24 designating the patient status as stable. In a document titled “DCI List of Hospitalizations” dated 07/15/2024 reads for Patient #9, “ ...04/16/24 - 04/28/24 Hospital ...Admitted to Inpatient Care ...” and “ ...04/28/24 - 05/28/24 Hospital ...Admitted to Inpatient Care ... Cardiac, BP, PVD, Cerebrovascular ...” and “ ...05/30 - present Hospital ...Admitted to Inpatient Care.. Cardiac, BP, PVD, Cerebrovascular, chest pain ...” In a document titled, “ Hospitalization Nursing Note” dated 05/03/24 reads, “ ...This nurse has been able to speak with patient over the phone and patient remains hospitalized at TMC. Patient reports that she may be transferred to a rehabilitation due to leg weakness. Patient to keep staff updated ...” In a document titled, “General Nursing Notes” dated 06/21/24 reads, “ Anemia Hgb: 10.8 on 04/10/2024 ... PATIENT IS CURRENTLY IN THE HOSPITAL AND HAS BEEN UNABLE TO PREFORM HER LABS AT THE CLINIC ...” In a document titled, “Patient Education Nursing Notes” dated 06/21/24 reads, “..Subject: monthly teaching ...Progress note: Monthly education provided on need for having an evacuation plan established in their homes, extra water and a supply of stationary food ...Teaching provided to each patient regarding establishing a home safety plan an fire drill ...” In a document titled, “Hospitalization” dated 07/03/24 and appears to be authored by a social worker reads, “ ...MSW contacted patient via phone and she shared she is in an acute facility ... does not have a projected release date. The patient has been in the hospital or rehab since mid -April ...” An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 02/28/24 designating the patient status as stable. No additional documents or CIPA were provided to address the change in patient #9’s health as it relates to an unstable health status. 2. Review of Patient #12 Chart revealed: In a document titled “DCI List of Hospitalizations” dated 07/15/2024 reads for patient #12, “ ... 01/28/24 - 02/05/24 Hospital ...Admitted to Inpatient Care ...” and “ ...04/03/24 - 04/12/24 Hospital ...Admitted to Inpatient Care ...Outcome Death ...” Review of treatment flow sheets revealed the patient obtained treatment on dates including: 03/22/24, 03/25/24, 03/27/24, 03/29/24, 04/01/24, 04/03/24 An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 01/23/24 designating the patient health status as unstable. The next Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was dated 02/28/2024, occurring 36 days from the previous plan of care meeting, and designated the patient health status as unstable. In an interview conducted on July 15, 2024, Employee #1 confirmed that Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) were not being preformed in a timely manner, and patient health statuses were not being addressed.”

“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: 50568 Based on review of review of facility documents, medical records, and interview, it was determined that the facility failed to ensure medical records that were completed and accurate for patients and records retained reflect the patient’s condition. Monthly progress notes completed by the licensed staff, including social workers and registered nurses, were not conducted in a timely manner that reflects patient’s condition. Failure to maintain patient records may lead to an interruption in the continuum of patient care, assessment, and treatment. Findings include: During the entrance conference conducted on July 15, 2024, three months of recent provider notes were request by Employee #1 for the following patients; Patient #9, Patient #10, Patient #11, Patient #12 and Patient #13. An additional request for documents on July 16, 2024 from employee #1, however Employee #1 could not produce the following notes: Patient #9 registered nurse notes for 5/2024, 04/2024 Patient #10 registered nurse notes for 5/2024 Patient #12 registered nurse notes for 1/2024 In an interview conducted on July 17, 2024, Employee #3 confirmed that the facility did have a template that encompasses a comprehensive view of the patient’s health that is available for registered nurses. This template was noted to be in use for other patient monthly registered nurse notes. Patient #9 social worker notes for 3/2024 and 4/2024 Patient #10 social worker notes for 4/2024, 5/2024, 6/2024 Patient #12 social worker notes for 1/2024, 2/2024, 3/2024 Patient #13 social worker notes for 4/2024, 5/2024, 6/2024 During the survey on July 16,2024, Employee #1 produced general notes for Patient #9, Patient #13. However the notes provided did not reflect a monthly note scribed by the Social worker that would reflect a comprehensive view of the patient’s health. In an interview conducted on July 17, 2024, Employee #3 confirmed that the facility did have a template that encompasses a comprehensive view of the patient’s health that is available for social workers. This template was noted to be in use for other patient monthly social worker notes. In an interview conducted on July 17, 2024, Employee #1 confirmed that the Employee #14 had not been completing monthly progress notes. Employee #1 confirmed that this deficiency had been noted within the facility’s Quality Assurance and Performance Improvement (QAPI) program.”