032643 East Tucson (Fmc)

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 50568 Based on document review, observation, and interview, the Department determined that the facility failed to ensure staff locked or otherwise secured medications when not in use. Failure to secure medications when not in use may result in unauthorized access to medication not prescribed to an individual and the potential for tampering or other compromise to the integrity of medications administered. Findings include: The facility policy titled “Medication Preparation and Administration” requires, “ ...Securement ...All medications will be kept in a locked cabinet except when in use ...” A tour of the facility was conducted on 09/23/2024, including both the “in center hemodialysis” and the “home hemodialysis” portions of the facility. During inspection of home hemodialysis rooms, in home training room #1, medications were discovered in an unlocked cabinet located above the rooms’ computer station. The unsecure medications include: opened Heparin 1,000 USP per mL multidose vial, an opened tube of Gentamicin Sulfate Cream 0.1%, an unopened Venofer 50mg Elemental Iron per 2.5mL vial, an unopened Venofer 100mg Elemental Iron per 5 mL vial. Employee #9 confirmed on 09/23/2024 that the medications are discovered in home training room #1 were not locked when not in use, as required by 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 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 2 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: The facility policy titled “Patient Assessment and Monitoring....” was published on May 1, 2023, revealed:” ...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....” A facility document titled “2024 AZ Hemodialysis Standing Orders”, revealed, “ ...Intra HD for a significant drop in systolic BP >40mm/Hg ...Notify nurse ....” “...Treatment Sheets....” revealed: Patient # 10 September 16, 2024, revealed: 12:25 BP 201/129 14:21 BP 177/113 HR 102 16:21 BP 183/105 HR 101 September 21, 2024, revealed: 10:25 BP 147/100 with a drop at 10:25 to 85/92 10:26 BP 155/97 with a drop at 10:41 to 113/67 13:08 HR 52 The facility administrator was unable to provide documentation of the RN being made aware of vital signs out of range and/or a change in vital signs. Patient #12 August 9, 2024, revealed: 15:00 BP 194/82 August 12, 2024 10:23 BP 87/59 12:24 BP 87/56 August 21, 2024, revealed: 11:27 HR 103 12:22 BP 79/59 HR 108 12:32 BP 77/55 August 26, 2024, revealed: 11:23 BP 68/44 HR 107 The facility administrator was unable to provide documentation of the RN being made aware of vital signs out of range. Employee #1 confirmed during an interview on September 25, 2024 that no documentation of RN notification and/or intervention for out-of-range vitals was available as required per facility policy.”

“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 medical records, and interview, it was determined that the facility failed to ensure medical records that were complete and accurate. Clinical notes completed by licensed staff on duty did not contain accurate information as it relates to a patient’s health status. Inaccurate clinical notes can lead to an interruption in the continuum of patient care, assessment, and treatment. Findings include: Patient #10’s chart revealed inconsistences which indicates that medical records and clinical notes written by staff were not complete and/or accurate. Records indicate that the patient was hospitalized on 08/16/2024, but a clinical note written by the Registered Nurse (RN) provides contradicting information. The RN had documented that they had provided the patient both information and education on 08/16/2024, despite the patient being hospitalized at another facility. Notes completed by other staff indicate the patient was not regularly present at the clinic. Review of Patient #10 chart revealed the following documents: “Psychosocial Progress Note” dated 8/27/2024 reads, “ ... LMSW called patient ... Patient did not answer the telephone. LMSW left voicemail ...” “Psychosocial Progress Note” dated 8/21/2024 reads, “ ... patient not present due to being hospitalized ... LMSW will follow up with patient upon her return ...” “Psychosocial Progress Note” dated 8/21/2024 reads, “ ... LAST ENTRY: 8/22/2024 ... LMSW unable to meet with patient due to being re-hospitalized ... LMSW to meet with patient upon her return to the unit ...” “Clinical Notes Report” reads, “ ...Collected Date/Time: 8/16/24 14:38 ... Pt educated on low potassium diet reinforced. Pt states understanding ...” and , “ ...Collected Date/Time: 8/16/24 08:39 ... Pt still admitted at TMC ...” A note by Medical Provider (DO) dated 8/1/2024 indicates the patient was present at the clinic for a face to face interaction with the provider. “Absences and Hospitalization” reads, “ ... Absence dates 8/16/2024 - 8/16/2024 Reason/Discharge Diagnosis: T82.41XA - Breakdown (mechanical) of vascular dialysis catheter, initial encounter ...” Employee#1 confirmed on 08/25/2024 the findings within patient #10’s chart was inconsistent and not accurate.”