Rai - E. 6th St - Beaumont

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36038 Based on interview and record review, the facility failed in one of three patients reviewed (Patient A) that the clinical event occurred during hemodialysis (HD- process of removing waste from the blood with the use of a machine) treatment was assessed by a registered nurse when the patient’s toes became stuck in the dialysis treatment chair. This failure resulted in Patient A sustaining an injury to the right foot, leading to the amputation of the right metatarsal (foot bone). Findings: On June 17, 2024, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of quality care issue. During a review of Patient A’s “History and Physical,” dated March 9, 2024, indicated Patient A had diagnoses which included, end stage renal disease (ESRD- inability of the kidney to make urine and remove waste from the blood). Patient received hemodialysis in the facility three times a week, Monday Wednesday and Friday for three hours and 30 minutes starting on June 29, 2022. During an interview on June 17, 2024, at 1:35 p.m., of Patient A’s family member (FM) , the FM stated Patient A’s Home Health Nurse (HHN) saw the blister on her right foot, when asked where did it came from, Patient A’s stated her right foot got stucked in the dialysis chair, 2 Patient Care Technicians (PCT) yanked it out. The FM stated nobody from the dialysis facility told me about it. During an interview on June 17, 2024, at 3:30 p.m., with Patient Care Technician (PCT) 1, PCT 1 stated on May 15, 2024, Patient A woke up complaining that she could not move her right foot. PCT 1 stated when he checked it, he saw that half of her foot had gotten stuck in the gap of the dialysis chair. PCT 1 stated he asked help from another PCT, and they were able to remove the foot from the chair. PCT 1 further stated he did not report the incident to the registered nurse. PCT stated he should have referred the incident to the registered nurse. During a review of Patient A’s facility document titled, “TREATMENT SHEET FOR THE FACILITY,” dated May 17, 2024, indicated, “...at 12:38 Pt. claims that HHN (Home Health Nurse) continue her foot care routinely at home...PCT reported that on 5/15/24, pt’s (patient’s) right foot was stacked (sic) on side of the chair prior to discharged and they just removed it ...Noted blister on the plantar side of right foot today ...” During an interview on June 17, 2024, at 3:50 p.m., with Registered Nurse (RN) 1, RN 1 stated she was not aware of the incident involving Patient A. RN 1 also stated she was not notified by the PCT about the right foot incident that occurred during the previous treatment. The RN further stated, if she had been notified, the foot would have been assessed for any sign of injury, and the physician and family member would have been notified. During a review of the document titled “ED (Emergency Department ) Physician Record (a critical document summarizing a patient’s Emergency Department visit, including medical history, course of treatment, and follow-up plans),” dated May 25, 24, indicated “ ...Chief Complaint: ...C/O (complaining of ) RT FOOT PAIN RELATED TO WOUND AND INJURY ON 5/13/24 PT (PATIENT ) STATES HER FOOT GOT CAUGHT IN RECLINER DURING DIALYSIS ...AND WAS REFERRED TO ER FOR NON-HEALING WOUND ...” During a review of the document titled “Operative Report, “ dated June 1, 2024, indicated “ ...During hospital admission gangrene has progressed from fifth toe to distal metatarsal involvement to include digits 2, 3 and 4 as well as the dorsal foot ...the digits and forefoot are currently nonsalvageable and transmetatarsal (toe bones) amputation was discussed with the patient ...Technique ...the incision was deepened full thickness to the bone ...a sagittal saw was utilized to resect the metatarsals 1, 2, 3, 4, 5 ...Should the patient not heal due to chronic peripheral arterial disease, she may require a below-knee amputation ...” During a review of the facility policy and procedure titled, “Patient Assessment and monitoring,” dated May 1, 2023, indicated, “ ...Data collection ...Direct patient care staff (PCT) general observation ...complaints reported by the patient ...If the PCT ...note any abnormal findings in the patient’s condition ...reported by the patient ...the registered nurse must assess the patient ...””