Shc San Jose LLC

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 38573 Based on interview and record review, the facility failed to ensure staff followed standards of care to ensure patient safety for one of three patients (Patient 1) receiving hemodialysis (medical procedure of removing waste products and excess fluid from a person’s blood through an artificial kidney) treatment. Patient 1’s lines was not clamped and resulted in blood loss. A Certified Clinical Hemodialysis Technician (CCHT) cleaned up the blood but did not notify a nurse or provider about Patient 1’s blood loss. The failure of not communicating Patient 1’s blood loss had the potential of not having clear knowledge of the incident and not developing an appropriate corrective action plan. Findings: Review of Patient 1’s record indicated he had arteriovenous (AV) fistula (a surgical connection between an artery and a vein to access blood so it can be filtered through a dialysis machine) on his left upper arm. Review of Patient 1’s Hemodialysis Flowsheet Treatment Log Detail, (known as treatment record), dated 12/04/2024, indicated the patient started dialysis at 2:26 p.m. The treatment record nursing notes dated 12/04/24 at 3:47 p.m. indicated, “Per physician’s order, placed on O2 [oxygen] via nasal cannula” at 2 liters per minute. There was no documentation about blood loss or blood leaking in the nursing notes. The treatment record indicated his dialysis treatment ended on 12/4/24 at 6:46 p.m. The Post-Dialysis Comments indicated, “After tx [treatment] patient reported to me about a blood loss incident that happened 30 mins into start of tx at 2:45 p.m. today. I can’t say much about this since I have no idea about the incident at all until now.” Review of Patient 1’s Incident Report Summary, dated 12/4/24 indicated, “I checked on pt [patient] at 2 hrs [hours]into his tx [treatment] at around 16:25 [4:25 p.m.]. I noticed that pt had O2 on and pt told me that he had blood loss and feeling SOB [shortness of breath]. He showed me the picture that he took. It seemed mod amt of blood loss at the station floor ... He stated that luckily, he was awake to feel SOB and call [CCHT B] ... I was not informed about this incident from [CCHT B]. I found out from the pt ... [CCHT B] stated that the heparin line was not clamp and the cap came off for some reason ... He also stated that it was small amt. [amount] of blood, and he cleaned it up. Notified CM [Center Manager] at 19:00 [7 p.m.].” During an interview on 12/9/24 at 11:56 a.m., with Certified Clinical Hemodialysis Technician B (CCHT B), he acknowledged that he was the CCHT assigned to Patient 1 on 12/4/24 when Patient 1 had blood loss. He stated that Patient 1 called him and pointed to the blood leaking from his dialysis line and onto the floor. CCHT B further stated that he cleaned up the blood and did not notify Registered Nurse A (RN A) about Patient 1’s blood loss. During a concurrent interview and record review on 12/9/24 at 12:06 p.m., with RN A, she reviewed Patient 1’s incident report summary and she stated that on 12/4/24 at around 4:25 p.m., she checked Patient 1 at two hours into his treatment and she noticed that Patient 1 had O2 on. Patient 1 told RN A that he was having shortness of breath and called CCHT assigned to him. RN A further stated that CCHT B did not notify her about the incident and Patient 1 showed the picture that he took of the blood on the floor. During a concurrent interview and record review on 12/9/24 at 12:10 p.m., with RN A of Patient 1’s Hemodialysis Flowsheet Treatment Log, RN stated she had a late entry note dated 12/5/24 at 11:16 a.m., for 12/4/24 at 4:25 p.m. The note indicated that RN A noticed Patient 1 had O2 on and Patient 1 reported he had lost blood 30 minutes into treatment and was having shortness of breath. RN A further stated that she notified the physician (MD) on 12/5/24 at 11 a.m., regarding the above incident and the MD told RN A that Patient 1 was at VMC for abdominal pain. When RN A asked the CCHT B about the incident, the CCHT stated that the heparin line was not clamp and the cap came off for some reason. During a concurrent interview and record review on 12/9/24 at 4:46 p.m., with RN C, RN C stated that on 12/4/24 at 6:01 p.m., the CCHT D told her that Patient 1 wants to talk to her and Patient 1 showed RN C the two pictures of the blood. She stated approximately 200 ml to 300 ml of blood was leaking from the site and onto the floor. She stated she was freaking out by looking blood in the pictures. She further stated that she called RN A about the blood loss and told RN A to notify the Center Manager (CM) and the Physician. Review of the facility’s policy, “Blood Loss,” revised 7/2023, indicated for incident reporting purposes, blood loss is defined as equal or greater than 100 mL. The policy also indicated, “Procedure 7. Inform charge nurse and physician /advanced practice provider (APP) immediately. Follow physician orders ... 8. Closely monitor patient; do not leave patient unattended. 9. Document events on the flow sheet. Complete an occurrence an occurrence/incident report for follow up and evaluation by QAPI team /Safety Officer.””