Davita Lakewood Crossing Dialysis

“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: 48269 Based on interviews and document review, the facility failed to ensure staff monitored and reported changes in patients’ blood pressure (BP), heart rate, and overall condition and documented communication to nursing staff and providers before, during, and after dialysis (the process of filtering a patient’s blood using a machine and filter) treatment based on facility policy. This failure was observed in two of six medical records reviewed (Patient #1 and Patient #5). Findings include: Facility policy: The Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy read, its purpose is to obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). For pre-treatment data collection/assessment, any abnormal findings or findings outside of any patient-specific physician-ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The assessment is a nursing responsibility. The nurse will assess the patient’s pre-treatment as warranted by the patient ’ s condition. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. For intradialytic (during dialysis) data collection/assessment, the licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one hour of dialysis treatment initiation or sooner as required by state law. Abnormal findings or findings outside of any patient-specific physician-ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. All findings, interventions, and patient response will be documented in the patient ’ s medical record. For post-treatment data collection/assessment, the PCT or licensed nurse will obtain and document basic data on each patient post-dialysis and compare to pre-dialysis findings. If an abnormal finding(s) or concern is identified post-treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ’ s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient ’ s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report any changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Abnormal findings include: Pre-dialysis blood pressure, systolic (the first BP number which measures the pressure in arteries when the heart beats) greater than 180 mm/Hg or less than 90 mm/Hg, and diastolic (the second BP number which measures the pressure in the arteries when the heart rests between beats) greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Intradialytic blood pressure, systolic greater than 180 mm/Hg or less than 90 mm/Hg, and diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. Post treatment blood pressure, if the patient can stand, standing systolic blood pressure greater than 140 mm/Hg or less than 90 mm/Hg, and standing diastolic blood pressure greater than 90 mm/Hg or less than 50 mm/Hg. If the patient is not able to stand, document reason and sitting blood pressure. Sitting blood pressure for patient’s that cannot stand, systolic blood pressure greater than 140 mm/Hg or less than 90 mm/Hg, and diastolic blood pressure greater than 90 mm/Hg or less than 50 mm Hg. Heart or pulse rate pre/intra/post, less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat. 1. The facility failed to ensure patient care technicians (PCTs) and registered nurses (RNs) monitored and reported changes in patients’ status and documented communication to nursing staff and medical providers before, during, and after intradialytic treatment based on facility policy. A. Medical Record Review i. A review of Patient #1’s medical record revealed a lack of monitoring and assessment by care staff before, during, and after dialysis treatment, including documentation that the provider was notified of abnormal findings. a. The treatment record for Patient #1 on 3/25/24 revealed the patient’s pre-dialysis sitting blood pressure (BP) was 194/114. Patient #1’s treatment was initiated at 6:43 a.m. At 6:59 a.m. the record read, BP 180/103 and the PCT documented diastolic the BP was high and the RN was notified. Patient #1’s BP continued to read high throughout the treatment with no documented interventions. At 10:38 a.m., the final BP reading was 185/107 with a PCT note that read, treatment terminated. The final discharge note read, routine discharge. A review of the medical record did not reveal evidence the physician was notified of the BP readings which exceeded facility parameters. This medical record review was in contrast to the Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy which read, the provider should have been notified of any concerns that would preclude the initiation of dialysis such as a pre-dialysis systolic BP greater than 180 mm/Hg and a diastolic BP greater than or equal to 100 mm/Hg. Also, according to facility policy, abnormal intra-dialytic BP such as a systolic BP greater than 180 mm/Hg and a diastolic BP greater than or equal to 100 mm/Hg should have been reported to the RN immediately. Further, the RN should have used their clinical judgment to determine if any clinical interventions were needed. The RN should have notified the provider of abnormally high BP readings. Additionally, for an abnormal post-treatment BP such as a standing systolic BP greater than 140 or a diastolic BP greater than 90, the RN should have used their clinical judgment to determine if any interventions were needed and should have notified the provider prior to discharge of the patient from the facility. ii. A review of Patient #5’s medical record revealed a lack of monitoring and assessment by care staff during and after dialysis treatment, including documentation that the provider was notified of changes in condition. a. The treatment record for Patient #5 on 4/1/24 revealed the patient’s treatment was initiated at 12:36 p.m. with a BP reading of 138/106. At 12:58 p.m. the record revealed Patient #5’s BP was 159/110. At 2:28 p.m. the patient’s BP was 164/115. At 4:36 p.m., Patient #5’s BP was 144/101 and the treatment was terminated. A review of the medical record did not reveal evidence the RN was notified of the BP readings which exceeded facility parameters. Further, there was no evidence the provider was notified of elevated diastolic BP readings, which exceeded facility parameters. This medical record review was in contrast to the Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment policy which read, abnormal intra-dialytic BP such as a diastolic BP greater than or equal to 100 mm/Hg should have been reported to the RN immediately. Further, the RN should have used their clinical judgment to determine if any clinical interventions were needed. The RN should have notified the provider of abnormally high BP readings. Additionally, for an abnormal post-treatment BP such as a standing systolic BP greater than 140 or a diastolic BP greater than 90, the RN should have used their clinical judgment to determine if any interventions were needed and should have notified the provider prior to discharge of the patient from the facility. B. Interviews i. On 4/10/24 at 8:37 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated they would notify the RN if the patient’s systolic BP was above 180 or the diastolic BP was above 100. PCT #1 said they would notify the RN and document any interventions they were directed to complete. PCT #1 said it was important to notify the RN if the BP was too high because it would be dangerous to the patient. They said the patient could get a severe headache, seizure, or a stroke if the BP was too high. ii. On 4/10/24 at 9:02 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated PCTs would notify the RN if there was an increase or a drop in BP by 20 points. They said the PCTs would document their observations and that the RN had been notified. RN #2 stated the RN would do any follow-up patient assessment, intervention, and documentation needed. Also, RN #2 said they would notify the provider for a sustained systolic BP of 200 or above. They said they would repeat the BP and observe the patient for a while before calling because the provider preferred that. RN #2 said they could give a PRN (use as needed) medication to lower the patient’s BP if it was 190 or above. RN #2 said it was important for PCTs to notify the RN of abnormally high BP for patient safety. iii. On 4/10/24 at 11:01 a.m., an interview was conducted with facility administrator (FA) #3. FA #3 stated if the patient’s systolic BP was above 180 or diastolic BP was above 100, the PCTs would be expected to notify the RN. They said the RN’s responsibility would be to assess the patient and notify the provider. FA #3 stated it was important for the PCT to let the RN know about abnormal findings such as an elevated BP so the RN could take action and prevent a bad patient outcome. They said the RN could intervene, give medications to prevent a stroke, and monitor the patient closely. Further, FA #3 stated it was important for the RN to notify the provider for a BP greater than 215 to get orders to treat the patient. They said the provider had taught the care staff to call when the systolic BP was greater than 215. These interviews were in contrast to the review of medical records for Patient #1 and Patient #5, which revealed multiple instances of abnormal blood pressures without the RN or provider being notified. iv. On 4/10/24 at 3:13 p.m., an interview was conducted with medical director (MD) #4. MD #4 stated the RNs had a PRN medication order they could give to a patient who had high blood pressure. In reference to Patient #1 and Patient #5, MD #4 stated the provider orders for BP medication did not indicate a parameter so the RN would know when they could give the medication. They stated this was something that should be corrected. Also, MD #4 said RNs should notify the provider for a systolic blood pressure above 180 and a diastolic blood pressure over 110. They said this was important because there could be risks to the patient of an adverse event like a stroke or a cardiac issue. They said even if the patient were to have chronically elevated and difficult-to-control blood pressures, these patients were still at risk of stroke and cardiac events. Further, MD #4 stated the facility needed improvement with notifying the provider of high blood pressures and documenting parameters for administering BP medications.”