Usrc Seaford

“CFC-PERSONNEL QUALIFICATIONS CFR(s): 494.140 This Condition is not met as evidenced by: 46255 Based on review of facility policies, facility documents, personnel records, staff interview, and review of American Heart Association (AHA) Standards of Practice 2020, the facility failed to ensure staff members have current CPR BLS certifications and failed to ensure that CPR was performed per AHA guidelines (V681). This failure resulted in an Immediate Jeopardy, posing a likelihood of serious harm, serious impairment, or death to patients. Immediate Jeopardy (IJ) was identified on December 4, 2023, at 2:38 PM. Immediate interventions implemented by the facility included removing staff with expired CPR certification from providing direct care to dialysis patients. One registered nurse and two technicians, who had current certifications were utilized to continue dialysis care for patients present in the facility. All staff members with expired CPR began online education, and facility educator was scheduled to complete the hands-on education for CPR certification for those staff members. The IJ was removed on December 7, 2023, at 11:25 AM after verification from the State Survey Agency, that the facility had implemented immediate corrective actions.”

“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: 46255 Based on review of medical records, facility policies, facility documents, and staff interview, it was determined that the facility failed to appropriately monitor patient intradialytic blood pressure and failed to respond to patient adverse symptoms consistent with facility policy in one of one medical record reviewed (Patient #1). Findings include: A. Facility policy titled “Intradialytic Monitoring of Patient” dated 9/2020 stated, “...The patient will receive a safe, effective and comfortable treatment...Notify patient’s physician of any significant change or problem...”. B. Facility policy titled “Hypotension” (low blood pressure, generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic). What’s considered low blood pressure for one person might be okay for someone else) dated 01/2020 stated, “...Determine that the patient is hypotensive by presence of one or more of the following: Gradual or precipitous decrease in blood pressure to the range(s) identified...Nausea...Decreased responsiveness...Place patient in Trendelenburg position (where the individual lies flat on their back, with their feet raised higher than their head) to facilitate blood flow to the vital organs...Decrease UF rate [Ultrafiltration rate - the speed at which fluid is removed during dialysis] to 300 ml/hr to limit continued fluid removal...Monitor vital signs every 5 minutes until stabilized...”. C. National Kidney Foundation KDOQI (Kidney Disease Outcomes Quality Initiative) Guidelines, dated 2005, stated, “...Intradialytic hypotension (IDH) is defined as a decrease in systolic blood pressure by >20 mm Hg or a decrease in MAP by 10 mm Hg associated with symptoms that include: abdominal discomfort; yawning; sighing; nausea; vomiting; muscle cramps; restlessness; dizziness or fainting; and anxiety. It impairs the patient’s well-being, can induce cardiac arrhythmias [irregular heart rhythm], predisposes to coronary [heart] and/or cerebral [brain] ischemic events...” D. Review of Patient #1’s medical record revealed: 1. Hemodialysis Flowsheet from 11/28/23 indicated the dialysis session started at 12:49 PM with a duration of 195 minutes, or 3 hours and 15 minutes. Pre-dialysis vital signs while sitting documented as blood pressure (BP) of 158/104 and heart rate (HR) of 71. At 1:07 PM, the patient’s blood pressure was 156/103 and heart rate 74. Patient was reclined in dialysis chair with feet up. At 2:04 PM, blood pressure remained elevated at 147/107. The patient was resting with eyes closed and regular breathing pattern. At 2:13 PM, the patient reported nausea and was provided with medication, Zofran, to improve nausea symptoms. At 2:39 PM, the patient’s blood pressure was obtained and remained elevated at 196/129. At 3:05 PM, with vital sign check, the patient’s blood pressure became extremely elevated at 246/143. The patient was medicated with Clonidine, to lower blood pressure. At 3:36 PM, the patient was resting with eyes closed and displayed a regular breathing pattern. On vital signs check (31 minutes after medicated for high blood pressure), the blood pressure decreased to 126/98 (systolic pressure decrease of 120 mm Hg, diastolic pressure decrease of 45 mm Hg), and heart rate was now 94. The speed of UF rate was set to 720 ml/hr. 2. Post-dialysis comments stated, at 3:39 PM, the patient was unresponsive with a blood pressure of 117/69 and an intermittently irregular heart rate of 78. The nurse documented the patient’s blood was returned to the patient’s body and extra saline solution was given to support blood pressure. The documentation did not include what speed the UF rate was set at. An automated external defibrillator (AED) was applied, but no shock to the patient was advised. An emergency response was requested via 9-1-1. E. Statement provided by facility via email on 12/1/23 at 3:47 PM from Employee #4, Facility Administrator stated, “ ... [Patient #1] showed to clinic on [patient’s] normal dialysis day. [Patient] was brought back and treatment started at 1240pm. Per staff, [patient] was not ...normal self ...was quiet and not playing on ...phone as usual. During treatment ...BP was elevated 150s/103, which was in range of [patient’s] norm. at [sic] 1413 patient requested Zofran for nausea. [Patient #1] continued to rest with ...eyes closed. At 1505, [Patient #1’s] blood pressure increased, RN [Registered Nurse] informed [Patient #1] that [his/her] blood pressure was even higher and offered a clonidine. [Patient #1] took the clonidine at 1506. At 1536, BP was 126/98. RN asked [Patient #1] if [he/she] was feeling any better. [Patient #1] was not. RN decided to end treatment due to [Patient #1] not feeling well. RN and [Patient #1] carried on a conversation as RN rinsed blood back. As RN was unhooking CVC [central venous catheter, a central line used sometimes for dialysis], [Patient #1] stopped talking to the RN ...” There is no documented evidence that the patient’s vital signs were re-assessed every 5 minutes or that the UF rate was decreased to 300 ml/hr to limit fluid removal, consistent with facility policy, after the patient reported nausea, after the patient’s blood pressure decreased, and after the patient was noted to have decreased level of consciousness. There is no documented evidence of provider notification regarding patient change in status. These findings were confirmed by Employee #4, Facility Administrator, on 12/7/2023 between 11:15 AM-11:30 AM.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 46255 Based on review of facility policies, review of facility documents, review of personnel records, review of American Heart Association (AHA) Standards of Practice 2020, and staff interview, it was determined, for 6 of 10 direct patient care employees, the facility failed to ensure its staff had current cardiopulmonary resuscitation (CPR) certification. Additionally, the dialysis facility’s staff failed to utilize CPR skills needed to perform the specific duties of their positions. Findings include: I. Facility policy titled “Employee Competency Assessment” dated 1/2020, stated “ ...US Renal Care requires employees involved in providing direct patient care to maintain Cardio-Pulmonary Resuscitation through completion of a Basic Life Support Health Care Provide [sic] approved by the American Heart Association ...” II. The AHA (American Heart Association) BLS (Basic Life Support) Standards of Practice 2020 stated, “ ...Look, listen, and feel for air exchange ...if the victim is an adult feel for a carotid pulse. If unable to find a pulse, begin compressions for 5 cycles of CPR. Recheck rhythm after 5 cycles of CPR ...” III. The AHA document “Understanding Blood Pressure Readings”, last reviewed 5/30/23, stated, “ ...Hypertensive crisis ... If your blood pressure is higher than 180/120 mm Hg or you are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, do not wait to see if your pressure comes down on its own. Call 911 ...” IV. Facility policy titled “Cardiac Arrest- Staff Roles “ dated 1/2020 stated, “...Staff member assigned to the patient shall begin CPR after determination of patient respiratory and/or cardiac arrest is made...”. V. Facility policy titled “Hypotension” [low blood pressure] dated 1/2020 stated, “ ...determine the presence of hypotension if one or more of the following: gradual precipitous drop in blood pressure, nausea, feeling strange, decreased responsiveness... place patient in Trendelenburg position [a position in which a patient lies flat on their back with feet elevated higher than the head] ...decrease UF rate [speed of fluid removed during dialysis] to 300 ml/hour, monitor vital signs every 5 minutes...”. VI. Review of Patient #1’s medical record revealed: Patient #1 began dialysis treatment at 12:40 PM. At 2:13 PM, patient complained of nausea, and was medicated for this symptom. At 3:05 PM, the patient’s blood pressure increased to 246/143 and patient was symptomatic. Patient was medicated with Clonidine, a medication used to treat high blood pressure. At 3:36 PM, during check of vital signs including blood pressure, Patient #1’s blood pressure decreased to 126/98. While Employee #1, Registered Nurse (RN), was conversing with Patient #1, the patient stopped talking and became unresponsive. Employee #1 returned the patient’s blood from the dialysis line to the patient’s body and administered saline via the patient’s dialysis port to support blood pressure. The Automated External Defibrillator (AED) was applied. At 3:41 PM, Emergency Response was activated via 9-1-1. VII. Statement provided by facility via email on 12/1/23 at 3:47 PM from Employee #4, Facility Administrator stated, “ ...At this time, one of our CCHTs [certified clinical hemodialysis technicians] came to get me from my office. I got to the floor and the RN and another tech were checking for pulse and trying to arouse [Patient #1]. I checked for a pulse and there was radial pulse, but I saw Patient #1 was not breathing. RN was getting crash cart, I grabbed Ambu bag [a mask and bag used to deliver manual breaths to a patient in respiratory distress, or not breathing] and tried to provide breaths. RN placed AED pads. AED cycled and advised no shock needed. I continued using bag on patient. EMT came thru clinic door and took over bag. Paramedics arrived and they could not find a pulse, Lucas [automated CPR device that can be applied to a patient to provide chest compressions at a regular rate] was placed on [Patient #1] and in a short period of time, [Patient #1] had a pulse again. Paramedic said she was in a-Fib w/ RVR [an irregular heart rhythm]. They placed a line [intravenous port placed into vein] and (sic) in her right arm. Paramedics placed [Patient #1] on stretcher and left of ER. No documentation of reassessing respirations or pulse after 2 minutes of ventilations consistent with AHA (American Heart Association) Guidelines. VIII. Emergency Medical Services (EMS) report titled “Pre-Hospital Care Report”, dated 11/28/23, stated paramedic arrival time was 3:47 PM (11 minutes after Patient #1 was initially unresponsive). Per the report, on arrival of EMS, the patient was found to be partially reclined in the dialysis chair while dialysis staff were providing rescue breaths via a bag-valve mask. The patient was found unresponsive and pulseless. Paramedics placed patient on the ground and initiated chest compressions via the LUCAS device. After two minutes of chest compressions, Patient #1 was found to have a carotid (large blood vessel in neck) pulse. When EMS personnel asked dialysis staff at the scene if chest compressions were performed prior to paramedic arrival, staff stated the AED advised no shock, so no compressions were performed. IX. On 12/4/23 at 2:45 PM, Employee #4, Facility Administrator, stated he had difficulty feeling for a carotid pulse, so he checked for a radial (wrist) pulse. X. In a History and Physical document, from 11/28/23 at 9:28 PM, from the local acute care hospital where Patient #1 arrived after cardiac arrest, the patient underwent a series of diagnostic imaging tests, which concluded the patient had anoxic brain injury with “ ...an extremely poor prognosis ...”. XI. During an interview on 12/4/23 at 12:15 PM, Employee #12 was asked to provide current CPR certification records for all direct patient care staff. Employee #12 revealed 6 out of 10 direct patient care employees had expired CPR certification. On 11/28/23, at time of Patient #1’s adverse event, 3 of 5 direct patient care staff had expired CPR certification. This included Employee #1, RN, who was providing care to Patient #1. Additionally, facility staff were unable to provide documentation of mock codes run in the last year to provide practice and keep staff current on code procedures consistent with facility policy. These findings were confirmed Employee #11 at 12/4/2023 at 2:30 PM.”