Shands Hospital - Pediatric Dialysis

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 15234 Based on record review and interview the facility failed to arrange for other facilities to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients. Findings include: Review of the facility emergency management plan titled “[Hospital Name] Emergency Operations Plan, last reviewed 4/10/2024, failed to show the facility had arranged for other facilities to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients. During an interview on 2/19/2025 beginning at 9:42 AM, the Pediatric Clinical Coordinator stated the facility would use the hospital’s associated outpatient clinic in the event of limitations or cessation of operations to maintain the continuity of services to patients. He acknowledged the hospital’s associated outpatient clinic was currently undergoing renovations, was closed and those patients were receiving services at an alternate location. The Pediatric Clinical Coordinator acknowledged the facility did not have arrangements with an alternate facility to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 15234 Based on record review and interview the facility failed to ensure 1 patient, Patient #6, of 6 sampled patients, received emergency preparedness orientation training. Findings include: Review of the facility admission roster showed Patient #6 was admitted to the facility on 10/7/2024. Review of patient emergency preparedness training documents failed to show Patient #6 or his representative had received emergency preparedness orientation training. During an interview on 3/19/2025 beginning at 10:21 AM, the Pediatric Clinical Coordinator stated Patient #6 or his representative had not received emergency preparedness orientation training. He stated patient orientation should be completed within 30 days of admission. Review of the facility policy titled “Admission of Patient,” dated March 2025, read “Initial orientation/assessment Plan of care initiated and completed at admission. Basic patient education provided, educational plan set and to be completed within 30 days. This aids in promotion of effective reaction to plan of care. Patient teaching will improve compliance with procedure and alleviate anxiety. The teaching record will to be initiated by designee nurse, social worker and dietician within 30 days of admission.””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 51504 Based on record review and interview the facility failed to follow the prescribed dialysate flow rate (DFR) for 3 patients, Patient #1, Patient #2 and Patient #5 of 6 in center hemodialysis patients reviewed. Findings Include: Record review of Patient #1’s dialysis treatment orders, in effect 2/28/25, revealed Patient #1 was prescribed a blood flow rate of 250. Record review of Patient #1’s dialysis treatment record, dated 3/12/25, revealed Patient #1’s blood flow rate was set at 205 and 240 throughout his dialysis treatment on 3/12/25. Record review of Patient #1’s dialysis treatment record failed to reveal documentation that justified or explained why Patient #1’s blood flow rate had deviated from his prescribed blood flow rate. During an interview on 3/19/25 at 12:40 PM, the Pediatric Clinical Coordinator stated that the deviation from Patient’s #1’s prescribed blood flow rate should have been recorded. Record review of Patient #5 dialysis treatment orders, in effect 2/26/25, revealed Patient #5 was prescribed a dialysate flow rate of 400. Record review of Patient #5’s dialysis treatment record, dated 2/26/25, revealed Patient #5’s dialysate flow rate was set at 300 throughout his dialysis treatment on 2/26/25. Record review of Patient #5’s dialysis treatment record failed to reveal documentation that justified or explained why Patient #5’s dialysate flow rate had deviated from prescribed dialysate flow rate. During an interview on 3/19/25 at 12:42 PM Staff A, the Pediatric Clinical Coordinator, stated that deviation from Patient #5 ‘s prescribed dialysate flow rate should have been recorded. 45576 2.) Record review of Patient #2’s dialysis treatment record, dated 2/28/2025 , revealed Patient #2 was prescribed a dialysate flow rate (DFR) of 500 milliliters/minute (ml/min). Record review of Patient #2’s treatment record, dated 2/28/2025, documented a dialysate flow rate below 500 ml/min 14 times. Record review of Patient #2’s treatment record, dated 2/28/2025, failed to reveal documentation that justified or explained why Patient #2’s dialysate flow rate had deviated from his prescribed dialysate flow rate of 500 ml/min. During an interview on 3/18/2025 beginning at 12:30 PM, Staff A, the Pediatric Clinical Coordinator, was unable to find documentation in Patient #1’s, #2’s and Patient #5’s clinical records that justified deviation from their prescribed dialysate flow rates. Review of the facility policy titled “Adult/Pediatric Hemodialysis Standard Protocols”, dated March, 2025, read “d. Blood Flow (Qb), Ultrafiltration Rate (UFR), Venous Pressure (VP) reading, and heparin infusion, vital signs to be verified and documented. The goal blood flow rate (Qb) will be determined by the MD/PA [Medical Doctor/Physician’s Assistant] in therapy plan. RN [Registered Nurse] to notify MD/PA if unable to reach minimum Qb prescribed. e. Dialysate Flow (Qd): Ongoing evaluation of Kt/V [K = clearance-the amount of urea your dialyzer can remove (liters/minute) t = time-the duration of treatment (minutes) V = volume-the amount of body fluid (liters)] goal, RN [Registered Nurse] to increase Qd to next level if needed in order to achieve Kt/V goal ...B. Doctor’s Orders 1. The nurse will notify the physician if he/she is unable to complete any of the dialysis orders (i.e. inadequate blood flow).” During an interview on 3/19/2025 at 1:55 PM, the Registered Nurse Dialysis Pediatric Clinical Coordinator stated Patient #2’s DFR on 2/28/2025 was not run at the correct DFR rate.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 45576 Based on observation, interview and record review the facility failed to monitor patients’ vascular access to prevent access failure in 3 out of 4 patients observed, Patient #1, Patient #2 , and Patient #6. Findings include: During an observation on 3/17/2025 at 10:35 AM, Patient #2 sleeping on his back with blanket lying across his body with assess port and central Venous catheter right upper back covered and not visible for assessment. During an observation on 3/17/2025 at 11:20 AM Patient #2 was lying on his back with a blanket lying across his body with his port and central venous catheter covered and not visible for assessment. During an observation on 3/17/2025 at 2:32 PM, Patient #6’s port was accessed by Staff A, Registered Nurse (RN). Patient #6’s shirt was pulled over his port and central venous access device located in his upper left back. Patient #6 repositioned himself in the seat, sitting upright with a blanket placed on his body up to his shoulders and access to his central venous catheter via port not visible for assessment. During an interview on 3/17/2025 at 2:57 PM, Staff B, Registered Nurse stated “No [Resident 2’ name] is so young and all of our patients are so young we can’t keep the site uncovered to observe. It makes them uncomfortable.” During an interview on 3/20/2024 at 9:25 AM, Registered Nurse Dialysis Pediatric Clinical Coordinator stated “no we do not keep the patients’ sites uncovered and visible. We do have signage posted in the department to remind the patients/parents to keep the site uncovered and visible.” 51504 2.) During an observation at 10:20 AM, Patient #1 was covered with a full body blanket covering his face and catheter site. During an observation of Patient #1’s dialysis treatment, Staff C, Registered Nurse, failed to remove the blanket off the catheter site to monitor vascular access site during the treatment. Review of signage posted in the dialysis center read “ Help Us Keep You Safe! Keep your access and bloodline connections in plain sight. Don’t hide your access or bloodline connections under a blanket! Your needles/catheter must be taped well to keep them from separating. If you move around a lot or if you fall asleep and forget where your are, 1. Your venous needle can accidentally get pulled out of the vein without making the dialysis machine alarm. 2. Your catheter could be pulled on and separate from the bloodlines without making the dialysis machine alarm. You can lose a lot of blood very quickly if your venous needle or catheter comes out or your catheter separates from the bloodline. Your nurses and technicians need to be able to see your access at all times to help protect you from danger-the loss of a large amount of blood. Nephrology Nursing Journal. July-August 2021. Vol. [Volume] 48. No. 4”Photographic evidence obtained.” Review of the policy and procedure titled “Vascular Access Management Process, dated March 2025, read “..To ensure that a patient on hemodialysis ( HD) will have a vascular access that optimizes the delivered dose of dialysis and is free of complications ...h. importance/rationale of not covering the face and vascular access site during the treatment. An attestation form will be signed by the patient to record completed education ...””