Treasure Coast Kidney Center North

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 29151 Based on record review, policy review and interview, it was determined, the Interdisciplinary Team (IDT) failed to identify 1 of 7 sampled in-center patients (Patient #7) as unstable, due to extended hospitalizations. The findings included: Facility policy titled Comprehensive Interdisciplinary Assessment and Plan of Care, dated 07/03/23 documents” Unstable patients must be reassessed by the IDT monthly. Unstable criteria: Hospitalization of more than 15 days.” Clinical record review conducted on 12/20/23 revealed Patient #7 was admitted to the facility on 07/18/22. Review of the record indicates Patient #7 was hospitalized from 07/21/23 thru 08/11/23, greater than fifteen days. The record failed to provide evidence the facility had identified Patient #7 as unstable, and failed to complete the appropriate reassessment to determine patient status. Interview with The Charge Nurse on 12/20/23 at 10:27 AM confirmed the IDT did not identify Patient #7 as unstable based on the extended hospitalization.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 29151 Based on clinical record review, policy review and staff interview, it was determined, the clinical staff failed to ensure 4 of 7 sampled in-center patients (Patients #1, #2, #3 and #6) were consistently monitored every thirty minutes during dialysis treatments. The findings included: Facility policy titled Patient Assessment and Monitoring dated 05/01/23 documents “Obtain blood pressure and pulse rate... document machine parameters and safety checks every 30 minutes or more as needed but not to exceed 45 minutes.” 1) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #1 was admitted to the facility on 07/07/20 for dialysis treatments, three times a week. Treatment Record dated 12/06/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 3:42 PM and the next monitoring was documented at 5:19 PM. Treatment Record dated 11/25/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 3:04 PM and the next monitoring was documented at 4:05 PM. Treatment Record dated 11/21/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 4 PM and the next monitoring was documented at 5:07 PM. Interview conducted with the Charge Nurse on 12/20/23 starting at 11:40 AM confirmed the findings. 2) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #2 was admitted to the facility on 06/13/22 for dialysis treatments, three times a week. Treatment Record dated 12/05/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 12:41 PM and the next monitoring was documented at 1:38 PM. Treatment Record dated 12/02/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 1:39 PM, the next monitoring was documented at 2:41 PM and the next one was documented at 3:46 PM. Interview conducted with the Charge Nurse on 12/20/23 starting at 11:32 AM confirmed the findings. 3) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #3 was admitted to the facility on 11/02/23 for dialysis treatments, three times a week. Treatment Record dated 11/30/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 10:42 AM and the next monitoring was documented at 11:28 AM. Treatment Record dated 11/28/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 11:06 AM, the next monitoring was documented at 12:03 PM. Interview conducted with the Charge Nurse on 12/20/23 starting at 11:27 AM confirmed the findings. 4) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #6 was admitted to the facility on 10/07/20 for dialysis treatments, three times a week. Treatment Record dated 12/01/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 11:07 AM and the next monitoring was documented at 12:42 PM. Treatment Record dated 11/17/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 10 AM, the next monitoring was documented at 11 AM. Treatment Record dated 11/03/23 document the patient’s vital signs, arterial and venous pressures, safety checks and access checks, were not monitored every thirty minutes. The staff documented monitoring at 10:32 AM, the next monitoring was documented at 11:38 AM. Interview conducted with the Charge Nurse on 12/20/23 starting at 11:09 AM confirmed the findings.”

“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: 29151 Based on record review, policy review and interview, it was determined, the clinical staff failed to ensure dialysis prescriptions were followed for 5 of 7 sampled in-center patients (Patients #1, #2, #3, #5 and #7). This failure included deviation of the prescribed Blood Flow Rate (BFR) and failure to document the reason for the deviation of treatment. The findings included: 1) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #1 has physician’s orders for dialysis treatment as of 11/01/23 for Blood Flow Rate (BFR) of 500. Treatment Records dated 12/11/23, 12/08/23, 11/25/23, and 11/21/23 indicates the patient did not receive the prescribed BFR. The record does not provide an explanation for the deviation from the prescription. Interview with the Charge Nurse conducted on 12/20/23 at starting at 11:40 AM confirmed the staff failed to adhere to the prescription and failed to document why the blood flow rate was not achieved as prescribed. 2) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #2 has physician’s orders for dialysis treatment as of 11/01/23 for Blood Flow Rate (BFR) of 500. Treatment Records dated 12/12/23, 12/09/23, 12/02/23, and 11/25/23 indicates the patient did not receive the prescribed BFR. The record does not provide an explanation for the deviation from the prescription. Interview with the Charge Nurse conducted on 12/20/23 at starting at 11:32 AM confirmed the staff failed to adhere to the prescription and failed to document why the blood flow rate was not achieved as prescribed. 3) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #3 has physician’s orders for dialysis treatment as of 11/02/23 for Blood Flow Rate (BFR) of 400. Treatment Records dated 12/02/23 and 11/04/23 indicates the patient did not receive the prescribed BFR. The record does not provide an explanation for the deviation from the prescription. Interview with the Charge Nurse conducted on 12/20/23 at starting at 11:27 AM confirmed the staff failed to adhere to the prescription and failed to document why the blood flow rate was not achieved as prescribed. 4) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #5 has physician’s orders for dialysis treatment as of 11/01/23 for Blood Flow Rate (BFR) of 400. Treatment Records dated 12/13/23, 12/11/23, 12/08/23, 11/27/23 and 11/21/23, indicates the patient did not receive the prescribed BFR. The record does not provide an explanation for the deviation from the prescription. Interview with the Charge Nurse conducted on 12/20/23 at starting at 11:06 AM confirmed the staff failed to adhere to the prescription and failed to document why the blood flow rate was not achieved as prescribed. 5) Clinical record review conducted on 12/18/23-12/20/23 revealed Patient #7 has physician’s orders for dialysis treatment as of 09/25/23 for Blood Flow Rate (BFR) of 400. Treatment Records dated 12/15/23, 12/04/23 and 11/15/23, indicates the patient did not receive the prescribed BFR. The record does not provide an explanation for the deviation from the prescription. Interview with the Charge Nurse conducted on 12/20/23 at starting at 10:51 AM confirmed the staff failed to adhere to the prescription and failed to document why the blood flow rate was not achieved as prescribed. Facility policy titled “Patient Assessment and Monitoring” dated 05/01/23 documents “Check machine settings and measurements. Check prescribed blood flow rate is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.””

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 29151 Based on record review and interview it was determined the facility failed to ensure nutritional supplements were provided to 1 of 7 sampled in-center patients (Patient #4) as evidenced by failure to offer and administer nutritional supplements as per the Oral Nutrition Supplement Protocol. The findings included: Facility Hypoalbuminemia Algorithm dated 08/23/20 documents “If albumin is less than 3.5 g/dl, initiate oral nutrition supplement program. If albumin is less or equal to 3.5 g/dl and patient is able to maintain adequate oral intake, consult the physician and obtain order for supplements. If albumin is less or equal to 3.5 g/dl and the patient is unable to maintain adequate oral intake, discuss enteral nutrition as an option. If albumin is less or equal to 3.5 g/dl and patient is severely malnourished, consult attending physician to assess for IDPN (Intradialytic parenteral nutrition) therapy.” Clinical record review conducted on 12/19/23 revealed Patient #4 had low albumin levels. laboratory studies indicates albumin level of 2.8 g/dl on 11/13/28; albumin level of 2.7 g/dl on 10/16/23 and 2.8 g/dl on 09/18/23. Physician’s order dated 11/26/22 noted Liquacel one ounce with each treatment. The order was discontinued on 11/27/23 with no further nutritional interventions. Review of the Treatment Records dated 11/29/23 thru 12/19/23 indicates the patient did not receive nutritional supplements to manage the low albumin. Interview with The Charge Nurse conducted on 12/20/23 at 11:29 AM revealed Patient #4 was receiving Liquacel oral supplement, the order was automatically discontinued and it was not renewed. The charge nurse added the team wanted to try the nutritional bars supplement, but it was determined it would be a choking hazard, so most likely the patient will resume the Liquacel as supplementation. The Charge Nurse was not able to explained why the nutritional supplement was discontinued with no further interventions to manage the patient’s low albumin levels.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 22517 Based on clinical and administrative record review and staff interview, the home training staff failed to provide the necessary and care and services to achieve and sustain the clinically appropriate hemoglobin level. This is evidenced by the Home training staff failure to promptly address and provide intervention for 2 of 3 Home dialysis patients (Patient # 8 and # 10) who experienced a drastic drop in their hemoglobin level; failed to provide evidence of promptly securing repeat laboratory evaluation and failed to ensure that the home patients documented the self-administration of medication used to treat their anemia management. The findings included: 1) Review of the clinical record for Patient # 8 revealed that the patient was originally admitted to the facility on 08/17/22. The physician prescribed for a change in modality on 03/15/23 for the patient to began performing hemodialysis at home. The patient completed her training and on 04/24/23 the physician prescribed for the patient to perform home hemodialysis treatment four times a week via NxStage Pure Flow. Further review of Patient # 8 laboratory results revealed that beginning 10/07/23, the patient experienced a significant drop in her hemoglobin level from a 09/07/23 Hgb level of 10.0 g/dl to 6.9 g/dl on 10/07/23. (Normal Hgb level 12.0 - 16.0 g/dl). The patient’s T-Sat (Transferin Saturation) on 10/07/23 was 29. There is no evidence of follow-up repeat labs and/or intervention for the patient’s low Hgb until 12 days later on 10/19/23, when a repeat lab was completed and the patient’s Hgb level remained low at 8.7 g/dl and notation of Mircera 150 mcg SQ and Venofer 100 mg being administered. Subsequent lab results are as follows: 10/23/23 - 8.8 g/dl; 11/02/23 - 8.4 g/dl; 11/27/23 - 7.6 g/dl; 12/05/23 - 7.2 g/dl; 12/14/23 - 6.8 g/dl. Medication administered 11/10/23 - Mircera 150 mcg SQ once. Then on 11/20/23, the physician prescribed for the patient to administer Mircera 200 mcg SQ every 2 weeks. However, the documented administered dose was listed on 12/14/23. Further review of the physician progress notes from 10/18/23, revealed the physician evaluated the patient on this date but noted that the patient’s hemoglobin was stable but that she did not have access to a current hemoglobin results and requested labs be drawn. The physician was not apprized of the 10/07/23, 6.9 g/dl Hgb results. An interview was conducted on 12/20/23 at 11:20 AM with the Home Training Nurses (HTN). The surveyor reviewed the above findings with the HTN. He confirmed the information and was unable to provide any additional information. 2) Review of the clinical record for Patient # 10 revealed that the patient was admitted to the facility on 08/16/21 and was prescribed to perform Continuous Ambulatory Peritoneal Dialysis (CAPD) at home. On 06/23/23 physician prescribed for the patient to complete four exchanges seven days a week. Further review of the Patient # 10 laboratory results revealed that beginning 09/12/23, the patient experienced a significant drop in her hemoglobin level from 08/03/23 hgb of 11.2 g/dl to 8.8 g/dl on 09/12/23. A subsequent lab was not recorded until 10/05/23 (23 days later) , when the patient’s hemoglobin level continued to decline to 6.5 g/dl. Additional lab results are recorded as follows: 10/10/23 -Hgb - 7.8 g/dl; 11/22/23 and 11/29/23, lab was canceled; 12/11/23, Hgb - 7.0 g/dl. The patient did receive a transfusion of 2 units of Packed Red Blood Cells (PRBC) in the Emergency Room on 10/10/23 (28 days after the patient experienced a significant drop in her hemoglobin). Further review of the Physician orders revealed a 09/12/23 Venofer 200 mg IV (intravenous) once; 10/05/23 - Venofer 200 mg IV once, 11/22/23 Venofer 200 mg IV, 11/30/23 Mircera 200 mcg SQ (subcutaneous) self administer at home once; 12/11 Venofer 300 mg IV once. An interview was conducted on 12/19/23 in the afternoon with the Home Training Nurse, who stated that the patient had a heavy bleeding month and they felt that was the reason for the drop in her hemoglobin but she has since stopped bleeding but her hemoglobin is still low. The surveyor discussed with the HTN, the apparent delay in the patient receiving responsive treatment. The HTN was unable to provide a reason for the apparent delay of treatment. Additionally, further review of the clinical record noted that the patient is self administering her anemia management at home. However the home records did not document the administration of the same. An interview was conducted with the HTN on 12/19/23 in the morning. The nurse confirmed that the home records do not reflect the patient administered the medication.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 29151 Based on policy review, clinical record review and interview, it was determined, the interdisciplinary team failed to ensure the patient plan of care was signed by the patient acknowledging the problems, goals and interventions put in place. The failure affected 2 of 7 in-center sampled patients (Patients #1 and #4). The findings included: Facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” dated 07/03/23 documents “The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. if the patient chooses not to sign their plan of care, the reason for the refusal must be documented in the patient’s medical record.” 1) Clinical record review conducted on 12/18/23 revealed Patient #1 was admitted to the facility for dialysis treatment on 07/07/20. The record documents the interdisciplinary team completed the annual comprehensive plan of care on 09/21/23. The record failed to provide evidence Patient #1 participated and signed acknowledgement of the plan of care or refused to sign the care plan. 2) Clinical record review conducted on 12/19/23 revealed Patient #4 was admitted to the facility for dialysis treatment on 11/24/06. The record documents the interdisciplinary team completed the annual comprehensive plan of care on 10/25/23. The record failed to provide evidence Patient #4 participated and signed acknowledgement of the plan of care or refused to sign the care plan. Interview with the Clinic Manager (CM) and the Charge Nurse conducted on 12/20/23 at approximately 11:39 AM confirmed the facility has no evidence the patients signed the plan of care acknowledging participation in the plan of care and the CM stated a new process will be implemented to capture the patient’s signature validating participation in their plan of care.”

“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: 29151 Based on record review, policy review and interview, it was determined, the Medical Director and facility staff failed to ensure the initial nursing assessments had all required elements, including a fall risk assessment. This failure affected 1 of 1 newly admitted in-center patient (Patient #3). The findings included: Facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care, dated 07/03/23 documents “ A registered nurse must perform, an assessment on patients before initiation of their first treatment to determine immediate needs including activity, ambulation status and fall risk.” Clinical record review conducted on 12/19/23 revealed Patient #3 was recently admitted to the facility on 11/02/23. The facility Initial Nurse Assessment, Treatment Flowsheets and Progress Notes failed to document the completion of a Fall Risk assessment. Interview with The Charge Nurse conducted on 12/20/23 at 11:27 AM confirmed the facility does not complete a fall risk assessment as part of the initial assessment.”