Bma - Palatka

“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: 40559 Based on record review and interview the facility failed to ensure 2 Patients (Patient #5 and Patient #9) of 6 sampled patients reviewed for in-center intradialytic assessments who experienced a change in status (blood pressure) during dialysis treatment received an assessment identifying the medical condition and status of the patient. Findings include: Review of Patient #9’s Patient transfer worksheet shows Patient was admitted to facility on 2/29/2024 with diagnoses including acute kidney failure and is an in-center Hemodialysis patient. Record review of Patient # 9’s intradialytic data for treatments revealed the following specific to Patient #9’s blood pressure monitoring: Treatment sheets reviewed from 03/14/2024 through 04/09/2024. 03/14/24: 13:44 Blood Pressure Reading: 172/104. PCT (Patient Care Technician) Notes: None 13:48 Blood Pressure Reading: 163/102. PCT Notes: resting comfortably; access visible; green AMP light. 03/21/24: 12:35 Blood Pressure Reading: 164/102. PCT Notes: None. 13:44 Blood Pressure Reading: 172/104. PCT Notes: None. 13:48 Blood Pressure Reading: 163/102. PCT Notes: resting comfortably; access visible; green AMP light. 03/23/24: 11:00 Blood Pressure Reading: 164/104. PCT Notes: Access visible; green AMP light; denies complaints. 12:01 Blood Pressure Reading: 161/104. PCT Notes: None. 13:45 Blood Pressure Reading: 172/105. PCT Notes: Access visible; green AMP light; denies complaints. 14:00 Blood Pressure Reading: 155/101. PCT Notes: Access visible; green AMP light; denies complaints. 03/25/24: 08:01 Blood Pressure Reading: 166/104. PCT Notes: Resting comfortably; access visible; lines reversed; green AMP light; denies complaints. 08:36 Blood Pressure Reading: 170/101. PCT Notes: none. Review of Patient #5’s Patient transfer worksheet shows Patient was admitted to facility on 12/14/2023 with diagnoses including Type II Diabetes Mellitus with Chronic Kidney Disease and End Stage Renal Disease and is an in-center Hemodialysis patient. Record review of Patient # 5’s intradialytic data for treatments revealed the following specific to Patient #5’s blood pressure monitoring: Treatment sheets reviewed from 03/14/2024 through 04/09/2024. 03/30/24: 06:45 Blood Pressure Reading: 173/100. PCT Notes: Treatment initiated without problem; access visible; Green AMP light; Denies complaints; Patient Alert. 07:02 Blood Pressure Reading: 178/103. PCT Notes: Green AMP light; Denies complaints; access visible. 09:32 Blood Pressure Reading: 149/109. PCT Notes: Green AMP light; Denies complaints; access visible All notes above were documented by a Patient Care Technician. No documentation of notification of nurse of significant change in blood pressure readings. During an interview on April 12, 2024 at 10:40 AM, with the Clinical Manager who confirmed the PCT did not document notification to the nurse or doctor or have the nurse document in their assessment when the blood pressure were out of the parameters. The Clinical manager also stated that her “expectation is that they notify the nurse of blood pressures which are out of range and document it in the system. The nurse could also note it in the assessment area.” During an interview on April 12, 2024 at 10:53 AM, with charge nurse who states “The techs are to notify the nurse on the floor of any blood pressures out of range. They should put a note in the flow sheet.” Review of facility policy titled, “Patient Assessment and Monitoring,” dated 9/29/2018 shows it reads,” ...Monitoring during treatment- step 1- Blood Pressure- record blood pressure. Recheck blood pressures after a drop that requires interventions such as administering normal saline ...Report to the nurse: Systolic blood pressures greater than 180 mm/Hg. Diastolic blood pressure greater than 100 mm/hg. Blood pressure less than or equal to 100 mm/hg systolic.””