Rcg - Ft Walton Beach

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 39374 Based on observations and interviews, the facility failed to maintain a safe, functional, and comfortable treatment environment which had the potential to affect all patients receiving in-center hemodialysis treatment, which at the time of the survey included a census of 57. The findings included: During a tour of the facility on 09/16/2024 beginning at approximately 11:10am, several environmental concerns were noted. The floor was noted to be either dirty or badly stained in most areas, with cracks in the linoleum floor tiles. There was a linoleum baseboard covering along the wall extending approximately 3-4 inches from the floor to the wall and there were areas where the baseboard was missing with exposed areas between the floor and the wall which were in the area where patients were receiving hemodialysis. The cupboards in the treatment area being used by staff and labelled with “clean” and “dirty” sink areas as well as cabinets across from these sinks were missing the laminate coverings in places, exposing porous particle board which is not able to be disinfected. (photographic evidence obtained) During an interview with Patient #1 on 09/16/2024 at 3:01pm, Patient #1 expressed dissatisfaction with the building and said “they need a new one (building).” In an interview with registered nurse (RN) B on 09/16/2024 at 4:09pm, she said cleanliness is an issue, the floor is very dirty, and patients complain. On 09/17/2024 at approximately 8:00am an interview and observation of the treatment area was conducted with the clinical manager, she acknowledged there were areas with missing baseboards and there was a roach bait trap observed in a corner at the end of two rows of dialysis treatment stations. The clinical manager said they have had problems with housekeeping, and she hired a new company, but the tiles are damaged from years of wear and tear and difficult to clean. She described the tiles as porous and worn. The clinical manager continued to explain they need a new building. During an interview on 09/18/2024 at 7:43am, Patient #10 described the building as “a dump” and said, “I heard they are looking for a new center. They do their best, but other places are much nicer and I have seen roaches running across the floor here recently.” On 09/18/2024 at 8:45am an interview was conducted with the medical director during which he expressed there have been issues with the building that have been addressed with the owner of the building and said the team is good about notifying the owner to get him to clean up the place and there is “chatter” about trying to find a new building but that is “out of my hands.””

“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: 39374 Based on interviews, record and policy reviews, the facility failed to ensure that patients’ blood pressures were monitored according to established timeframes during treatment for 2 of 8 patients sampled for record review of in-center hemodialysis (Patients #2 and #3) and physician notification of a patient’s continued inability to reach the physician ordered estimated dry weight (EDW) goal for 1 of 8 sampled patients (Patient #5). The findings included: Medical record review for Patient #2 revealed that for 1 of 6 treatment records reviewed between 09/02/2024 and 09/13/2024 the facility failed to follow its policy for monitoring patients during dialysis as evidenced by having no documentation of monitoring Patient #2 on 09/02/2024 between 1:08pm and 2:00pm. Medical record review for Patient #3 revealed that for 2 of 6 treatment records reviewed between 09/05/2024 and 09/16/2024 the facility failed to follow its policy for monitoring patients during dialysis as evidenced by having no documentation of monitoring Patient #2 on 09/12/2024 between 11:52am and 1:02pm and between 3:01pm and 3:51pm. There was no evidence of monitoring documented on 09/16/2024 between 12:06pm and 2:12pm and between 2:12pm and 3:01pm. In an interview with registered nurse (RN) B on 09/16/2024 at 4:09pm, she said the technicians are supposed to monitor patients at least every 30 minutes and described that monitoring includes the blood pressure should be checked every 30 minutes and making sure the access site is uncovered. A review of facility policy titled “Patient Assessment and Monitoring” published 05/01/2023, reference number 45284, version 4, on page 4 of 7 states “during treatment obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” 45951 Review of the facility’s policy titled Patient Safety Event Reporting and Documentation, dated 02/16/23 revealed the following: Reporting of any patient information should occur in person or verbally. Documentation should include that the physician was notified. Reportable categories and events include Dialysis Weight/UF Goal Variance-dialysis weight variance above or below the expected post weight. Review of the facility’s policy titled Volume Management in ESRD Patients on Hemodialysis, dated 09/07/21 revealed the following: This policy defined Estimated Dry Weight (EDW) as the “lowest tolerated post-dialysis weight with minimal signs or symptoms of hypovolemia or hypervolemia. EDW is used to calculate the target weight removal (TWR) for each dialysis treatment”. This policy further stated that if a patient is “unable to achieve EDW” then “treatment adjustments based on fluid assessment, symptoms, and blood pressure are critical to improve a patient’s volume status. EDW order should be updated post treatment to reflect treatment adjustments and patient fluid status”. Review of Patient #5’s medical record revealed Patient #5 had a history of not meeting his physician ordered Estimated Dry Weight (EDW) as evidenced by his post-dialysis weights. Review of 9 treatment records from 08/27/24 to 09/14/24 revealed Patient #5 did not meet his ordered EDW goal for all 9 treatments. Review of each treatment record revealed the physician ordered EDW goal was 119.2 kilograms (kg). On 08/27/24, Patient #5’s pre-dialysis weight was 123.9kg and post-dialysis weight was 121.3kg indicating he was 2.1kg over his ordered EDW. The post-dialysis note documented “post treatment, treatment tolerated, no adverse events. Hemostasis achieved prior to discharge” but did not document additional time offered to the patient or communication with the physician regarding the EDW not being met. On 08/29/24, Patient #5’s pre-dialysis weight was 124.0kg and post-dialysis weight was 120.6kg indicating he was 1.4kg over his ordered EDW. The post-dialysis note documented the patient declined additional time on the dialysis machine to remove additional fluid; it did not document communication with the physician regarding the EDW not being met. On 08/31/24, Patient #5’s pre-dialysis weight was 123.7kg and post-dialysis weight was 120.3kg indicating he was 1.1kg over his ordered EDW. The post-dialysis note documented “treatment tolerated well. No distress. 3.5 over EDW” but did not document additional time offered to the patient or communication with the physician regarding the EDW not being met. On 09/03/24, Patient #5’s pre-dialysis weight was 126.2kg and post-dialysis weight was 122.7kg indicating he was 3.5kg over his ordered EDW. The post-dialysis note documented “post treatment, treatment tolerated, above EDW, advised daily fluid limit” but did not document additional time offered to the patient or communication with the physician regarding the EDW not being met. On 09/05/24, Patient #5’s pre-dialysis weight was 127.3kg and post-dialysis weight was 123.1kg indicating he was 3.9kg over his ordered EDW. The post-dialysis note documented “post assessment-patient tolerated treatment well, no complaints” but did not document additional time offered to the patient or communication with the physician regarding the EDW not being met. On 09/07/24, Patient #5’s pre-dialysis weight was 126.7kg and post-dialysis weight was 122.9kg indicating he was 3.7kg over his ordered EDW. The post-dialysis note documented the patient declined additional time on the dialysis machine to remove additional fluid; it did not document communication with the physician regarding the EDW not being met. On 09/10/24, Patient #5’s pre-dialysis weight was 126.3kg and post-dialysis weight was 123.0kg indicating he was 3.8kg over his ordered EDW. The post-dialysis note documented the patient declined additional time on the dialysis machine to remove additional fluid; it did not document communication with the physician regarding the EDW not being met. On 09/12/24, Patient #5’s pre-dialysis weight was 128.3kg and post-dialysis weight was 123.9kg indicating he was 4.7kg over his ordered EDW. The post-dialysis note documented the patient declined additional time on the dialysis machine to remove additional fluid; it did not document communication with the physician regarding the EDW not being met. On 09/14/24, Patient #5’s pre-dialysis weight was 129.7kg and post-dialysis weight was 126.2kg indicating he was 7.0kg over his ordered EDW. The post-dialysis note documented the patient declined additional time on the dialysis machine to remove additional fluid; it did not document communication with the physician regarding the EDW not being met. An interview was conducted with Staff D, Facility Administrator and Staff F, Manager of Clinical Quality on 09/18/24 at 11:50 AM. Staff D and Staff F independently reviewed Patient #5’s medical record and confirmed there was no documentation of communication from the nursing staff to the physician regarding Patient #5’s continued inability to reach the physician ordered EDW. The last physician note Staff D found in Patient #5’s chart was written on 08/01/24 and did not discuss EDW concerns. During this discussion, Staff F confirmed the nursing staff should have reported the EDW concerns to the physician and documented notes regarding the EDWs and communication with the physician.”

“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: 45951 Based on observation, record review, and interview, the facility failed to ensure physician notification of a patient’s continued inability to reach the physician ordered blood flow rate (BFR) goal for 1 of 8 sampled patients (Patient #6) and the facility failed to ensure correct physician ordered dialysate was used for 2 of 8 patients observed receiving in-center hemodialysis treatments (Patient #3 and 9). The findings included: Review of the facility’s policy titled Patient Safety Event Reporting and Documentation, dated 02/16/23 revealed the following: Reporting of any patient information should occur in person or verbally. Clinical staff are required to report all Safety Events to the physician. Documentation should include that the physician was notified. Reportable categories and events include Medication Error/Wrong Medication-administration of a wrong medication; also, Incorrect Blood Flow Rate (BFR)-prescribed BFR not utilized for dialysis treatment; also, Incorrect Dialysate Formula Used-prescribed dialysate solution not utilized for dialysis. Review of Patient #6’s medical record revealed Patient #6 had a history of not meeting her physician ordered Blood Flow Rate (BFR) goal. Review of 9 treatment records from 08/26/24 to 09/13/24 revealed Patient #6 did not meet her BFR goal for 4 of 9 treatments. Review of each treatment record revealed the physician ordered BFR was 450 milliliters per minute (mL/min). On 08/26/24, Patient #6’s BFR ran at 350mL/min for the whole treatment time. No notes were written during the treatment indicating why the BFR did not reach the ordered goal. On 08/30/24, Patient #6’s BFR ran at 400mL/min for the whole treatment time. No notes were written during the treatment indicating why the BFR did not reach the ordered goal. On 09/02/24, Patient #6’s BFR ran between 250mL/min and 350mL/min for the whole treatment time. No notes were written during the treatment indicating why the BFR did not reach the ordered goal. On 09/09/24, Patient #6’s BFR ran at 300mL/min for the whole treatment time. No notes were written during the treatment indicating why the BFR did not reach the ordered goal. An interview was conducted with Staff D, Facility Administrator and Staff F, Manager of Clinical Quality on 09/18/24 at 11:59 AM. Staff D and Staff F independently reviewed Patient #6’s medical record and confirmed there was no documentation of communication from the nursing staff to the physician regarding Patient #6’s continued inability to reach the physician ordered BFR. During this discussion, Staff F confirmed the nursing staff should have reported the BFR concerns to the physician and documented notes regarding the BFRs and communication with the physician. 39374 On 09/16/2024 at approximately 12:27pm, observed registered nurse (RN) B remove the dialysate line from the wall where Patient #3 was in the process of receiving hemodialysis treatment. She connected the line to a jug filled with dialysate and labelled “3K (potassium) 2.5 Ca (calcium). In an interview with RN B immediately after this observation, RN B explained the wall distribution provides a 2K (potassium) and 2.5Ca (calcium) dialysate and said they didn’t realize Patient #3 was on the wrong bath and fixed it, remarking “it happens.” When asked if she had to notify anyone of the error, RN B responded, “I can notify the doctor and let them know; usually the tech (technician) goes back to check.” During an observation on 09/17/2024 at approximately 9:16am, Patient #9 was observed receiving in-center hemodialysis and the dialysate connection was attached to the wall distribution system which is 2K (potassium) and 2.5Ca (calcium). A review of Patient #9’s orders showed that the dialysate ordered was for Patient #9 to receive 2K3Ca dialysate. Patient Care Technician (PCT) C was assigned to Patient #9 and was asked to verify the prescription during the observation. When the prescription was verified, PCT C acknowledged Patient #9 was receiving the incorrect dialysate. In a follow up interview with PCT C at 9:23am she said she notified RN B about giving the wrong bath and RN B was going to notify the doctor. In an interview with the medical director on 09/18/2024 at 8:45am, he expressed that he gets notified when there is a wrong bath and his biggest concern would be the potassium (level). A review was conducted of policy titled “Patient Assessment and Monitoring” published 05/01/2023, reference number 45284, version 4. The policy contained steps for monitoring patient and machine parameters during treatment which provided the following instructions on page 6 of 7: “check dialysate flow rate setting is correct, and the prescribed flow is being delivered.””

“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: 45951 Based on record review and interview, the facility failed to ensure physician notification of a patient’s low Hemoglobin level that required weekly anemia testing for Hemoglobin less than 10 for 1 of 8 sampled patients (Patient #1). The findings included: Review of the facility’s policy titled Patient Safety Event Reporting and Documentation, dated 02/16/23 revealed the following: Reporting of any patient information should occur in person or verbally. Documentation should include that the physician was notified. Reportable categories and events include Clinical Lab Management-missed communication and/or follow up of a critical/out of range lab result. Review of Patient #1’s medical record revealed Patient #1 had a history of low Hemoglobin. Weekly laboratory results were reviewed, revealing on 08/31/24, Patient #1’s Hemoglobin was 8.3 (normal range is 12.0 to 16.0). Further review revealed on 09/09/24 Patient #1’s Hemoglobin was 8.6, and on 09/12/24 the result was 8.6. Review of Patient #1’s medical record revealed no notes from the nursing staff or the physician addressing these laboratory results. Review of Patient #1’s medication orders revealed no medication was ordered as a result of the low Hemoglobin results. An interview was conducted with Staff D, Facility Administrator and Staff F, Manager of Clinical Quality on 09/18/24 at 11:30 AM. Staff D and Staff F independently reviewed Patient #1’s medical record and confirmed there was no documentation of communication from the nursing staff to the physician regarding the above laboratory results. During further review of Patient #1’s chart, Staff D stated there was a medication algorithm present for Aranesp (this is a medication used to stimulate a person’s bone marrow to produce red blood cells). Staff D further stated the medication Aranesp had previously been given to Patient #1 but was not being given to Patient #1 at that time. When the surveyor asked for clarification, why was the Aranesp given previously when Patient #1’s Hemoglobin numbers were higher but not at that time when they were below 9, Staff D stated that the staff had been inputting the Hemoglobin results into the algorithm with the last update into the algorithm being on 09/11/24. During this discussion, Staff F confirmed the nursing staff should have reported these results to the physician and documented notes regarding these results and communication with the physician. Staff F further stated the Aranesp medication should have been restarted for Patient #1 based on these Hemoglobin results.”