Fmc - West Pensacola

“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: 42926 Based on patient treatment record reviews, staff interviews, and review of the facility’s policies and procedures, the facility failed to identify and report abnormal blood pressure occurrences for 3 of 10 patients sampled (Patient #4, #5, #6) and failed to document nursing assessments within one hour of initiation of treatment for 2 of 10 patients sampled (Patient #2,#3) The findings include: Patient #2: In 2 of 9 treatment records reviewed (dated 5/11/2024 and 5/25/2024), nursing staff failed to document an initial assessment within 1 hour of initiation of dialysis treatment Patient #3: In 2 of 4 treatment records reviewed (dated 5/24/2024 and 05/27/2024), nursing staff failed to document an initial assessment within 1 hour of initiation of dialysis treatment. Patient #6: In 8 of 10 treatment record reviewed, Patient #5 had elevated blood pressures. In 8 of 10 of the treatment records (dated 05/06/2024 through 05/27/2024) staff failed to notify a provider per policy for blood pressure out of parameters. The treatment record review did not indicate that Patient #6 was treated per standing order for elevated blood pressure in 7 of 10 treatment records. 39374 Patient #5: In 9 of 9 treatment records reviewed, Patient #5 had elevated blood pressures (greater than 180 millimeters/Mercury (mm/Hg) systolic). In 7 of 9 treatment records (dated 05/08/2024 through 05/27/2024) staff failed to notify a provider per policy for blood pressure out of parameters. The record review did not indicate Patient #5 was treated per standing order for elevated blood pressure in 9 of 9 treatment records reviewed. A review of a policy titled, Patient Assessment and Monitoring, published 05/01/2023 with reference number 45284, version 4, included the statement, “The RN (Registered Nurse) will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement for additional instruction.” The policy also contained language for actions to take during treatment, including reporting to the nurse systolic blood pressures greater than 180mm/Hg, diastolic blood pressure greater than 100mm/Hg, and blood pressure less than or equal to 100mmHg systolic. A review of “Standing Hemodialysis Orders v5.01” contained standing orders for PRN (as needed) medications including Clonidine (a medication used to lower blood pressure) 0.1mg for BP>180 systolic repeat x1 after 30 minutes. Notify physician for >180 after repeat administration. In an interview on 05/29/2024 at 4:00PM, the Medical Director said, “above 180 they need to call us, if its out of the normal range for the individual patient then we need to know about it. If they are always noncompliant and always high when they come, they call me and I give a protocol for that patient.” 47306 Patient #4: In 3 of 9 treatment records reviewed (dated 3/30/2024, 4/13/2024, and 5/21/2024) had elevated blood pressures (greater than 180 millimeters/Mercury (mm/Hg) systolic before, during, and after the treatments. The treatment records reviewed revealed the staff failed to notify a provider prior to beginning treatment per policy for blood pressures out of parameters. The record review did not indicate patient #4 was treated per standing order for elevated blood pressure in 3 of 9 treatment records reviewed. On 5/29/2024 at 3:28PM an interview was conducted with the Director of Operations (DO) regarding policy for reporting abnormal blood pressures to a provider. The DO indicated it is facility policy for the Nurse to notify the Provider of any abnormal vital signs prior to beginning treatment, during treatment, and at the end of treatment. On 5/29/2024 at 3:57PM an interview was conducted with Staff A (Licensed Practical Nurse) regarding the treatment record for patient #4 dated 3/30/2024. Staff A was asked to review patient #4’s pre-treatment and during treatment blood pressures. Staff A was asked if he recalled reporting the abnormal blood pressures to a Registered Nurse or calling a Provider. Staff A indicated he did not notify a Registered Nurse or a Provider. Staff A indicated he should have reported the high blood pressures to a Registered Nurse and let her handle any interventions. A review of a policy titled, Patient Assessment and Monitoring, published 05/01/2023 with reference number 45284, version 4, included the statement, “The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement for additional instruction.” The policy also contained language for actions to take during treatment, including reporting to the nurse systolic blood pressures greater than 180mm/Hg, diastolic blood pressure greater than 100mm/Hg, and blood pressure less than or equal to 100mmHg systolic. A review of “Standing Hemodialysis Orders v5.01” contained standing orders for PRN (as needed) medications including Clonidine 0.1mg for BP>180 systolic repeat x1 after 30 minutes. Notify physician for >180 after repeat administration.”