Dci Albany West Town

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to ensure the facility’s Emergency Preparedness Plan (EPP) was evaluated and updated at least every 2 years. The facility census was 91. Findings were: A review of the facility’s EPP and Governing Body Meeting minutes revealed that the last documented review and evaluation of the EPP was on 4/16/21. During an interview on 2/9/24 at approximately 10:00 a.m., the Nurse Manager confirmed that the EPP was not evaluated and updated since 2021.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 03383 Based on observation and a review of Centers for Disease Control and Prevention (CDC) recommendations, it was determined that the Infection Control Committee failed to ensure that three of eight patients (P#5, P#11, P#12 ) observed who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal. This deficient practice had the potential for cross contamination and increased risk of infection and could affect 91 hemodialysis patients who were dialyzing at this facility. Findings were: During observation in the patient treatment area on 2/7/24 between 10:00 a.m. and 1:45 p.m., the following was observed: - P#5, who was seated at Station (S) 1 held pressure to dialysis access needle sites. When hemostasis was attained, P#5 left the facility without performing hand hygiene. P#5 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#11, who was seated at S2 held pressure to dialysis needle sites and left the facility without performing hand hygiene. P#11 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. - P#12, who was seated at S8 held pressure to dialysis needle sites and left the facility without performing hand hygiene. P#12 was not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to demonstrate that staff followed standard infection control practices. The facility failed to ensure that the bleach solution used for disinfection of contaminated surfaces, medical devices, and equipment was mixed with correct amount of bleach to water ratio. Failure in effective environmental disinfection could lead to transmission of bloodborne pathogens and other infections from one patient to another in hemodialysis unit. The facility was 91. Findings were: During observation in the Patient Treatment Room on 2/8/24 between 4:41 a.m. and 4:55 a.m., the following was revealed: - PCT DD did not measure the amount of water when she made four containers of bleach water used to clean and disinfect clamps, medical devices, and equipment. - PCT DD placed a container in the clean sink, ran water into container, poured bleach into 30 ml (milliliter) medicine cup and poured it in the water. PCT DD then filled the container with more water, and poured another 30 ml of bleach in the water. PCT DD performed this on both sides of the Patient Treatment Room. PCT DD did not measure the amount of water needed to ensure that the ratio of bleach to water was 1:10 per facility policy. During an interview on 2/8/24 at 5:00 a.m., when asked by this surveyor if the container had fill lines that showed measurement of water, PCT DD stated “No”. PCT DD did not know how much water the container held. However, PCT DD stated I mixed 30 cc (ml) of bleach per gallon of water. A review of Procedure No. 315 titled, “Surface Disinfection - Dilution of 1:10 Bleach Solutions” dated 1/16/2019 stated: “Appropriate fill levels may be marked directly on mixing containers to facilitate the mixing of 1:10 bleach solution.””

“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: 03383 Based observation and staff interview, it was determined that the facility failed to ensure that one of one double doors at the back of the building, was maintained to prevent entry of insects and vermin; and to provide a safe environment for 91 patients who were dialyzing at this facility. Findings were: During a tour of the facility on 2/7/24 at 9:15 a.m., the following was observed: - The back double doors leading to the outside had approximately 1/4 inch - 1/2 inch gap between the double doors and the floor width across the end (12 inches width across the right door) that could allow insects and vermin to enter the building. The Educator confirmed the above findings on 2/7/24 at 9:15 a.m. and stated the strips are still present but a gap could be seen on the right side after closer inspection of the doors.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 03383 Based on a review of records and staff interview, it was determined that the facility failed to ensure the the social worker completed KDQOL for three of nine sampled patients (P#1, P#2, and P#8). The facility also failed to ensure one of one ampled patients (P#2) was provided assistance with transplant referral. Findings were: A review of records revealed the following: - P#1’s KDQOL was due on 2/7/24. - P#2’s KDQOL was due 1/9/24. P#2 was admitted to the facility on 9/26/23 and voiced interest in kidney transplant during initial assessment with no follow up. - P#8’s KDQOL was due on 12/5/23. During an interview with the Social Worker (SW) on 2/8/23 at 11:49 a.m., SW confirmed the above findings. She also stated she is late with referral to transplant center for P#2. SW indicated she inherited this dialysis clinic in September 2023 and had to prioritize finding placement for patients.”

“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: 03383 Based on a review of medical records, staff interviews and review of Policies and Procedures, it was determined that the medical director failed to ensure that staff followed Physician’s Standing Orders and adhered to facility policies pertaining to hypertension [elevated blood pressure (BP)] or hypotension (low blood pressure) to ensure that five (5) of nine (9) patients (P#1, P#2, P#3, P#6, and P#8) sampled who experienced high or low BP readings before, during, and after dialysis treatment, and/or experienced tachycardia (rapid heart rate), received medical care/interventions appropriate to the patient’s needs. This failure could negatively affect the health and safety of 91 hemodialysis patients who were dialyzing at this facility. Findings were: - A review of Physician’s Hemodialysis Standing Orders dated 2024 stated: Clonidine 0.1 mg (milligram) x 1 (one time) for systolic (top number) blood pressure > (greater than) 180 or diastolic (bottom number) blood pressure > 105. Recheck blood pressure in 30 minutes and one hour. Notify physician if patient is symptomatic or no response to medication. If pulse is less than 60, call physician before administering Clonidine”. Hypotension: Administer saline bolus at 100 ml IV (in the vein) intervals as needed. MAY DECREASE GOAL BY 0.5L (500 ML) UNTIL BLOOD PRESSURE IMPROVES. Repeat blood pressure after interventions. CCHT and PCT may administer NS (Normal Saline) under direct supervision of licensed staff. A review of treatment flowsheets dated 1/15/24 - 2/6/24 showed the following: Patient (P) #1: P#1’s dialysis prescription: Tx (Treatment) time: 3 hours 30 minutes, EDW (Estimated Dry Weight): 81 kg (kilogram), BFR (Blood Flow Rate): 400 mL/min, DFR (Dialysate Flow Rate): 600 mL/min. On 1/29/24: - P#1’s pre dialysis weight was 82.8 kg and post weight was 81.2 kg. - P#1’s B/P was 191/88 mmHg (millimeters of mercury) at 10:23 a.m. and 168/81 during initiation of dialysis treatment at 10:36 a.m. - At 11:00 a.m., P#1’s B/P dropped to 100/57 mmHg. Registered Nurse (RN) OO documented “Awake”. - At 11:30 a.m., P#1’s BP was 116/65 mmHg. - At 12:00 p.m., P#1’s BP dropped to 112/64 mmHg. - At 12:30 a.m., P#1’s BP dropped to 103/58 mmHg. - At 1:00 p.m., P#1’s BP dropped to 98/57 mmHg. BFR and UFR decreased to 0 (zero) by Patient Care Technician (PCT) FF. - At 1:30 p.m., P#1’s BP dropped to 83/47; BFR at 400 mL/min (milliliter per minute) and the UFR was at 610 mL/min. Record did not show that PCT FF notified the nurse. - At 1:31 a.m., P#1’s BP was 83/42. There was no documented evidence that PCT FF notified the nurse. - Treatment was terminated at 2:14 p.m. PCT FF did not follow the standing order for hypotension. The RN was not notified and there was a lack of documented interventions done to support P#1’s low BP. The above findings were discussed and reviewed with the Nurse Manager (NM) and Assistant Area Operations Director (AAOD) on 2/8/24 at 12:35 p.m. The NM and AAOD confirmed that treatment records did not show that RN was notified about the patient’s low BP readings. P#2: P#2’s dialysis prescription: Tx time: 4 hours, EDW: 88.5 kg, BFR: 400 mL/min... On 1/25/24: - P#2’s pre dialysis weight was 89.7 kg and post weight was 88.1 kg (below EDW). - P#2’s BP was 173/108 mmHg at 10:54 a.m. and 171/106 mmHg during initiation of dialysis treatment at 11:04 a.m. - At 11:31 a.m., P#2’s BP increased to 202/101 mmHg. Treatment record did not show that PCT HH rechecked BP or notified the RN about elevated BP. - At 12:01 p.m., P#2’s BP was 166/86 mmHg. - At 12:31 p.m., P#2’s BP was 137/63 mmHg. - At 1:02 p.m., P#2’s BP was 172/101 mmHg. - At 1:31 p.m., P#2’s BP was 172/142 mmHg. - P#2’s BP was not rechecked for one hour. - At 2:32 p.m., P#2’s BP was 172/103 mmHg. - At 3:04 p.m., P#2’s BP was 177/105 mmHg. - At 3:07 p.m., P#2’s BP was 161/96 mmHg. - At 3:12 p.m., P#2’s BP was 190/100 mmHg and treatment was terminated. The RN was not notified and there was a lack of interventions that addressed P#2’s elevated diastolic BP readings. On 1/30/24: - P#2’s pre dialysis weight was 88.9 kg and post weight was 87.4 kg (below EDW). - P#2’s BP was 173/96 mmHg at 11:50 a.m. and 177/96 mmHg during initiation of dialysis treatment at 11:52 a.m., by LPN QQ. - At 12:01 p.m., P#2’s BP was 190/96 mmHg. Record did not show that PCT HH rechecked P#2’s BP or notified the RN about elevated BP. - At 12:31 p.m., P#2’s BP was 171/103 mmHg. Again, the record did not show that PCT HH rechecked P#2’s BP or notified the RN about the elevated BP. - At 1:01 p.m., P#2’s BP was 174/95 mmHg. 1/25/24: - P#2’s pre dialysis weight was 89.7 kg and post weight was 88.1 kg (below EDW). - P#2’s BP was 173/108 mmHg at 10:54 a.m. and 171/106 mmHg during initiation of dialysis treatment at 11:04 a.m. Treatment record did not show that LPN QQ rechecked P#2’s BP or notified the RN about elevated diastolic BP. - At 11:31 a.m., P#2’s BP was 202/101 mmHg. Treatment record did not show that PCT HH rechecked P#2’s BP or notified the RN about P#2’s elevated BP. - At 12:01 p.m., P#2’s BP was 166/86 mmHg. - At 12:31 p.m., P#2’s BP was 137/63 mmHg. - At 1:02 p.m., P#2’s BP was 172/101 mmHg. - At 1:31 p.m., P#2’s BP was 172/142 mmHg. - P#2’s BP was not monitored for one hour. - The RN was not notified of the elevated diastolic BP reading. - At 2:32 p.m., P#2’s BP was 172/103 mmHg. - At 3:04 p.m., P#2’s BP was 177/105 mmHg. - At 3:07 p.m., P#2’s BP was 161/96 mmHg. - At 3:12 p.m., P#2’s BP was 190/100 mmHg and the treatment was terminated. There was a lack of documented interventions that addressed P#2’s elevated BP readings. 1/27/24: - P#2’s pre dialysis weight was 89.7 kg and post weight was 87.7 kg (below EDW). - P#2’s BP was 212/108 mmHg at 10:44 a.m. and 180/100 mmHg during initiation of dialysis treatment at 10:57 a.m. - Treatment record did not show that RN UU notified the physician per standing orders and facility policy for hypertension. - At 11:01 a.m., P#2’s BP was 196/110 mmHg. - At 11:31 a.m., P#2’s BP was 157/136 mmHg. - Treatment record did not show that PCT HH rechecked P#2’s BP or notified an RN of the elevated diastolic BP. - At 12:01 p.m., P#2’s BP was 108/74 mmHg. There was a lack of documented interventions done for P#2’s elevated BP readings. 2/1/24: - P#2’s pre dialysis weight was 89.3 kg and post weight was 86.8 kg (below EDW). - P#2’s BP was 152/83 mmHg and heart rate (HR) was 104 at 11:31 a.m. and 123/74 mmHg during initiation of dialysis treatment at 11:41 a.m. Treatment record did not show that LPN QQ notified the RN about the rapid HR. - At 11:31 a.m., P#2’s BP was 202/101 mmHg. - Treatment record did not show that PCT HH rechecked P#2’s BP or notified the RN about elevated BP. - At 12:01 p.m., P#2’s BP was 111/68 mmHg and HR was 120. The RN was not notified of the rapid HR. - At 12:03 p.m., P#2’s BP was 145/85 mmHg and HR was 111. - At 12:31 p.m., P#2’s BP was 124/76 mmHg and HR was 111. - At 1:01 p.m., P#2’s BP was 147/79 mmHg and HR was 116. Record did not show that RN TT notified the physician about the increased HR. - At 1:31 p.m., P#2’s BP was 138/95 mmHg and HR was 104. - At 2:01 p.m., P#2’s BP was 129/72 mmHg and HR was 105. - At 2:41 p.m., P#2’s BP dropped down to 69/38 mmHg while HR increased to 111. P#2 was symptomatic and complained of nausea and vomiting. RN OO administered 400 ml bolus of NS, decreased BFR and UFR. - There was a lack of documented physician notification per policy. - At 2:43 p.m., P#2’s BP was 155/86 mmHg and HR was 87. - At 2:47 p.m., P#2’s BP was 160/89 mmHg and HR was 92. - At 3:01 p.m., P#2’s BP was 133/72 mmHg and HR is 105. - At 3:10 p.m., P#2’s BP once again dropped to 59/21 mmHg and HR was 96. The physician was not notified. - At 3:12 p.m., treatment was terminated early with 400 ml of NS administered with rinse back. - At 3:18 p.m., P#2’s BP was 191/94 mmHg and HR was 107. - At 3:10 p.m., P#2’s BP was 160/90 mmHg and HR was 109. 2/3/24: - P#2’s pre dialysis weight was 88.6 kg and post weight was 87.5 kg (below EDW). - P#2’s BP was 137/101 mmHg and HR was 107 at 11:13 a.m. and 158/99 mmHg and HR was 104 during initiation of dialysis treatment at 11:16 a.m. Treatment record did not show that LPN QQ notified the RN about the elevated HR. - At 11:31 a.m., P#2’s BP was 202/101 mmHg. There was a lack of documented interventions done. - At 12:01 p.m., P#2’s BP was 157/104 mmHg and HR was 101. - At 12:34 p.m., P#2’s BP was 143/98 mmHg and HR was 107. Record did not show that RN TT notified the physician about P#2’s increased HR. - At 1:02 p.m., P#2’s BP was 156/88 mmHg and HR was 108. - At 1:31 p.m., P#2’s BP was 140/90 mmHg and HR was 108. - At 2:01 p.m., P#2’s BP was 140/97 mmHg and HR was 107. - At 2:23 p.m., P#2’s BP was 113/76 mmHg and HR was 121. P#2 became symptomatic and complained of nausea and vomiting. RN OO administered 400 ml bolus of NS, decreased BFR and UFR, but did not notify the physician per policy. - At 2:26 p.m., P#2’s BP was 152/94 mmHg and HR was 110. - At 2:33 p.m., P#2’s BP dropped down to 59/21 mmHg and HR was 96. - At 3:12 p.m., treatment was terminated early and P#2 left AMA (Against Medical Advise). There was no documented evidence that the physician was notified of P#2’s extremely low BP episodes and rapid HR during the last two treatments. On 2/6/24: - P#2’s pre dialysis weight was 86.3 kg and post weight was 86.1 kg (below EDW). - P#2’s BP was 129/86 mmHg and HR was 110 at 11:53 a.m. - Treatment record did not show that RN RR notified the physician about the elevated HR. - At 12:01 p.m., P#2’s BP was 138/96 mmHg and HR was 109. - At 12:31 p.m., P#2’s BP was 139/95 mmHg and HR was 109. - At 1:01 p.m., P#2’s BP was 135/92 mmHg. And HR was 112. - At 1:31 p.m., P#2’s BP was 138/94 mmHg and HR was 109. - At 2:01 p.m., P#2’s BP was 135/91 mmHg and HR was 112. - There was no documented interventions done and the physician was not notified of P#2’s rapid HR. - At 2:31 p.m., P#2’s BP was 143/95 mmHg and HR was 117. - NS 100 ml bolus was administered by PCT II. P#2’s vital signs were not rechecked after the intervention. - At 3:02 p.m., P#2’s BP was 148/86 mmHg and HR was 122. - Treatment was terminated by RN RR. - At 3:03 p.m., P#2’s BP was 165/102 mmHg and HR is 117. - At 3:07 p.m., P#2’s BP was 149/109 mmHg and HR was 114. - At 3:08 p.m., P#2’s BP was 111/69 mmHg and HR was 127. - At 3:09 p.m., P#2’s BP was 114/80 mmHg and HR was 129. - At 3:11 p.m., P#2’s BP was 95/69 mmHg and HR was 128. - At 3:12 p.m., P#2’s BP was 120/49 mmHg and HR was 127. - At 3:14 p.m., P#2’s BP was 134/86 mmHg and HR was 121. - At 3:16 p.m., P#2’s BP was 160/86 mmHg and HR was 120. - At 3:24 p.m., P#2’s BP was 159/89 mmHg and HR was 117. - At 3:31 p.m., P#2’s BP was 141/100 mmHg and HR was 117. There was a lack of documented evidence that a physician was notifed of P#2’s rapid HR during the last three treatments. The above findings were discussed and reviewed with the NM and AAOD on 2/8/24 at 12:54 p.m. Both confirmed that treatment records did not show that physician was notified about P#2’s extremely low BP episodes and rapid HR. P#3: P#3’s dialysis prescription: Tx time: 4 hours, EDW: 54.5 kg, BFR : 500, DFR: 1.5 x... On 1/20/24: - P#3’s pre dialysis weight was 56.3 kg and post weight was 55.0 kg. - P#3’s BP was 74/41 mmHg at 10:58 a.m. and 78/26 mmHg, HR was 90 at 11:00 a.m. BP was 39/22 during initiation of dialysis treatment at 11:06 a.m., by RN RR. Treatment record did not show that RN RR notified the physician about P#3’s extremely low BP. - At 11:09 a.m., P#3’s BP was 51/35 mmHg and HR was 70. Treatment record did not show that RN RR rechecked P#3’s BP or contacted the physician about extremely low BP readings. - At 11:31 a.m., P#3’s BP was 60/18 mmHg. Noted that patient was asymptomatic. - At 11:36 a.m., P#3’s BP was 106/23 mmHg. - At 12:03 p.m., P#3’s BP was 143/53 mmHg. - At 12:31 p.m., P#3’s BP was 178/104 mmHg and HR was 55. - At 1:01 p.m., P#3’s BP was 100/56 mmHg. - At 1:35 p.m., P#3’s BP was 92/79 mmHg. - At 1:43 p.m., the treatment was terminated early. There was a lack of documented evidence that RN RR notified the physician about P#3’s extremely low BP readings. On 1/25/24: - P#3’s pre dialysis weight was 54 kg and post weight was 54 kg (arrived below dry weight). - P#3’s BP was 98/54 mmHg at 11:05 a.m. and 78/26 mmHg at 11:15 a.m. - At 11:16 a.m., P#3’s BP was 98/54 mmHg. - At 11:31 a.m., P#3’s BP was 90/50 mmHg. NS 100 ml was administered. - At 12:01 p.m., P#3’s BP was 104/52 mmHg. - At 12:32 p.m., P#3’s BP was 91/50 mmHg. NS 100 ml was administered. - At 1:01 p.m., P#3’s BP was 91/52 mmHg. - At 1:35 p.m., P#3’s BP was 106/61 mmHg. - At 2:02 p.m., P#3’s BP was 81/50 mmHg. NS 150 ml was administered. - At 2:31 p.m., P#3’s BP was 84/48 mmHg. - At 2:34 p.m., P#3’s BP was 82/55 mmHg. - At 2:47 p.m., P#3’s BP was 82/49 mmHg. NS 300 ml was administered with rinse back. - At 2:49 p.m., treatment was terminated. - At 2:47 p.m., P#3’s BP was 96/61 mmHg. There was a lack of documented evidence that the RN and physician were notified about P#3’s low BP readings. 1/30/24: - P#3’s pre dialysis weight was 55 kg and post weight was 54.9 kg. - P#3’s BP was 132/47 mmHg and HR was 84 at 11:09 a.m. - At 11:18, P#3’s BP was 92/53 mmHg and HR was 102 during initiation of dialysis treatment. - At 11:31 a.m., P#3’s BP was 81/49 mmHg and HR was 96. Record did not show that PCT RR notified the RN about the patient’s low BP and elevated HR. - At 12:01 p.m., P#3’s BP was 93/51 mmHg and HR was 103. - At 12:31 p.m., P#3’s BP was 94/60 mmHg. And HR was 107. - At 1:06 p.m., P#3’s BP was 94/59 mmHg and HR was 101. - At 1:31 p.m., P#3’s BP was 99/59 mmHg and HR was 99. - At 2:01 p.m., P#3’s BP was 100/54 mmHg and HR was 99. - At 2:31 p.m., P#3’s BP was 103/58 mmHg and HR was 105. - At 2:51 p.m., P#3’s BP was 89/54 mmHg and HR is 104. - At 2:53 p.m., P#3’s BP was 95/67 mmHg and HR was 105. - Treatment was terminated by LPN QQ. Treatment record did not show that RN RR notified the physician about P#3’s rapid HR. The above findings were discussed with the NM and AAOD on 2/8/24 at 1:30 p.m. Both confirmed that treatment records did not show that the physician was notified about P#2’s low BP and rapid HR. P#6: P#6’s dialysis prescription: Tx time: 3 hours and 30 minutes, EDW: 79 kg, BFR: 350 mL/min, DFR: 1.5 x mL/min... On 1/29/24: - P#6’s pre dialysis weight was 83.5 kg and post weight 82 kg. - At 12:30 p.m., P#6’s HR was 122. - At 1:00 p.m., P#6’s HR was 122. - At 1:30 p.m., P#6’s HR was 129. - At 2:00 p.m., P#6’s HR was 131. - At 2:30 p.m., P#6’s HR was 132. - At 2:35 p.m., P#6’s HR was 131. There was a lack of documented evidence that the RN and physician were notified of P#6’s tachycardia during the entire treatment. On 2/5/24: - P#6’s pre dialysis weight was 85.2 kg and post weight was 86.3 kg. - At 12:01 p.m., P#6’s B/P was 169/75 and HR was 57. - At 1:02 p.m., P#6’s HR was 111. - At 1:08 p.m., P#6’s HR was 112. - At 1:30 p.m., P#6’s HR was 129. - At 1:31 p.m., P#6’s HR was 119. - At 2:02 p.m., P#6’s HR was 94. - At 2:17 p.m., P#6’s HR was 117 and treatment was terminated. There was a lack of documented evidence that the RN and physician were notified of P#6’s tachycardia during the entire treatment. P#8: P#8’s dialysis prescription: Tx time: 3 hours and 30 minutes, EDW: 91 kg, BFR: 500 mL/min, DFR: 800 mL/min... On 1/18/24: - P#8’s pre dialysis weight was 97.2 kg and post weight was 94 kg. - P#8’s BP was 135/80 during initiation of dialysis treatment at 12:20 p.m. - At 12:30 p.m., P#8’s BP was 142/85 mmHg. - At 1:00 p.m., P#8’s BP was 152/98 mmHg. - At 1:30 p.m., P#8’s BP was 169/104 mmHg. - At 2:00 p.m., P#8’s BP was 178/108 mmHg. - At 3:00 p.m., P#8’s BP was 193/117 mmHg. - At 3:30 p.m. P#8’s BP was 191/115 mmHg. - At 3:37 p.m., P#8’s BP was 202/116 mmHg. There was a lack of documented interventions and the RN and physician were not notified of P#8’s elevated BP readings.. The above findings were discussed and confirmed with the NM, Educator, and AAOD on 2/8/24 at 2:16 p.m. During an interview with the Charge Nurse (CN) on 2/9/24 at 11:08 a.m., CN stated that when a patient has low BP, 100 ml of NS is administered. They wait 3-5 minutes and retake the BP. If BP is still low, the physician is notified. Stated “We can reduce the patient’s goal and obtain an order to put the patient on Crit-Line (a medical device that allows the healthcare team to assess how well a patient’s body is responding to the fluid removal rate during dialysis), and ask the patient if he/she took BP medicine. Some patients have an order for Midodrine (medication used to treat low BP) that they take at home. Stated that for high BP, we can give Clonidine, it is a standing order for all patients. If this doesn’t work, we call the physician. The physician did not want to be contacted for patients who consistently run low blood pressure. A review of Policy No: (N 1 of 2) E-6 titled, “Patient Assessment Pre - Hemodialysis” last updated October 2010 stated: The physician should be notified before dialysis is initiated on any patient with abnormal findings uncommon for the individual patient including: a. Elevated Blood Pressure ... e. Severe Hypotension ... j. Tachycardia A review of Procedure No: 221 titled, “Management of Hypotension during Hemodialysis” dated 1/20/2019 stated: Policy: 1. Notify charge nurse immediately if blood pressure is outside of the clinics established parameter reporting guidelines. 2. Patient loss of consciousness will be reported to the physician and occurrence report completed. 3. Do not leave the patient unattended until normal blood pressure is restored. 4. Put patient in Trendelenburg position and administer normal saline (NS) at first signs of hypotension. 5. Vital signs should be monitored at least 30 minutes, or more frequently based on assessment, during dialysis. Any drop in systolic blood pressure by greater than 20 mmHg should be reported to the charge nurse. 6. Medication reconciliation should be done for any patient experiencing symptomatic hypotension and nephrologist notified. If appropriate, antihypertensive medications should be held prior to dialysis. If appropriate, nephrologist may order Midodrine to help with blood pressure. 7. Any patient with a blood pressure that is known to be low, or beginning to drop should be asked to keep feet in elevated position. 8. Patients should be discouraged from retracting treatment chair footrest and placing feet on floor; this may induce or exacerbate hypotension. 9. Patient should be educated on ways to prevent hypotension. The following items are included, but not limited to: - Ensure accurate pre and post dialysis weights. - Ensure accurate dry weight. - Antihypertensive medication may need to be held prior to treatment, per physician order. - Dietary sodium intake should be decreased. - Fluid intake should ideally be < 1 L (Liter) per day. Procedure: 1. Assess patient for signs and symptoms of hypotension, including level of consciousness. If hypotensive, continue to step 2. 2. Place patient in Trendelenburg position. 3. Restore blood pressure with normal saline bolus in increments of 100-200 ml via the IV administration set. 4. Place dialysis machine in minimum UFR mode. 5. Administer oxygen at 2-3 L via nasal cannula. 6. If patient remains hypotensive, administer additional normal saline bolus to restore blood pressure. 7. Recheck blood pressure following normal saline bolus. 8. If patient remains hypotensive or is unresponsive or is unresponsive following normal saline bolus, repeat bolus. 9. If patient remains hypotensive following normal saline bolus: discontinue treatment, return blood, and notify nephrologist. A review of Procedure No: 218 titled, “Management of Hypertension during Hemodialysis” dated 1/20/2019 stated: Policy: 1. A licensed nurse must assess patient for hypertension. 2. Notify physician for further orders if symptomatic hypertension is noted during dialysis or if blood pressure is out of established parameters. 3. Clinics will establish parameters of when to report hypertension to physician (i.e., Systolic BP > 180 mmHg & Diastolic BP > 100 mmHg). 4. Vital signs including blood pressure will be monitored every 30 minutes. 5. Antihypertensives will be administered per standing order/protocol (as available in hemodialysis unit). 6. If symptoms are severe and do not improve with interventions, discontinue hemodialysis and call physician for further orders. 7. All interventions will be documented on the flowsheet to provide complete record of care... A review of Procedure No: 204 titled, “Management of Arrhythmias (a condition in which the heart beats with an irregular or abnormal rhythm) on Hemodialysis” dated 1/20/2019 stated: Policy: 1. A licensed nurse must assess patient at the first sign of arrythmias. 2. Notify physician for further orders if an arrhythmia is noted on dialysis. 3. Reduce UFR to minimum. 4. Reduce BFR to 200. 5. Monitor vital signs, if hypotensive, treat with 100-200 cc normal saline bolus. 6. Administer oxygen at 2-3 L (liter) via nasal canula or per standing order 7. Administer antiarrhythmic medications as ordered by MD. 8. Evaluate EDW frequently UFR should be adjusted based on patient age, weight, and comorbidities to avoid intravascular volume depletion, hypotension, and cardiac stunning. 9. All interventions will be documented on the flowsheet and occurrence report completed in the event of arrythmia.”