Usrc Covington Dialysis

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 25727 Based on a review of medical records, staff interviews, and review of the facility’s Policies and Procedures (P & P), it was determined that the Medical Director failed to ensure that one of one Licensed Practical Nurse (LPN AA), a Float Staff who worked at this facility, adhered to facility’s P & P pertaining to patient safety relative to bathroom usage during treatment. On 3/12/24 at 4:00 p.m., a determination was made that a situation in which the facility’s noncompliance with 42 CFR Part 494.150 - Responsibilities of the Medical Director, resulted in an Immediate Jeopardy (IJ) that caused harm to the health and safety of one of one patient (P#1), who experienced severe blood loss while at this facility. The Facility Administrator was informed of the IJ finding on 3/12//24 at 4:00 p.m. The noncompliance related to the IJ was identified to have existed on 3/7/24 at 1:55 p.m. The IJ situation was abated during the survey on 3/13/24 at 3:00 p.m. Findings were: Cross References: V 541 - Failure of the interdisciplinary team to develop and implement an individualized plan of care that met the specific safety needs of one of one patient (P#1) who demonstrated signs and symptoms of dementia. V 715 - Failure of the medical director to ensure that all P & P relative to patient safety were adhered to by all staff.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 25727 Based on a review of medical records, staff interviews, and review of the facility’s Policies and Procedures (P & P), it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. On 3/12/24 at 4:00 p.m., a determination was made that a situation in which the facility’s noncompliance with 42 CFR Part 494.180 - Governance, resulted in an Immediate Jeopardy (IJ) that caused harm to the health and safety of one of one patient (P#1), who experienced severe blood loss while at this facility. The Facility Administrator was informed of the IJ finding on 3/12//24 at 4:00 p.m. The noncompliance related to the IJ was identified to have existed on 3/7/24 at 1:55 p.m. The IJ situation was abated during the survey on 3/13/24 at 3:00 p.m. Findings were: Cross References: V 541 - Failure of the interdisciplinary team to develop and implement an individualized plan of care that met the specific safety needs of P#1 who demonstrated signs and symptoms of dementia. V 715 - Failure of the medical director to ensure that all P & P relative to patient safety were adhered to by all staff.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 25727 Based on a review of records and staff interview, it was determined that the interdisciplinary team (IDT) failed to develop and implement an individualized plan of care that met the specific safety needs of one of one patient (P#1) who had been known to have dementia (loss of thinking, remembering, and reasoning skills). This failure had caused severe harm to the health and safety of P#1. Findings were: A review of P#1’s Initial Comprehensive Assessment/Plan of Care dated 4/12/23 and 90-day Reassessment/Plan of Care dated 6/29/23 revealed that P#1 was deemed stable by the IDT. A review of Psychosocial Progress Notes entered and electronically signed by the Social Worker dated 7/31/23 showed “P#1 has dementia and confusion”. This was the first time “dementia” was mentioned in P#1’s medical records. The Psychosocial Progress Notes dated 10/31/23 and 1/18/24 also showed P#1 has dementia... However, P#1’s plan of care was not updated accordingly, based on the above mentioned psychosocial assessments. There was a lack of documented evidence that an individualized plan of care specific to patient safety during dialysis, was developed and implemented by the IDT to ensure patient safety during dialysis treatment since P#1 developed signs and symptoms of dementia. The above findings were confirmed by the Clinical Specialist on 3/26/24 at 2:10 p.m. For detailed findings, cross reference V 715: Failure of the medical director to ensure that Policies and Procedures pertaining to patient safety relative to bathroom usage during treatment, were adhered to by all staff.”

“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: 25727 Based on a review of medical records, staff interviews, and review of the facility’s Policies and Procedures (P & P), it was determined that the Medical Director failed to ensure that one of one Licensed Practical Nurse (LPN AA), a Float Staff who worked at this facility, adhered to P & P pertaining to patient safety relative to bathroom usage during treatment. On 3/12/24 at 4:00 p.m., a determination was made that a situation in which the facility’s noncompliance with 42 CFR Part 494.150 - Responsibilities of the Medical Director, resulted in an Immediate Jeopardy (IJ) that caused harm to the health and safety of one of one patient (P#1), who experienced severe blood loss while at this facility. The Facility Administrator was informed of the IJ finding on 3/12//24 at 4:00 p.m. The IJ situation was abated during the survey on 3/13/24 at 3:00 p.m. Findings were: A review of P#1’s medical records showed the following: The Hemodialysis Flowsheet dated 3/7/24 that was documented and electronically signed by LPN AA showed the following: - At 14:57, “Pt (Patient) escorted to the rest room with needles securly (sic) taped to access site, moments after charge nurse went to check on patient, and found patient bleeding in restroom from self removed needle site with one needle removed by patient and the other needle still in place. Patient was found unresponsive but breathing, all medical staff was alert (sic) and given instruction to maintain the safety of Patient and request Emergency responce (sic) team”. A review of record created by the Facility Administrator (FA) dated 3/8/24 showed the following: “Per clinical staff the patient arrived from home alert and able to identify were (sic) she was. Patient was cannulated (inserted fistula needles for dialysis) and treatment ran for 2 hour (sic) and 50 min (minutes), when requested to use the restroom. assigned (sic) LPN then returned patients (sic) blood and Needles (sic) were secured with tape, patient was escorted to the restroom. RN (Registered Nurse) noticed that the patient was in the restroom for awhile and went to check on her when she discovered the patient lying on the floor unresponsive in a pool of blood with both needles pulled, estimated blood lost (sic) greater than 200mls. (sic) Patient threw the arterial needle in the toilet and the venous needle also pulled but still taped to her arm. RN then called for a code and the charging RN ran to assist and was suck (sic) by the venous needle, clinical staff attempted to revive the patient. AED (Automated External Defibrillator - a medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal) applied and suggested to start compressions, staff continued code until EMS (Emergency Medical System) 911 arrived. EMS was able to revive the patient, she was alert and screaming to let her go when they strapped her to the sretcher, patient was then transported to the ER (Emergency Room) for further evaluation. Patient’s daughter was notified by staff and MD (Medical Director) and supervisor was (sic) notified by the FA. FA contacted the ER a (sic) hour later for a follow up, RN (named) stated, the patient on arrival had a Hemoglobin of 6.9 and hematocrit of 20.1, rapid infusion of two units of blood was given and the patient was alert and stable...” NOTE: The acceptable Hemoglobin for dialysis patients ranged between 10 g/dL - 11 g/dL [(g) grams per dL (deciliter)]. During an interview with the Nephrologist/MD on 3/12/24 at 1:30 p.m., it was revealed that P#1 has cognitive impairment. MD stated “Patient is not with it; it comes and goes”. During an interview with the FA on 3/12/24 at 1:45 p.m., she stated that P#1 has shown symptoms of mild dementia and has been progressing, but P#1’s family was in denial. During an interview with RN AA, RN BB, PCT (Patient Care Technician) AA, and LPN BB on 3/12/24 between 2:05 p.m. and 3:00 p.m., it was revealed that P#1 has demonstrated signs and symptoms of dementia but was left alone in the Bathroom for approximately five to ten minutes without supervision. PCT AA stated that “everybody has been concerned about P#1 because she is not mentally stable and has progressively gotten worse during the last several months”. RN AA, RN BB, PCT AA, and LPN BB stated that the incident could have been prevented. LPN AA was not available for an interview during the survey. A review of Policy # C-ID-0130 titled, “Bathroom Usage During Treatment” dated 8/2020 showed the following: PURPOSE: To provide assistance for patients using the bathroom facilities during the dialysis treatment. POLICY: 1. Encourage patients to use the bathroom prior to treatment... If the patient’s vital signs are stable, the patient may use the bathroom with assistance from a staff member following the safety procedures below. 2. Staff will offer to stay with the patient inside the bathroom and document patient response on the flowsheet. PROCEDURE: 7. Staff will accompany the patient to the bathroom and will stay with the patient inside the bathroom unless the patient specifically requests privacy... then the staff will make a reasonable effort to stand outside the bathroom door... The Immediate Jeopardy was abated on 3/13/24 at 3:00 p.m. upon completion of the following: - An in-service was conducted on 3/13/24 by the Facility Administrator and Clinical Specialist on Policy and Procedure: C-ID0130 titled, “Bathroom Usage During Treatment” with emphasis on following the safety procedures. - An in-service was also conducted on 3/13/24 by the Regional Director on Float Staff about reviewing “Special Instructions” on the patient’s flowsheet to help identify patients who may be deemed high risk. Only Float Staff who have attended the in-service will be scheduled to work at this facility. - A Governing Body Meeting was held on 3/13/24.”