Emory Dialysis at Greenbriar

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 50523 Based on a review of medical records and facility Policy and Procedures (P&P), and staff interviews, it was determined that the Interdisciplinary Team (IDT) failed to ensure that one of one patient (P#1) sampled who presented for dialysis treatment with a pre-dialysis weight of 2.2 kg (kilograms) below her target weight or dry weight (a patient’s ideal body weight without excess fluid), received dialysis treatment per physician’s dialysis orders as evidenced by a UF (Ultrafiltration: process of removing fluid from the body during dialysis) goal that was set to remove 1500 milliliters (mL) of fluid or 1.5 kg (expected weight loss). This deficient practice could have contributed to P#1’s unresponsiveness after dialysis treatment. Removing too much fluid during hemodialysis can lead to serious consequences such as low blood pressure (hypotension), muscle cramps, dizziness, nausea, fatigue, and in severe cases, organ damage due to inadequate blood flow, potentially increasing the risk of cardiovascular complications; thus, careful monitoring of fluid removal based on a patient’s “dry weight” is crucial during dialysis sessions. The facility census was 129. Findings were: Cross reference V 543 - Failure of Registered Nurse (RN AA) to follow the primary nephrologist’s “Unique Orders” specific for P#1’s UF goal each dialysis treatment.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on patient record review, a review of facility Policies and Procedures (P&P) and staff interviews, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This deficient practice negatively affected the health and safety of P#1 which led to P#1’s death due to cardiac arrest and congestive heart failure (CHF, a chronic condition in which the heart cannot pump {systolic} or fill {diastolic}adequately, with symptoms that include shortness of breath, fatigue, swollen legs, and rapid heartbeat), according to the facility’s discharge summary. The facility’s in-center hemodialysis census was 129. Findings were: Cross references: Cross reference V 543 - Failure of the Interdisciplinary Team (IDT) to ensure that one of one sampled patient (P#1) who presented for dialysis treatment with a pre-dialysis weight of 2.2 kg (kilograms) below her target weight or dry weight, received dialysis treatment per physician’s dialysis orders and facility P&P. V 715 - Failure of the Medical Director to ensure that one of one sampled patient (P#1) who presented for dialysis treatment with a pre-dialysis weight of 2.2 kg (kilograms) below her target weight or dry weight, received dialysis treatment per physician’s dialysis orders and facility P&P.”

“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: 50523 Based on a review of medical records and facility Policy and Procedures (P&P), and staff interviews, it was determined that the Medical Director failed to ensure that one of one patient (P#1) sampled who presented for dialysis treatment with a pre-dialysis weight of 2.2 kg (kilograms) below her target weight or dry weight (a patient’s ideal body weight without excess fluid), received dialysis treatment per physician’s dialysis orders as evidenced by a UF (Ultrafiltration: process of removing fluid from the body during dialysis) goal that was set to remove 1500 milliliters (mL) of fluid or 1.5 kg (expected weight loss). This deficient practice could have contributed to P#1’s unresponsiveness after dialysis treatment. Removing too much fluid during hemodialysis can lead to serious consequences such as low blood pressure (hypotension), muscle cramps, dizziness, nausea, fatigue, and in severe cases, organ damage due to inadequate blood flow, potentially increasing the risk of cardiovascular complications; thus, careful monitoring of fluid removal based on a patient’s “dry weight” is crucial during dialysis sessions. The facility census was 129. Findings were: A review of the facility’s Incident report from August 2024 to January 2025 revealed: - An entry was recorded on 10/29/24 at 4:11 p.m., logged in as an Emergent/ Unplanned Transfer pertaining to P#1. The incident report revealed that P#1 was unresponsive post dialysis treatment. Cardio-Pulmonary-Resuscitation (CPR) was immediately commenced, and a 911 call was made to activate the Emergency Medical Services (EMS). An Automated External Defibrillator (AED) was used to deliver one electric shock to P#1. A review of P#1’s “Hemodialysis Treatment Flowsheets” revealed the following: - On 10/20/24, P#1’s target weight was changed from 80.0 kg (kilogram) to 76.0 kg. - On 10/22/24, P#1’s pre-weight was 76.2 kg, and post-weight was 75.5 kg, which was 0.7 kg below P#1’s target weight. - On 10/24/24, P#1’s pre-weight was 76.5 kg and post weight was 76.0 kg. - On 10/26/24, P#1’s pre-weight was 74.3 kg and post-weight was 74.3kg, which was 1.7 kg below target weight (76 kg). - On 10/29/24, P#1’s pre-weight was 73.8 kg, which was 2.2 kg below target weight. At 5:07 a.m., RN AA set P#1’s UF goal to remove 1500 mL (milliliter) of fluid. At 5:12 a.m., RN AA performed a pre-nursing assessment and documented that P#1’s “heart rate was regular, respirations were ok, lung sounds were clear, and P#1 was edema free” (sic). P#1’s hemodialysis treatment was completed at 8:55 a.m. and the total removed fluid was 1500 mL. Between 5:31 a.m. and 8:55 a.m., the only documentation under the “Hemodialysis Session Observations” was, “patient resting” (sic). There were no other observations and no documentation if P#1 was asked by the Direct Patient Care Staff (Nurses and Technicians) how P#1was feeling or if P#1 had other abnormal findings/complaints. At 9:19 a.m., P#1 was found unresponsive, CPR was initiated and 911 was called to activate the EMS. At 9:32 a.m., EMS personnel arrived and continued with CPR then transported P#1 to the Emergency Room. - A review of P#1’s admission orders revealed that on 9/19/19 (P#1’s admission date), under doctor’s “Unique Orders” specific for P#1, it stated, “May challenge target weight +/- up to 1.0 kg PRN (as needed) and do not UF more than 1.0 kg each treatment”. (sic) This unique order still showed in P#1’s flowsheets, even up to 10/29/24. There were no other documented or verbal orders regarding change of dry weight, nor challenging P#1’s UF goal greater than 1.0 kg per treatment. - A review of the “End Stage Renal Disease (ESRD) Death Notification” form revealed that P#1 expired on 10/29/24 at the hospital. - A review of P#1’s facility discharge summary revealed that the discharge diagnosis were cardiac arrest and congestive heart failure. - A review of facility Policy, titled, “Calculation of Fluid Removal Goal”, that was last revised on December 2022, stated: 7. Challenging the patients’ dry weight: Challenging the dry weight is determined by the nurse, not the patient. Documentation should be recorded in the nursing assessment on the reasoning for challenging the dry weight (this includes any sign or symptoms of fluid overload: lungs sounds, edema, hypertension ...) -A review of facility Policy, titled, “Documentation of Patient Care in the Electronic Medical Record”, that was last revised on July 2014, stated: 3. Charting by exception should be utilized in progress note documentation. The general rule is that only unusual or unexpected findings, or those outside the normal treatment, are recorded. - On 1/28/25 at 12:26 p.m., Patient Care Technician, (PCT) AA stated that P#1’s target weight was changed due to P#1’s weight loss. PCT AA stated that P#1 came in below her target weight during her last few treatments and no UF goal was set to remove fluid, but just to clean P#1’s blood. PCT AA also added that she did question RN AA on why the UF goal was set to remove 1500 mL of fluid when the P#1’s pre-weight was below her prescribed target weight. PCT AA also stated that RN AA wanted to challenge P#1’s weight and that was the reason she set the UF goal to remove 1500 mL fluid. Additionally, PCT AA stated that P#1 remained stable throughout the entire treatment. - On 1/28/25 at 12:54 p.m., Licensed Practical Nurse (LPN) AA, stated that he was the nurse assigned to oversee treatment of P#1 on 10/29/24, and that he was scheduled to come in to work at 5:30 a.m. However, when he got in to work, RN AA had already initiated P#1’s treatment and had already performed the pre-nursing assessment. LPN AA also stated that he did notice that P#1’s UF goal was 1500 mL but he did not question RN AA or reassess P#1. LPN AA stated, he figured that RN AA was challenging P#1’s UF goal. - On 1/28/25 at 3:04 p.m., RN AA stated that she did set P#1’s UF goal on her dialysis machine to remove 1500 mL of fluid on 10/29/24. RN AA also stated that she performed P#1’s pre-nursing assessment on 10/29/24, and she discovered that P#1 presented with edema all over and heard crackles while auscultating P#1’s lungs. RN AA stated she thought she documented the findings. RN AA’s statement did not corroborate with her pre-nursing assessment documentation dated 10/29/24, stating that P#1’s “respirations okay, heart rate regular, lung sounds clear, and edema free”. - During a telephonic interview on 1/28/25 at 3:42 p.m., P#1’s Nephrologist stated that it was difficult to challenge P#1’s UF goal because P#1 would become hypotensive (low blood pressure) during hemodialysis treatment when UF was higher than 1.0 kg. P#1’s Nephrologist also added that he had unique orders in P#1’s chart stating not to remove more the 1.0 kg each treatment. - During a telephonic interview on 1/29/25 at 4:18 p.m., the Medical Director acknowledged the findings and stated, “Okay, thank you for letting me know”.”

“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: 50523 Based on a review of medical records and facility Policy and Procedures (P&P), and staff interviews, it was determined that the Medical Director failed to ensure that three of three Direct Patient Care Staff (Registered Nurse [RN] AA, Licensed Practical Nurse [LPN] AA, and Patient Care Technician [PCT] AA) sampled, adhered to the facility’s P&P and followed the Nephrologist’s specific orders relative to setting one of one sampled patient’s (P#1’s) UF (Ultrafiltration: process of removing fluid from the body during dialysis) goals. Removing too much fluid during hemodialysis can lead to serious consequences such as low blood pressure (hypotension), muscle cramps, dizziness, nausea, fatigue, and in severe cases, organ damage due to inadequate blood flow, potentially increasing the risk of cardiovascular complications; thus, careful monitoring of fluid removal based on a patient’s “dry weight (a patient’s ideal body weight without excess fluid)” is crucial during dialysis sessions. The facility census was 129. Findings were: Cross reference V 543 - Failure of the Interdisciplinary Team (IDT) to ensure that one of one sampled patient (P#1) who presented for dialysis treatment with a pre-dialysis weight of 2.2 kg (kilograms) below her target weight or dry weight, received dialysis treatment per physician’s dialysis orders and facility P&P.”