Dci - Crawford Long 016

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on a review of facility records, staff interviews, and a review of the National Kidney Foundation-Dialysis Manuals, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This deficient practice negatively affected patient (P) #1’s health and safety, as a result of not receiving his prescribed hemodialysis treatment for seven days (from P#1’s last hemodialysis treatment date of 11/11/25 to 11/18/25), because of a clotted access and failure of the Interdisciplinary Team (IDT) to ensure that necessary referrals were made and followed through. The facility’s in-center hemodialysis census was 77. Findings include: Cross-Reference: V550 - Failure of the Interdisciplinary Team (IDT) to ensure that one of one patient (P#1) sampled, received his prescribed hemodialysis treatment by ensuring that his dialysis access (an essential, lifesaving access point for hemodialysis to filter blood, remove toxins and fluids when kidneys fail), remained open and unobstructed and failure to ensure that necessary referrals were made and followed through.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 53051 Based on a review of facility records, staff interviews, and a review of the National Kidney Foundation-Dialysis Manuals, it was determined that Interdisciplinary Team (IDT) failed to ensure that one of one patient (P) #1 sampled, received his prescribed hemodialysis treatment by ensuring that his dialysis access (an essential, lifesaving access point for hemodialysis to filter blood, remove toxins and fluids when kidneys fail), remained open and unobstructed and ensure that necessary referrals were made and followed through. This failure negatively affected the health and safety of P#1 who was hospitalized due to uremic encephalopathy (a brain dysfunction from toxin buildup due to severe kidney failure). Failure to receive hemodialysis treatment for seven consecutive days (from P#1’s last hemodialysis treatment date of 11/11/25 to 11/18/25), can lead to serious health risks, including fluid overload, electrolyte imbalances, increased toxin levels in the blood that could lead to uremic encephalopathy, and potentially life-threatening complications such as cardiac arrest and death. The facility’s in-center hemodialysis (ICHD) patient census was 77. Findings include: A review of P#1’s Progress Notes, revealed the following: - On 11/13/25, P#1 was present at the facility but missed his hemodialysis treatment. The documentation stated that the reason for the missed treatment was, “unable to dialyze”. - On 11/15/25, P#1 was present for treatment. Reason for the missed treatment: unwilling to dialyze. - On 11/18/25, P#1 came again for his dialysis treatment. The documented reason for the missed treatment was: “unable to dialyze”. - CM/RN AA documented on P#1’s Progress Note, dated, 11/18/25, that stated: P#1 had presented to the dialysis facility not easily aroused with the clotted access for three consecutive treatment days. P#1 had three referrals sent to the Access Center for declotting. The Access Center had been unable to reach a representative at the nursing home where P#1 resided. On Saturday, the charge nurse from the facility had called the nursing home and left the Access Center number with the receptionist. Emergency Medical Services (EMS) had been called to transport P#1 to the hospital for evaluation. The nephrologist had also been notified. (sic) A review of P#1’s last three Hemodialysis Flowsheets, dated 11/1/25, 11/4/25, and 11/11/25, revealed the following: - P#1 had a Left Upper Arterio-Ventricular Graft (AVG - a hemodialysis access created by surgically connecting an artery to a vein using a synthetic tube, allowing adequate blood flow for dialysis when a natural fistula is not suitable). - P#1’s hemodialysis treatment duration prescription was 195 minutes (which P#1 completed during these three dates). - Prescribed Blood Flow Rate (BFR - the speed at which blood is pumped from the patient through the dialysis circuit, usually measured in milliliter per minute [ml/min.]), was 400 ml/min. - Under Access Assessment (both Pre- and Post Assessment) on 11/1/25, 11/4/25, and 11/11/25, the documentation showed: - Access had no signs and symptoms of infection. - Positive for thrill (a palpable vibration felt over a hemodialysis vascular access (AV fistula or graft), indicating that blood is flowing properly through the access). - Positive for bruit (a whooshing sound heard with a stethoscope over a hemodialysis vascular access (AV fistula or graft), reflecting turbulent blood flow and indicating that the access is patent and functioning). P#1’s “arterial pressure”, on the following dates, showed: - On 11/1/25, arterial pressure ranged from negative (-)160 to (-)230 millimeters of mercury (mmHg) with a BFR of 400ml/min. - On 11/4/25, arterial pressure ranged from (-)160 to (-)200 mmHg with a BFR of 400ml/min. - On 11/11/25, arterial pressure ranged from (-)170 to (-)240 mmHg with a BFR of 400ml/min. According to the National Kidney Foundation - Dialysis Manuals: - In dialysis, the “arterial pressure”, which often refers to Prepump Arterial Pressure, abbreviated as (Pa) is usually negative, indicating suction to draw blood into the machine. Normal pressures range from negative (-)50 to (-)200 mmHg, depending on factors like BFR and needle placement. Pressures more negative than (-)200 to (-)250 mmHg suggest possible issues such as access stenosis or needle malposition, or clotting, with such values below (-)250 mmHg seen as critical and requiring action. A review of P#1’s Hospitalization records dated 11/18/25, revealed the following: - P#1 was diagnosed with uremic encephalopathy secondary to recurrent missed hemodialysis treatment. During a telephonic interview with CM/RN AA (who was not at the facility during this complaint investigation survey), on 12/11/25 at 1:10 p.m., she stated that when a patient has an access failure, the RN or anyone in the facility can call the vascular center to give the patient’s full details for referral. The vascular center will then reach out to the patient with the appointment schedule. In the case of P#1, the vascular center was supposed to call the nursing home to arrange P#1’s appointment schedule. CM/RN AA also added that P#1 came to the facility three times with the clotted access. Two times, P#1 was sent back to the nursing home without treatment because the access was still clotted. The third time, P#1 came back to the facility for dialysis treatment looking lethargic and not easily aroused, and still with a clotted access. CM/RN AA also stated that she called the nursing home on 11/18/25, to find out why P#1 hadn’t been sent to the vascular center and she was told by a nursing home personnel that they had never received any call from the vascular center. CM/RN AA further stated that she then called the Emergency Medical Services (EMS) to transport P#1 to the hospital, and P#1’s nephrologist was also notified. During a telephonic interview with the Medical Director (MD) on 12/11/25 at 1:48 p.m., she stated that when the patient has an access failure, the nurses will call to inform her, and then they will arrange for the patient to be referred to the vascular center. The MD also stated that she was not aware that there was a patient who didn’t have dialysis for the whole week because of access failure. The other factor might be that the patient didn’t belong to her group. But still, she didn’t approve of the fact that the patient didn’t have dialysis for the whole week. That was not their standard because the patient’s life depended on having functional access so that they can get treatment. During a telephonic interview with P#1’s nephrologist on 12/11/25 at 3:23 p.m., he stated that when a patient is having an access failure, the nurses will inform him, and they will refer the patient to the vascular center. He mentioned that he only became aware of P#1 having an access failure on 11/18/2025 when the nurse called him to inform him about P#1’s condition and about his clotted access. He was not aware that P#1 didn’t receive treatment on 11/13/2025 and 11/15/2025. During an interview with the facility’s Administrative Assistant (AA) on 12/11/25 at 3:30 p.m., to obtain any referral documents for P#1 related to the vascular center, she stated that there were no recent referrals for P#1 documented in their records. The facility AA added that she contacted the two vascular centers that the facility typically referred patients to, and both vascular centers confirmed that P#1 had no appointments scheduled with them in the past week. They also indicated that they had no records of any referrals dated 11/13/25 or 11/15/25. During an interview with the Area Regional Director on 12/11/25 at 3:45 p.m., she stated that the facility did not have P & P regarding Access Failure. The only P & P they had was initial cannulation of a new access. A review of the facility’s Complaint and Grievance Logs from October 2025 to December 11, 2025, showed that there was no documented evidence of a complaint/grievance related to P#1’s access. A review of the facility’s Adverse Occurrence Report didn’t show any report regarding P#1’s clotted access and regarding P#1’s unexpected hospitalization on 11/18/2025. At the time of this survey (12/11/25), P#1 was still admitted at the hospital’s Intensive Care Unit (ICU).”